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It really is. Okay. Good morning. Welcome everyone. I think you probably coming from all sorts of different countries. So, uh we'll see how we go. Uh My name is Fiona Sim. I'm a public health, a consultant and I was a G P as well until a few years ago. So I'm going to be talking about the sciences and art of public health, which hopefully will be interested if you've heard this before, it's been a little bit updated. Um, but if you don't want to stay, if you had it before then, obviously that's, that's your choice, but welcome if you haven't heard this talk before, um, it's going to be largely UK biased, which I kind of apologize, but I don't, but hopefully it will be meaningful wherever you are either studying or plan to practice medicine. Um I'm happy to be interrupted. I may rely on Hannah to tell me if there's questions coming up in the chat or if uh anybody's got a hand up. If I don't catch it, I'm going to put my video off now. I think when I'm talking so that you can, well, I'll leave it on, I guess as long as you can see enough of the screen. Um and you're not distracted like that. So let's get going. Anybody want to tell me what is public health, please? If you don't want to. That's okay. I'll just answer my own questions, but you can feel like answering. That would be lovely. Okay. So public health is about the health of communities and populations and I'm just going to share a few uh definitions with you. So the top one, Donald Acheson was the chief medical officer in England and chief medical advisor to the UK government in the late 19 eighties, eighties and 19 nineties. And he came up with this definition which I think it's quite nice. Uh And he described the art and science of preventing disease, prolonging life and promoting health for everyone, for the whole population through the organized efforts of society. So it's not down to individuals, it's down to society as a whole to improve the health of our population. This was updated some years later by Derek Oneness who was brought in to uh advise the UK government about improving the health of the population. Interestingly, he was a banker. He had no background in health, in medicine and not in public health either. But he was actually really good at what he did and produced very interesting report with a lot of health from those who did understand public health and he changed, you can see tweaked it a little bit the science not of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organisations, public and private and community, communities and individuals. He wanted to make it a bit more explicit that this was about everybody getting involved, not just leaving it to the organized efforts of something called society which nobody really understood in his view. So it was a slightly broader definition but meaning the same thing, although he did introduce the concept that individuals could somehow hold that responsibility. Um And that possibly is, is a little bit contentious. On the other hand, all of us have some responsibility. I would suggest to understand health and a lot of us think it's really important that people should be health literate, understand about health matters that will affect them potentially or their families. And this the last one here is the worth World Health Organization uh Europe definition from just a couple three years ago, um about public healthy overall vision is to promote greater health and well being in a sustainable way while strengthening integrated public health services and reducing inequality. So that's really important, I think. So, two things that came in there that hadn't been in our earlier definitions. One is about sustainability and that's about planetary health to a very large extent and about making things happen that will last rather than short term interventions that then disappear. The sustainability here, I think has got those two meanings and also about reducing inequalities, which most of us working in public health from the last many years, I would have automatically assume if we talk about public health, we're talking about reducing inequalities between individuals, between populations and communities. And that made it very much more explicit, just shows really that back in the 19 eighties and even in the noughties, it wasn't, these things were not particularly thought I was being part of public health, which is quite incredible. Most of us were working in public health at the time. It would have been absolutely center stage. Anyway, so these are definitions and we've got arm science plugged in there. So I'm going to take a few slides up to about science and then a little bit about the art and then try and bring it together for you and throwing in a an introduction on inequalities to show you how that fits in as well. I hope so. That's the plan for the next half an hour or so. And then hopefully you can ask me some questions. That would be great. Ok? You happy for me to carry on any questions of it at this moment, I'm assuming not. Okay. So the main the basic science, public health, usually we think of as epidemiology and that is the incidents, distribution and potentially the control of diseases and other factors relating to health. I'm sure you will know that already. But maybe others got a general, a neat definition for you. I think. So. It's a study and it's data driven of the determinants of health and of health related states and defense. And you have to define the population, specify the population that you're talking about in order to make use of epidemiology. So you're talking about the whole country globally. You're talking about a local community or even a local school or hospital in the city or region. Once you've determined the population, you're going to address in terms of epidemiology, your study, your data can look at the distribution and determinants of health related parameters and and more in terms of more lay language study of how diseases occur in different groups of people, but not only how they occur, but why? So for epidemiology to be useful, it shouldn't just be looking at what happens, it should be looking at how so that something can be done about it. So there are some pure epidemiologists and I would say I'm not one I would fail the test. Who would say no, just understanding about the patterns of disease is about is epidemic demonology. Whereas those of us involved with public health in the real world will say, well, that's, that's essential but not enough. We actually need to understand what we can do about those differences in uh in health and the determinants of health where they are negative where they're, where they're harming people's health, where something could be done about it to improve things. So the information would be used. So basic data turned into information to be used to plan and evaluate interventions to prevent illness and to manage those patient's in who disease is ready to developed. So my contentions would be and you may not agree. But as a, as a medical student, I think as most of you would be or as a a recently qualified doctor, my contentions be epidemiological information is just as important as clinical pathological findings. So there you go. Now, part of that, you may want to argue with that perhaps afterwards. But part of that is a simple thing. For example, if you know that the disease is common, so common things happen commonly and you're setting up, you've got a patient sitting in front of you. So one doctor, one patient, one medical student, one patient and they've got lots of symptoms and you examine them, they've got lots of signs and then you produce yourself and for the patient, a differential diagnosis list. So you're going to put the ones that are the most likely at the top of your list because they are the most common. How do you know that them most likely because you're using epidemiology? Okay. So if a patient comes in um with a runny nose and sneezing, the most likely diagnosis is that they've got to come to the common cold. The second most likely diagnosis in 2023 is that they've got COVID. So, and in some areas where there's COVID and nothing else happening, you might put that as number one, but you're using epidemiology even though you probably don't think of it in that way. Um And, and more complex set of symptoms get, the more you'll be using uh an understanding of the pattern of disease and how well things are more likely to happen or less likely to happen. And the more specialized your practice, the more likely you are to be seeing things that are rarer that other doctors will have referred to you to, to diagnose or to treat. So you're looking at a tip of the iceberg in terms of epidemiological pattern of disease. Anyway, so that's my contentions that uh epidemiology is pretty important. Okay? All right. Uh So I'm going to use the pandemic that quite a lot of the examples throughout this talk because it's incredibly useful to do. It's pretty much recent live data. Um And why not use it to teach? Uh And all of you have had some experience, experience of living through the pandemic. So if you want to apply epidemiology during the pandemic, people have done obviously since beginning 20 at the end of 2019, beginning of 2020. So what population do you want to look at and why you didn't decide? Is it your local town? Is it a smaller area within a town or a city? Is it a whole country. Is it a region uh whatever, what do you want to explore? And again, why? So examples might be, you want to look at COVID 19 cases or do you actually want to look at the prevalence or incidence of the virus or do you want to look at um people with particular other conditions seemingly either related or unrelated to the pandemic and their admission to hospital, for example? Or do you want to look at the impact of homelessness uh during the pandemic or of addict addiction or of inequalities or any other factor? Uh You have to decide what it is you want to explore and why to use the data sensibly, you can just look at it without the Y but my content, my, my really strong argument. But again, if you don't know why you're looking at it, then you're just playing with numbers. Uh And that's probably not particularly valuable. So it's always good to have a question as to why you want to look at the data. Why do you want that information? So you might want to look at the prevalence, incidents, mortality or other outcome of disease or other factor here interested in? Are you comfortable with those chances you have to do? We know what prevalence and incidents? Uh If you're not sure, tell me, go through that, I'm hoping you will be quite happy with those terms. If anybody's not done very much studying yet, you may not be comfortable. Nobody's saying anything. So, I'm assuming you're okay with us. All right. Okay. And just one question here, it's a pit fall. It's a, it's a whole that people fall into. When is the know prevalence, say over disease or the, or is instance not the actual prevalence or incidents? We fall into this a lot in the UK. Uh, and probably everywhere else as well. Anybody want to tell me what, why, when, when do you think the known prevalence wouldn't be the actual presence of anything not necessarily about, about COVID 19 of any disease? Nobody volunteering your hands. Um Okay, I just go for it, please as it uh thanks for happening uh from some places that south of States of uh a place around the All right. Thanks to you. I said your father uh staples number of uh this, this is uh southwest too. Uh Just the Publix and the Republicans. Yeah. I'm sorry, I don't know if you, if anybody else could hear that better than me. I've just been turning my body up to, to try and capture what you're saying. Hannah. Did you hear that better than me? Because it was very distorted. Yes, I didn't catch all of it as I'd make it if you try again or if you want to write in the chart, I do. And if you want to try again, closer to the mic, but that will type it in and, and suggested Yes, I was saying about the sleep uh fine. Where at the state of the gallon? So the Nipah virus was, yeah, you said you think it's not, you think the know prevalence isn't the same as or incidence isn't the same as the actual. Can you just explain why? So the other people does, many people know even they're scared of it and you know what it really goes so many. So you could responsive that, that any person it might just smooth or both of it. Yes, because yes, it's a simple call for some concerns with difference between uh the same deadly, right? So people just run away from the uh sometimes, you know, with false cases and the small spaces with the admitted would be uh rewards. We had the real cases and then the false cases with that uh affecting the pieces have become, are set is to instead of being discharged. Okay? I think I understood that. Um and it's about case detection, I think, is that right? That you say some people don't actually get as far as getting medical care. Absolutely. Um And that certainly applies to communicable diseases like the the virus that you've suggested, it also applies to many other uh non communicable diseases as well. Many of the long term conditions uh that people present with very often, are they present late. Um for example, or not at all until there's a critical event. So, so I think you're very, it's a good uh example to use an infectious disease. But I would just want to remind us all that actually, probably one of the most common conditions where the know prevalence is. Well below that, the actual prevalence is, for example, it's as I say, it applies to lots of diseases, it applies to hypertension. So a lot of people don't get that BP checked because there's not a routine system, either in their country or in their local area or having their BP checked. And the first thing that they know is when they have a critical event, they might have a heart attack or stroke. So the HIV uh certainly. Absolutely. Likewise. Yes. Again, another communal disease. But yeah, absolutely. So there's a lot that are really just bringing that out because a lot of people rely on prevalence or incident. So prevalence is, is the no um pattern of disease at a particular time in a population and incidents is the rate of new cases coming along. And both of those are quite commonly under estimates of the reality and that's what what we're talking about. So, just to be aware, so that if you read somewhere that the prevalence of say even type two diabetes very much under diagnosed in many, many population, many communities as well as communicable diseases as you said, um and hypertension and lots of other long term conditions very much under under reported. And sometimes you get very strange differences between populations and they're not real. So just, just to be aware that the name prevalent doesn't necessarily reflect the actual prevalence for instance. So I won't go on about it anymore. But thank you for, but thank you for your examples which really helped. But it's more a caution, just a note uh that uh that we're aware of that. Okay, let's keep going. I do. Okay. So the other sciences that we use is demography and that's a study of statistics, including birth deaths, migration, which illustrate the structure and the typical stability of human population. So that easy. So for something like me, it's really interesting as well. Um but it shouldn't just be interesting, it should be okay. Well, why is that important? So the distribution of populations can be defined at different levels. So again, like epidemiology, looking at disease, this is looking at populations either locally at a very local level. Um So in a village or town or, or even uh an institution like a hospital or school um right up to regional national global levels. Um and the boundaries that you place on your population can be political, economic, geographic, whatever boundaries you declare. Um And as long as you can collect data about that population, you can conduct demographic study on it. Um So the two go hand in hand, you can't really make much use of epidemiology without understanding the underlying demography and the demography will tell you a lot about population but less about diseases which, which is where epidemiology comes in. So, so that it's science. Okay. So I'm just, just a few examples. Life expectancy at birth in the UK. Um this is a slide that was published, I think, yes, based as published in 2020 based on 2018 projections. And you can see a slow uh kind of steady increase in life expectancy for men in the UK, live shorter lives than women on average uh when measured as life, especially birth. But what's happened? Anybody know what's happened in the last two years? Does that change? I don't have that. I couldn't find the graph. I'm going to be looking for it. I can assure you um anybody know what's changed in the last two years, that projection is no longer true. Increased. Indeed. Yeah. So the absolutely correct. Thank you. So the increase in life expectancy seems to have been flowing down and eat and it looks as though it may even be reversing. Now, what have, what in a way? It's a kind of a, so what question if your life expectancy of birth is uh 85? Does it matter if it goes down to 82? 83? 84? Actually? Yes, it does. Um And the UK government is now beginning to look again at the, for example, at a, at a macroeconomic level as to whether the change in the pensions age, you may have seen in France they recently changed their pensions agent. A lot of, uh, anger expressed about it. The UK has also been changing its pensions age and now looking at whether maybe it shouldn't be going to 68 prevention age, maybe it doesn't need to rise much about 66 where it currently is both men and women. Uh, used to be 65 for men and 60 for women. That's changed in the last decade. It's currently 66 for men and women and it's due to go up to 68 by 2040. It would be interesting to see what decisions are made in the next little while. But that drop in life expectancy and certainly drop it, the increase in life especially that actually looks like it's becoming a real drop will be looked at really carefully. Part of it obviously is due to the pandemic. So it would be interesting to see how much of it remains over the next decade, see what direction it goes. But that's really important piece of demography and apply to fiscal, national economic fiscal policy and just bring that in as an interesting something. The other thing that we've we see in the UK is life expectancy. This is the men. Um If you look at that, what do you, what conclusion might draw from that graph? The highest life expectancy is the darkest blue, the lowest life expectancy is the green. Can you see a pattern there. You're looking at health inequalities, staring at it. We haven't, uh really willing just to tell me what you're seeing. Uh, excuse me, the, the studies and the hill and maybe I think somebody expect this unit and, and actually squished. You're breaking up horribly. I'm sorry, I don't, I don't get your mic against the other people. Life expectancy of people living near to the, uh, the south. Yes, much higher than uh indeed. So like many, many other factors uh when it comes to health and epidemiology as, as well as demography, the life expectancy shows a uh a pattern where the south of the country is does better than the north. So we've already got women living longer than men, but we've got men and women in the south of the country by and large living longer lives than in the north. Uh And there are lots of explanations for that, which is another story that electoral epidemiology and a similarly but slightly less obvious pattern in women. This is of course, pre pandemic, but the patterns are still there but longer lives aren't necessarily the same as healthy lives. You probably will. This is obvious really. But it's important to, I think to bring it out. So if you look at healthy life expectation seems to the yellow band um that hasn't changed hugely. So what we're seeing is uh or uh women in particular life length of life increasing. So your life expectancy at birth has increased, but largely due to an increase in years of ill health, which by and large we don't think is a good thing. Most people would say if they want their lives to be longer, they would like them to be longer in good health. Most people, if you ask them in middle age or young adulthood, once people get to older age, many of them will say, well, we want to be here anyway, very few people, very small minority people who don't want to continue to live uh who still have the capacity to make that to have that opinion. Obviously, a lot of those people in very poor health no longer have the capacity to tell you whether they want to be alive or not. Uh But uh but many of us are living longer but in poor health, which is not uh ideal by invades, there's a lot of work going on now worldwide about improving health during those longer lives. Okay. So, moving on to the pandemic, this is the first uh wave of the pandemic in the UK, which really started March 2020. Um And I just thought I'd bring in something about this to show how that uh how that panned out. Pamela have a pandemic panned out. So, what you've got here is that is the blue lines are deaths happening um for any cause other than COVID being recorded. And the orange is where COVID was written on the death certificate was included. There were a lot of people who died of COVID during that first wave where COVID wasn't recorded because there was very little testing going on and a lot of people were dying and particularly own elderly people or very elderly people. And COVID just simply wasn't corded. So the data is of limited use outside of hospital where the diagnosis was much more likely to be made. You can see that far more deaths attributable to, to COVID. Um But if you look at what's happened, um you can see that there were more people dying at home uh than the dotted line, which is, which is the five year average. And there were more people dying in hospital and they were more uh and they were um actually overall less people dying in uh in hospital other than the big peak uh in uh in April and May 2020 where enormous others with people would, would be admitted to hospital in very, very sick and dying. So what was happening was that more people were dying in care homes, which is then permanent place of residence for almost for many elderly people and at home. Um and the winter center, it's um it's part of Cambridge University. We did a quite a lot of work on why people were dying, why we're more people dying at home. And you might want to tell me what you think about that, why we're more people die at home of non COVID uh diagnosis. Any ideas and indeed in care homes have not okay. The diagnosis. Lack of availability of the, yeah, cases of the pool, which is so much that we're not no beds anymore for new incidences. Yes, that was, I think, I think we think that, I mean, you know, until there's been even more analysis down on this, we don't know. And it's got to be hypotheses. And that's certainly one of the hypotheses is that people couldn't access hospital and therefore, couldn't access healthcare and died at home or couldn't access secretary care. Another hypothesis which I think is equally credible. Certainly in, uh in the UK, the government was encouraging people not to use healthcare, it was saved. The NHS was, the number one priority was just to save the NHS so that the NHS could support people who were very, very sick with COVID and keep the NHS running. I'm sorry, they're saying not to use the healthcare. They don't make the same not to use the thing. You don't go to the doctors. So the two, the two arguments, the one that, that I think you put was that people couldn't get into hospital, which is perfectly reasonable as a hypothesis and certainly true to an extent. And there were many people who couldn't access healthcare, but there were also, and we don't, I don't know, the numbers were equal but the other hypothesis. And I think it's probably a bit of both. For the reason I think almost sent me is both was that there were people who were avoiding using hospitals, partly because the government, the government didn't want them to use healthcare. That was the message coming out loud and clear was to leave the hospitals for people who were really sick with COVID. So if you were just becoming ill, you might, isn't, that was just, the government is saying if you're sick, be suggest God just say that again because you break out. It's uh scandalous or I would say it's strong when, when you're sick and the girl were just saying, basically, don't get, is that okay? Very scared. I don't know if I want to start to call it a scandal because there were many scandals associated with the pandemic. And I'm not sure that that was one of them, but certainly it was one of the impacts of the messaging coming from government was that people would avoid using healthcare for two reasons. One that the government was telling them to save the NHS for those people who needed it for COVID. And the other was that many people were frightened to use healthcare for fear of catching COVID and they felt that they were safer at home. So there are a lot of people who didn't present for medical care for healthcare when they would have benefited from it. There were many other people who went into hospital who then caught COVID and may or may not died as a result of going into hospital and catching COVID. So I don't think so much of a scandal as a really difficult situation where the health system actually was overwhelmed to a very large extent. Um And many of those people who stayed at home, so we're only looking at mortality here. So what we're also seeing in 2022 2023 is people with delayed diagnoses who have survived that they're not part of these data, but they're presenting late with very often very very significant diagnosis, particularly of cancer and heart disease who may well have shortened, have shortened life expectancy because of delayed diagnosis. And we're seeing a lot of that as well, uh particularly with delayed cancer diagnosis uh resulting in uh incurable disease that otherwise may well have been amenable to security treatment. So it's a really interesting mixed picture uh due to the different uh different factors. And we don't know which factor was, I don't know if there was one more important factor than others, probably not, but it was a whole mixture of these factors of people avoiding healthcare for different reasons and the system not being able to cope with providing healthcare um during that period. Okay. And this is simply the same, this is the same data but broken down into, into numbers more uh more easily. And you can see uh the greatest uh mortality rates, uh, were amongst the elderly and the very elderly, um, which probably would expect with hindsight, we know that perhaps the case for COVID. Um, I'm sorry, this is the age one, the other one's case of 10. Okay, let me move on. So the other thing that I want to talk about before we leave the sciences, but we're really moving into the arch a bit is about avoidable mortality. So the definitions of so avoidable mortality makes an assumption that not everybody who dies really needed to die at that particular time. Okay, we know that life and death are are definitely no, no that every one of us is going to die. But avoidable mortality is about people die prematurely because is that might have been prevented or treated effectively. So these are the definitions which I'm hoping you'll find quite useful. So, avoidable mortality is divided into preventable mortality. So those of deaths that could be maybe avoided through public health measures and primary prevention and treatable mortality debts that can be avoided mainly through healthcare interventions, which will include secretary prevention treatment treat. Okay. So the latest data that's being published just the 2020 which obviously was uh the first year with pandemic. So I've given you hear the comparison with 2018 because it seemed worthwhile doing that. So it's a huge proportion. I don't know whether any of you would have thought I should have probably asked you how many deaths what proportion deaths you think are, are avoidable. But looking at these definitions, these are official figures from office for National Statistics uh in the UK. So these are not made up figures. These are, these are figures that have been arrived at applying these definitions. And uh so we're talking about almost 23% of deaths were considered to be avoidable, which I think is quite huge. I don't know if you think it's huge. It is. Um So getting on for a quarter of death, uh that's a little bit higher than in 2018. If you look at the total number of deaths, it's very significantly higher as well. So in uh in 2020 largely attributable to pandemic, but also to those other deaths that happened that for which people didn't go to hospital. So and the difference between and the and the breakdown uh 2018, the breakdown, I couldn't find the breakdown yet. For 2020 I don't think it's been published yet. Um So of the avoidable, less than 2018 64% were considered preventable. That's that first category and 36% uh for treatable conditions, the roughly 2001 3rd. And to note that COVID 19 for this, uh under this definition has been assigned as a preventable cause of death in people under 75 but not in the very elderly. Uh not that elderly, not in people over 70. So that's avoidable mortality and a lot of it. So we talked about nearly a quarter of deaths being considered be a good. Um And this is a pattern again, just to show you a little bit more inequality where the death rates are higher on average as you go north and to some extent, uh west but very much more south distinction. The gradient. Okay. And in 2020 you can look here over the last decades, two decades, the avoidable mortality was beginning to come down and flatten out. And then 2020 has thrown that out again. Pushed it right up again. So the avoidable deaths in 2020 were higher and had been seen for the last 10 years for the previous tendons. And we're watching with interest to see what the next year and to bring up. Unfortunately, the data takes quite a while to analyze and produce services. 2020 years. I sent it to the latest available. Okay. Moving on unless a bruise got any questions about art, I'm going to move on to science rapidly. No, I'm moving on to art. So sorry. Okay. Why aren't as well as science? Okay. So scientific evidence is absolutely essential but just not enough insufficient on its own. So, data analysis, intelligence vitally important but they very rarely make a difference. If you just present data, it's analysis, intelligence drawn from data to people who make policy decisions, decision makers, politicians, policymakers, they rarely make a difference. They can. So that sounds interesting. But what we do. Okay. So what other agreements are necessary for good health improved outcomes? So let's quickly look at the art. Okay. Have you all seen something like this diagram before? Dark, dark green and white head? And you haven't? Okay. So then we need to have a talk about inequalities. We'll do that another time. But these about the determinants of health and if you haven't had this before, really important and basically, you've got your individual who's got their own genetic makeup and their own age and ethnicity, determining their health. But on top of that and increase and incredibly important or not only their own lifestyle factors, but they're the social factors around them, their own community, whether they work, whether they've got access to clean water, whether they are educated, whether they've got safe housing, safe communities, what the agriculture and food production environment is like and even a bigger layer above that surrounding all of us is socioeconomic environment, cultural and the built and unbuilt environment all around us or define our health as individuals and, and as communities, incredibly important. And uh that was a piece of work that was done all those years ago and still is important. So where this brings this out, it's really important piece of work done by funded by the Robert Wood Johnson Foundation in the United States is telling us that clinical care. So what we get from healthcare contributes 20% to our health, whereas our behaviors contribute 30% and even more important socioeconomic factors, 40% of our of our health is determined by these other things which are actually nothing to do with health on the, on the surface, but are hugely important for our health and 10% to the built in Ireland, including quality of the air that we breathe. So really important breakdown. And hopefully that to me, that kind of makes that previous slide for those who are not so keen on pictures. This brings back, brings back a little bit more of the science again to show how important all these other factors are to our health, both individually and to our population health. Okay, a little bit about inequalities again. So in accordance by definition, we're talking about here as, as art, okay, they're unfair. There are avoidable differences in health across the population and between different groups within society. They arise because the conditions we were born in, we grow, live work and aging and these conditions influence our health and our opportunities and potential for good health and how we work and age and live uh in society. So okay, any policy up in different groups, I think we probably could do with the whole session on equality, but I put it in just so it doesn't get lost between groups within a population could look like a status. So life expectancy, we saw those previous graphs differs between different groups within the population, even different geographical areas within a single country like the UK. Um it would affect, it was prevalence of different kinds of conditions. Behavioral risks would be different depending on whether you really part of the population or the community, which is a smoking group or a non smoking population. And again, that varies tremendously within between communities. The wider determinants if you have access to good secondary and tertiary education, the chance the probability is that your health will be better than somebody than the community where where education is relatively poor, difficult to access. Likewise, the quality of the housing and your environment in which you live. So poor populations by and large have poorer health. We know that for a fact. So that's why, that's why inequalities the term is used on the basis that which is fundamentally unfair and then not forgetting that people's access to healthcare itself, even though healthcare, perhaps you could say as a minority player, but pretty important, 20% of our health is determined by access to healthcare. If you don't access healthcare, the chances are your health experience is going to be worse. Um So Michael Marmot has done probably the most worldwide to bring to raise the awareness, our, our awareness and the awareness of politicians, the world world over to health inequalities uh wanting to go in there. But if you want to read his written lows, his review of 2010 is on is easily accessible. And a review of that was done 10 years on in 2020 unfortunately, shows how little progress has been made. And certainly in this country in the UK, where I'm sitting our inequalities got wider in that decade uh rather than narrow, which is really pretty bad. Um and accounts through some extent, at least a significant extent to why our experience of within with the pandemic has been much worse than many other quite similar wealthy countries. Okay. So healthcare inequalities, unfair differences in access to uh to benefit from as care provision and almost always associated with other inequalities. Okay. So to finish, I think, and hopefully we've got a few minutes. Good question. I think I've tried to help you chance to see that we've, that we're seeing a lot of avoidable deaths. We see a lot of avoidable ill health. So that's really quite depressing. Lots of inequity health inequalities. Nevertheless, that's an important role for health services, for healthcare and for the clinicians working in the health service to have that understanding of that bigger picture of population health, public health. There's an important role, as I've said, the non health services and other sectors, 80% of their health is determined by these other sectors, health inequalities exist the world over and even within countries and even within cities, we see huge inequalities which is still tolerated and there isn't the outcry, there isn't a scandal about why we put up with this and they should be. But that's a lot, that's an opinion on making a judgment. We need those science and art to change things, to convince politicians, for example, and policymakers that things are worth changing. Healthy population is a more productive population and the wealthier population. But it takes a lot for a government to recognize that and do something about it. And ours in the UK is one of the most unequal populations uh in the, in the, amongst the uh the rich countries that were running. Um So having a public health mindset and a voice uh to help to move things forward, I would suggest is she important and hopefully assumption in your views as well? Okay. So this is just to remind us really, this is quite a nice quote. I think part of the fact that becomes from Uk's first female doctor, it just reminds us that we are all as doctors, uh responsible watchman, guardians of life and health of a generation. So it's not just about, I want one relationship with patient. It's about understanding and speaking out about health or our population's. I hope you don't mind me including that. Okay. Any questions I've added a couple of references. When you see the slides afterwards, you can check out. I've only put in three, I think rather than burden you. But there's hundreds that people look at any questions about about five or six minutes. I think I'd love to hear from you. Any questions, comments, disagreements, anything you like looking in the chat to see if I missed him? No, gosh, you put it in the chat. If you don't want to ask out loud, looks like hella, I don't think anybody unless embassies writing right now. We're more than happy to have a question for several. Okay. I mean, that's very small group, shall I have to say? Put it in the chapel? It'll speak up. Hopefully you found it useful. Hopefully, find it interesting. And if not my apologies, uh look, we'll just see me again and I wish you all the best in your studies and um I think I'll finish that. There's no more questions. He sure is. The last minute she had a difference for many, many years. Uh She, she was the last styles of the solar buildings you want to see the previous slide? Uh the last, the lifestyle, the rift. Yeah, that one. Yeah. Thank you. Ok, pleasure. It's