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Uh w um so, so if you want to start coming up while I introduce you, that would be great. Is a Dermatology registrar at Saint John's Institute of Dermatology and honorary lecturer at King's College London. She obtained a phd on stem cells and regenerative medicine at King's and is also dedicated to global health Dermatology. She is co-founder and trustee of the Burner Skin Care Initiative of UK Registered charity, the commission to promote excellence in skin care for the people of Myanmar. Thank you so much. I use, I use, how about the online? Ok. Can you hear me? Yeah. Great. Fantastic. First of all, thank you so much for your infectious enthusiasm and passion for global health and setting up the scene fantastically. Well, so I'm going to, that's the end actually. Could I have the first slide, please? Great. So we'll go back back. Fine. So, first of all, I'm not a global health expert, but I do have a story to tell and I really hope that you'll find it interesting and it's a story very dear to my heart and it's an initiative, very dear to my heart. So I will talk about dermatology and global health, the burner skin care initiative. So as disclosures um co founder and trustee and also the Yes, I, as I will refer to the child is funded through corporate social responsibility and other academic ones. And uh I will show quite a lot of patient images which of course I have the consent but please do not take photographs of the patient images but do take lots of photographs of the other other life. So this is what I aim to cover in the next uh 45 minutes, which is such a luxury. Thank you so much for that awful time. So I'll set the scene about Burma or Myanmar and how we founded the Burma Skin Care Initiative charity, the BSI journey and achievements to date and also how we turn challenges into opportunities during the time of the three CS, the COVID, the military coup and the Civil War and the concept of essential emergency skin care that we have innovated during that time and how we have applied what we've developed for Burma to other countries such as Greenland, Armenia and South Africa. Um And how, what we do is relevant to the NHS. So hopefully we can address some of the questions that audience asked earlier. Burma. I don't think II need to convince you that it's a beautiful country. Of course, I'm very proudly biased and um it's not, of course, not as well known as Thailand for instance, but it is a, a country in Southeast Asia. It's now known, known as Myanmar, but I will use the name interchangeably Burma and Myanmar, which is a huge topic for most people. And it has mountainous regions in the north and very hot flatlands in the middle with sort of the underman sea uh coastline in the south. So what it means is that the sort of skin disease pathology that you see in Burma are very diverse and it's a large country about almost three times the size of the UK. And um there are 55 million people with more than 100 and 30 ethnic groups. So really very diverse, beautiful, once upon a time, one of the richest countries in Asia. But sadly, now one of the poorest because of this over 60 years of military dictatorship following gaining the independence from the British in 1948. Recently, there was at the British Museum, there was a to my exhibition, I don't know if anyone actually had a chance to see that, but it really had me in tears very powerful. So because of the systematic disinvestment in healthcare, education and infrastructure in the country by the military dictatorship, of course, it's uh one of the poorest healthcare systems in the world. And indeed, you know, as uh you know, Jack touched on there is the, the VH OS NCD agenda and of course, one thing that does combine all of them is the skin disease. There is no condition that skin disease doesn't have relevance to. However, there are only three dermatology centers in Burma and currently only about 30 dermatologists serving the whole country, 55 million people. And yet they are concentrated in, yo, that's the economic capital. Um With where the red triangle is and also man, which is the central with the golden triangle there. But this is sort of the current situation. But in the past, there were about 90 dermatologists before the military coup and the COVID. So you can imagine that all these 2 million plus um internally displaced persons, they have almost no access to skin care at all. So huge unmet need. But why am I actually doing this? I'm a, you know, senior dermatology registrar, like academic background in stem cell and gene therapy. I was born and bred in bur but why am I doing this? So a little bit about that reason. Really? So I was born and bred in, in a village called, that's the longer Delta. So this is the the aorta of the country. So the longest river running from the north to the south. That's why the soil is so fertile. A lot of farming, um important resources, natural resources. I also grew up little bit in between the age of 9 to 15 in Yangon. So really chaotic city and in 1988 to 1996 there were two major uprising against the military dictatorship. With a lot of bloodshed in the streets. So one thing that that does lead to poverty, of course, is politics. You cannot be not political or you know, um uh be cleared away from politics if you actually are involved with global health at different levels. So in 1988 I was uh in my primary school and I still recall how the schools were closed down, the medical students were shot to death in the streets. Similar thing happened, but not to such a big extent in 1996. So that's when one of my dad's uh school friends came to visit Burma and he very kindly sponsored to um to gain education in the UK. No one would want to leave your family and friends in your to another country. Why would you want to do that? And of course, it is a matter of survival and it's a matter of uh opportunities in life. So I was fortunate enough to end up in, in 1997 the oldest town in Wales. That's why I went to secondary school G CSE A levels. So of course, that's always sort of understood and appreciated what it means to have life opportunities. So I want to give something back and having a dream. You know, as Jack said to, to have an idea is one thing to be able to materialize that is another level. And as luck would have it or serendipity, whatever you call it, I met uh Professor Chris Griffiths who's in the audience, a really privileged to have him as a guest here. And I met him in 2018, out of all the places in New Orleans in Orlando at uh a dermatology conference there. And as you do, not in the conference room but outside of the conference room, when you really network and actually talk about, you know, creative ideas. That's when I spoke to him about my dream to do something for Obama within Dermatology. And uh so I invited him, you know, the professor Chris is within, in the world of dermatologists, nobody who doesn't know him. And of course, I was still a junior sort of um um fellow in dermatology. And I invited him, would you like to come to Burma to visit the Dermatology centers? And he said, yes, and seven months later, that's where we ended up in Mandalay General Hospital during the war. So l is the Jones of for her. So that's another professor as the another. So she and the team, um we literally landed the day before and then we in Yangon and then we flew out to Mandela the next day and as soon as we arrived, that's what we did, you know that fori I love it. And uh um and of course we did the war round, the team was fantastic and we saw lots of patients and one thing to emphasize about global health. You know, just to emphasize again about the importance of non communicable diseases. You know, we're not just global health is not synonymous with topical medicine. In here. Of course, we saw infectious diseases, my to deep f fungal infections, but also really severe autoimmune blistering skin conditions such as pemphigus, vulgaris, a rare variant. And then we saw sort of end of, you know, extremely severe psoriasis who have not been cared for with comorbidities developing such as cardiovascular disease, diabetes and all these um you know, systemic manifestations and associations with inflammatory uh skin conditions. So this is just to illustrate the very rudimentary facilities that we have in in Mandalay. And that is meant to be the third largest dermatology center in the country. And that outpatient is actually the outpatient, not the waiting area, which is the backyard of the hospital. So no privacy in all the that we have the privilege to value and practice are somewhat challenging out there. And then after Monday lady went to general Hospital. So the lady in, I don't know if there's a pointer, that's it. So the lady in in Violet. So this is professor, she singlehandedly trained most of the dermatologists in Burma and she set up the biggest dermatology center in the country. So fantastic, you know, people really enthusiastic like dry sponges, um you know, for learning and um and collaboration. So important. First message is about understanding the groundwork, the lay of the land rather than going in there inflicting an idea and actually being Burmese myself, um I have the unique advantage of understanding both cultures and and being the bridge in in that gap. So we sat down with the local dermatologists and nurses and identified variously skin care axis and you can see it's pretty much every aspect. And of course, this is our motto, turn every challenges into. So how can we actually address these? And with that in mind, we came back to the UK in early 2019 and we thought, how can we best really make it sustainable? You know, we can't just sort of go out there out once in a while and do teaching that's not sustainable. That's the thing of the past now. So we then founded a charity, a childcare Foundation trust called the Burner Skin Care Initiative with a vision of providing equal access to quality skin care for the people of my, built on three key pillars, clinical research and education. But of course, at the forefront of what we do, we've got three main principles is to ensure sustainability, equitability through partnership. So that is really very big and very ambitiously. We drew the 10 year big vision plan strategic plan and just to illustrate you feel short, medium and long term. And ultimately, our long term vision is to develop and establish a regional dermatology training and research center akin to the one in Tanzania. So literally within a matter of nine months to a year, we achieved all those in green boxes. So for instance, the first inaugural um international Dermatology meeting was held in that. So I'm just gonna take you through the key highlights. So one of the first things that we were able to do for the first time for the Dermatology registrars and young consultants is to provide fellowships uh through uh a sort of fair competition um so that they can uh attend international conferences. So these two doctor fly doctor then register from General Hospital. They attended um the European Society of Dermatology meeting in bordeaux. And for that was the first time they were able to enter a fair competition and actually brought the fellowship and they were really very um inspired by the international collaboration that networks that they attain. And we also had the um doctor A and doctor G um for fellowships to come and observe in the UK. But because of the coup and the, the COVID, they were unable to, to come over. So this was really fantastic back in 2010, 20 early February, um literally, so towards the end of February, just before the pandemic started, we held the first ever international Dermatology meeting in Burma and we flew out UK dermatologists and also those from uh Germany and had four day long conference and the first day was dedicated to the nurses only. So that was the first time that nurses in Burma had the first ever opportunity to have any educational or uh professional meeting. But the key was to have sustainable sustainability roundtable so that we can identify what actually matters to them. And um during the trip, we also went out to the uh various orphanages and township hospitals. So literally at the, you know, southernmost town um of Burma. And that's where a lot of migrant health population from Thailand sort of move in and out of Burma. And we visited uh a general hospital uh where there is only one physician looking after a population of half a million people with 100 bed hospital. So really quite a lot of our means. These are nuns at that. We saw these are, are all things from um who lost their parents in the Civil War that's been going on since the, the British had left the the country. And of course, we saw a lot of uh non communicable diseases such as eczema, but also uh scabies and, and infectious diseases too. So we wrote about it. We've published articles about uh initiative and also Deborah. So this is um dystrophic epidermolysis for a rare Genetic Skin disease charity that I uh based a lot of my research on. So we've collaborated with them to talk about the importance of rare genetic skin disease in low and middle income settings as well. Now, importantly, I'm so really proud about this because, you know, uh thanks to Professor Chris Griffith, who he's part of a lot of um dermatological organizations and with, of course, very Chelsea and Westminster, very young. Doctor Claire Fuller, he's a consultant dermatologist here and Doctor Ruth Murphy and Tonya. So who were the presidents past presidents of the vicious Association of dermatologists with their crucial uh leadership, we were able to use the BSI as an exemplar to put derma global health dermatology or global skin skin health on the world's agenda. Prior to that, there was a global health agenda in any of the key committees or meetings. So, from local British associations to European societies to even the international level. So that's been really very worthwhile in bringing global health to the world stage in the world. It's not advancing for some reason. That's fine. I try a little bit stuff. Um Yeah, let's try that. So the other part was, you know, a little image of us at um it's a monastery again, these are all as well brilliant. Thank you. It magic touch. So, of course, it's the, you know, ultimately, we would like to set up a regional Dermatology training and research center in Burma. And in order to do that, we went to visit says Terence Ryan in Oxford, who actually set up the um regional Dermatology Training Center in Moshi in Tanzania and he's given us the blueprint which is still sitting with us due to various um unprecedented challenges. So in March 2020 so we had a lot of projects in great moving at a great momentum. But March 2020 came, the first wave of COVID-19, everything was shut down. Of course, we then how to turn all our projects um on hold. But also turning and prioritizing what key projects we should be pushing forward and how we can really uh rethink about our objectives so that we can help manage the pandemic situation at the time. So of course, shortly afterwards, there was the military coup um that took place in Burma and the clock really turned back more than 60 years. So we had a bit of pseudo democracy between 2011 to 2021 under the leadership of Franco Su Kyi, who is still uh who was in prison following the coup and now she's under house arrest. And this time around again, the medical professionals took the leadership um to protest against the military dictators peacefully in the street. But that was met with um with the violence and murder essentially and the already fragile healthcare system collapsed completely. So all the hospitals were turned into military base occupied by the military dictator, uh the soldiers. So really infuriating, you know, on a personal level because I still have my family out there. But of course, for what we're doing with the Burma Skin Care initiative, there's a lot that we have to overcome and we think with our challenges and uh may I ask you for your touch again, please. Should, should I sort of we do the wait, am I pressing the right way? Yeah, two hours. Great. So this is a website that actually takes count of how many healthcare professionals as well as political prisoners are uh affected by the military. Two. So I started, you know, one of the, the a couple of talks that I gave back in March last year in November, you can see a dramatic rise in members and this was taken on the eighth of May. So from 100 and 59 people killed by junta in March last year, it's gone up to almost 5000. And I'm sure since the eighth of May, the number has gone up still. So this is a real problem. We are talking about healthcare professionals being intentionally killed, targeted. Of course, we hear about that between Israel and Palestine. And sadly, not every crisis around the country make it to the world's new stage instead of helping its people. The military used the um weaponized the COVID against its own people. So following the flu, there were two governments. So the military dictatorship and the people of elected national unity government, this parallel government unfortunately is in exile. So that means that they are operating outside of the country. They do have presence on the ground but not in a, you know, they cannot be in an obvious way because otherwise they will be targeted. So what we first did following the coup was to join forces with that health and education trust because we have a colleague from who's the lead of uh that firmer doctor, who's a colleague and friend of ours. And she then held together, brought together the colleagues around the UK and burner. And it's formed four different working groups, advocacy, communications, education, and fundraising. And uh we had the opportunity to really bring dermatology and the importance of skin disease to the before we meant during the COVID pandemic that, you know, CD stones, just because COVID is there, except that the resources have shifted dramatically. And then we sort of had to catch up with everything else. And now let's not make the same mistake twice here. So let's start from the beginning plan carefully how we're going to sustain the skin skin care. So photographers chair, the advocacy uh and communications group, we brought the dermatology to the fore and also really came up with an innovation of this concept of essential emergency skin care exactly as I as I described earlier to treat all these essential and emergency health service, skin care services to be sustained during the crisis. And of course, that's derived from Professor Tony Redman, uh founder of the UK Med and I see that somebody from the UK med is speaking as well. So that's fantastic. So he coined the term of essential emergency medicine or health care doing exactly that. And um through the advocacy and communications. We managed to write about it. Um you know, provide a solidarity to our colleagues in Burma. But of course, it's just challenging when you get into politics. And we also work with high level um high power individuals within the Parliament House of Lords as well as the International Court of Justice. But I have to be very mindful because not, not to uh put my family and friends into jeopardy as well. So what is essential emergency skin care? So we found that this on five integrated frameworks developing one page clinical protocols so that any nonspecialist can pick it up and triage common and emergency skin presentation and manage it as a so called first aid. So for instance, somebody coming in with blistering skin condition. So is it going to be autoimmune type or is it more of infectious diseases so that they can then manage and triage appropriately? So we've got 10 different clinical protocols developed for Burma. But interestingly the first country to use that is actually Ukraine because of the war in Ukraine. Professor Tony Redman's team, the UK MET team was out there and he knows Chris Griffiths and therefore we share the protocols with them and that's been translated to Ukrainians. And recently, uh a lot of the press that's going to be adapted for use in Tasmania as well. Webinars. We've got educational workshops and webinars, video workshops by the nurses about um basic skin management. Uh we also developed uh the first ever undergraduate curriculum, they adapted from the British uh curriculum relevant for local use along with first. And we do have uh a really exciting teledermatology platform that we are uh we've developed uh for Burma. So come on to these individual ones a little bit more detail. And if you are interested, we have written about the essential emergency skin care in the British Journal of Dermatology, published it last year. So clinical protocols are shared with our local NGO partners such as the medical action. Some of you may know the organization, they've got links with Mock and Oxford and the largest HIV um medical care that they are providing in Burma, the le mission. And also we've shared them with the Mr Gps and frontline healthcare workers. And as I, as I said, that's been shared with up. So one of the ways that we were able to make it relevant to the UK NHS as well is to get the junior doctors involved, you know, these things take uh manpower. So one way of me trying to sort of energize and induce the young generation to be interested in global health. Uh webinars are provided to the medical students, nurses and frontline healthcare workers by um the, the um expert dermatologist from the UK that says malaria, speaking about uh common emerging skin disease in Children nurses workshops. So we some more head from the British Dermatology or Nursing Group and Rebecca have been instrumental in healthy support for nursing education as well. And Professor M Singh has led the undergraduate curriculum development for Burma adapted from uh the UK that making it relevant locally. So tel ERM why did we set up Telm? So just to say that, so a little bit of uh spread of where the elder uses are. So these are where the M clinics are throughout the country. So all over and particularly in the northern state, it's sort of war RDD areas. So people cannot seek any specialist care at all. So that's been really immensely helpful. Now, why did we develop tender? We when we went out to to be in 2018, the words had gone out and various friends and, and colleagues were sending it images of uh Children uh with skin, severe skin conditions. And you can see, you know, from auto bullous skin conditions to rare genetic skin diseases, pigmentosa with really um you know, debilitating skin conditions and severe sis. So this is this boy would probably uh lose his. So who has an infiltrating tumor, basal cell carcinoma in his arm? So, and furthermore, we had during the pandemic, we had further images coming through. So we needed to develop a sustainable way of providing guide uh advising guidance to the, the two colleagues of them. So we um teamed up with consulting connect, which is the largest um one of the largest uh teledermatology platforms in the UK, you may or may not know about it and you may even use it and they have provided the app to be used uh for Burma Pro, which is fantastic. And so these are the sort of cases that we are seeing, you know, not just infectious diseases, but also noninfectious immunal um pustular melanosis and also really quite severe uh cases, but as well as sort of more ringworm, fungal infections as well. And um and just to demonstrate a wide range of pathology coming through. But another another fantastic thing is that these cases make excellent educational materials. So, you know, one of our aims is to have joint uh co case conferences so that we can learn from each other as well. We were able to provide more fellowship despite the COVID coup and the Civil War and more online uh fellowships to attend various conferences. We also held 10 weeks long um uh CPD S um on Psoriasis Masterclass um in partnership again with the International Council. So that's where we didn't just talk, you know, provide educational support for colleagues in Myanmar. Myanmar was one of the leads and involving Nepal Laos and Cambodia as well. So that was really a great success. Um We have ongoing research projects which we had to uh repurpose. So, rather than going out to Burma, this is Doctor Jim who was at the time Dermatology registrar. She's our consultant um linked in with the Liverpool School. Of tropical medicine. And she is now going out to uh Borneo to um to learn about the deep mycoses epidemiology and how we can apply that to them. We also had the plan to perform a skin disease survey because without these fat, you cannot negotiate with uh the government. Well, if there is a government, but you cannot make policy changes. So we needed to understand the epidemiology of skin disease in Myanmar. But rather than being able to go out to Burma because of several reasons, we then went out back to the global which is directed by Griffiths. We went out to Greenland Armenia in South Africa. So a little bit of uh snippets about the experience in Greenland. So really incredible um country of course, is uh less green than Iceland. Um So it took two days, you know, two plane rides and a helicopter ride to arrive at the Eastern Greenland, Tusla. So population of about 56,000 and um uh sorry in the whole of Greenland, but Tusla is 1900 a third of the population is under the age of 18. But you know, beneath the seemingly tranquil scenery, there's a lot of domestic violence, alcohol abuse, murder, and um and diabetes hypertension, the usual and a lot of non communicable for skin diseases. So we based at the Skin Health Center, we had a team of dermatologists from the UK Germany, but importantly, the local partners from uh from Denmark were out there. Is this to give you an overview of, you know, again, uh global health is not topical uh medicine. The, the the most prevalent uh skin condition was you had eczema. Interesting. So that's the sort of uh condition that we saw in and also very mild variety of psoriasis which we don't really see in the UK. So previously, it was thought that in the Inuit population there's no psoriasis, but that's not correct. So by being out there really seeing the people in the community who've learned that that's not the case. So that's actually been updated, a new knowledge game. We also went out to Armenia again, you know, it's a country not so well known. Um of course, a sandwich between Azerbaijan and uh and Turkey and then Georgia and the North. But fairly recently, there was AAA conflict between Azerbaijan, which is, has been ongoing uh between Armenia and Azerbaijan and it went through the 1915 genocide by, by uh the Turkish. And on the contrary to Greenland, we saw lots of varieties of, you know, great variety of um huge pathology from uh psoriasis, different forms to vitiligo and again aggressive skin cancer to Hidra ait subcu and now the inflammatory skin condition. But of course, it depends on the context. So we went to tertiary and secondary hospitals there as well, lots of genetic skin conditions. And um this particular boy he had, of course, it looks really sort of quite worrying for the parents, but it did turn out to have a rare form of lung and cell histiocytosis. But that is fortunately self healing. So we helped avoid it then from investigating too much into uh into underlying conditions. And this is the epidermolysis below the rare genetic skin condition that that I base my research on blistering from birth to death. And of course, part of the advantage is that you see the beautiful um landscapes. So in December last year, we went out to South Africa as part of the GPA of this team led by there Griffiths. And again, local partnership is key to professor NSA Lova based in uh East East Urban. She sort of brought together the local community healthcare workers. So for instance, you know, this was my team, we went out to uh two villages, individual households really um identified what sort of skin diseases are prevalent out there. And at the same time provided locally relevant help that they needed. So what I did manage to do was this young man who's uh you know, really smart, really enthusiastic and I managed to teach in five ch in conditions that we saw locally. And he was able to recognize our uh to eczema to, you know, rw to everything else. And um now, of course, there, there are so many uh aspects that we can actually bring back home and learning from the local parts and you know, one thing for sure, it gives you, it widens one's horizon, gives you a bigger perspective in life. We do have so many challenges, challenges in you and it has no doubt about it, but still one of the best healthcare systems in the world and this sustainable local partnership is really key. So if you're interested, there is the research handbook that we have uh written about the V SI and its challenges. And of course, we are constantly thinking about innovative ways to put skin disease on the world stage. And fittingly at Chelsea, we have a garden at Chelsea next week. So do visit us if you are around and if you would like some tickets, we, we may have one or two spa tickets left. But essentially um the garden is replete with symbolisms about the charity importance of Skin Disease and its partnership and its management. And indeed, it's, it is ultimately about providing equal access to skin care for people for bur but beyond that as well. So with that, I'd like to thank you all and, and if I have any time for questions, I'll be thank you so much for sharing that for today. Um Please do write any questions on the chat for those online. Um Has anyone in the room got any questions that they'd like to ask? You can just raise your hand and they'll come to you with a microphone. We did have some questions for you um that were sent in before the and one specific one you mentioned that there's only two dermatologists in at the moment and issues. How do you feel the training of doctors in the over the next few years? Really excellent question, you know, um you can do I need to speak because yeah, really excellent question. Of course, workforce is one of the key challenges. That's why we're working with different local partnerships. So that is one way for us to train the workforce. Not just it's, it really is about task sharing, you know, that's another concept. So sharing the knowledge, expertise and training, not just with the dermatologist or medical students or doctors, but also with frontline healthcare workers. So one thing to bear in mind is flexibility and adaptability are key. So, you know, some um dermatologists may not agree with it. And there is a debate for about who should look after skin disease. And ultimately, even the British College of Dermatology is supporting this task sharing concept and that's one way. And of course, you know, the latest from Burma is that the ne national unity government is occupying more than 70% of the the country now. So I have no idea what the political situation is going to turn into in the next year or so. But in the meantime, it really is about being a political, as much as one can be work with the local partners, train them up whoever they are, those people are actually on the ground. Thank you. Um And another question you mentioned your clinical guidelines. Um are they specifically for the doctors working in the country at the moment or is it something that doctors here today can take with them if they were to go abroad and then use in the countries, they're going to? Sure the last time, I mean, you know, it's already applied in Ukraine and it will be utilized in Tasia and we share those with the, the colleagues in Greenland as well. So absolutely, they are on our website. So if you go to the skin care.org, there are resources and um publications, et cetera. Brilliant. Thank you. And you've got some questions in the room. You can, you could just go and look at green as well. So, absolutely, they are on our website. So if you go to Burma skin care.org, because there are resources and um applications to access your uh video work and uh the uh as well. So, absolutely, um very relevant questions. So in terms of key barriers for dermatology, you know, the obvious one is the language barrier in order to overcome that what we do is really sit down well online with the the local partners and identify group leaders who can actually the cases and communicate with the expert dermatologist from the UK. So guys and Kings and Thomas, that's where uh the, the consultants are based. And usually just thinking about it, not even, you know, in, in the UK, we can provide such a, an expert service everywhere. So really fantastic uh thing to do um the other um barriers in terms of accessing online. So resources is, you know, the internet is sporadic but um these are downloadable and you know, through the webinar series, we have made it available for them locally, through their Facebook pages and so on. So, you know, we, we try to think cover all angles where possible, but of course, you're right. These are key challenges. So we've got 15 minutes for a General Q and A session and but you to stay on the stage just in case. So everyone who wants to ask the question that high, then you can start and that can be session as well because you session. OK. Thank you so much. Um I'm a pediatric registrar and thank you for your talks and um I just amazing and inspiring. I can't believe you've done it in such a short period of time. So my question was um how do you balance it because uh I gave you a registrar and how do you balance it alongside training in particular? Yeah, excellent question. I um I think, I think that's um life journey that I had really played an important role in what I do. So, in, in some ways, this is actually a joy because I have the choice to do what I want to do and this is not a matter of survival in learning English or, you know, passing these down so that I can actually, you know, get education and have a life. Um It is challenging. I have a, a young son and I also do academic uh research. So how do I manage it? And I think it really is about having and an amazing team around you. So, of course, with Professor Chris Griffiths, I got the privilege of having him as a dear friend, as well as a colleague, as well as a co founder. And we have, we are boing ideas and it's, it's like, ok, so what else, what else? But also over the years, we have formed a really fantastic, small but efficient team and being able to delegate which not everybody agrees with when it comes to, you know, your T TBD, et cetera. But I, but then actually, I don't know, I, I'd like to ask Jack for some. How do you choose TBD? Because we don't really have a choice, the TVD that are s to et cetera. But in in any case, um, so weekends, I really keep weekends free for family and stuff, evenings. Nothing. So I do have very weird working patterns in that. I do wake up really early and, you know, sometimes I, you know, put, put my son to, to, to bed and then stay up. That's my quiet time to catch up with various things. So it is, you know, people say, oh you can have it all. No, if you can't, something's gonna give, but it depends on you to prioritize what matters to you. Um Yeah, so II think I was um so very interesting. It's more common rather than a question. And I co is telemedicine has really changed the landscape of how we deliver. OK. And uh what I found is that uh personally trying to adapt my clinical style and trying to make a diagnosis without an examination. Um if we're trying to do it globally uh and across the planet. And that's what this is partly about in dermatology. I remember as a medical student being cleared by dermatologists who cannot diagnose skin disease on a on a photograph. And I always remember as a trainee and going to trying to say to my dermatology probably send you an image like know can't make a diagnosis through an image. So it was very interesting to hear your world because of course you can make diagnoses. But the the pathology that we are seeing is so far down the line that it's what the diagnosis is, at least going upstream is why it's so mild and he's trying to make a diagnosis before it gets that bad. I don't know whether we can rely on telemedicine to make the correct diagnosis without an examination. So it's not a conflict I have with myself with beyond the explosion. Of telemedicine as that's gonna happen in the world. Thank you so much for that appointment that you gonna start. It's better to have the tele and help the cases that require help and none at all. But absolutely, you're right. We do have to bear in mind of these such rare cases just to emphasize the importance of yes, we can diagnose certain spot diagnoses uh based on the image. But that's why when we design the consultant connect up for Verner, we carefully thought through the sort of questions that we need in the history. So there is a a list of, you know, it's not, they're not gonna be spending half an hour in answering these but key questions, you know, past treatment, is it responding to steroid, et cetera, et cetera and together with the history? And I'll tell you the quality of the cases and the history that we get from consultant far superior than any of the cases that I get to do during my on call hours as a registrar. So with those carefully designed um questionnaire, let's say along with the equality images, it is really possible. And by the way, we're not just seeing the clear cases here, we are seeing some subtle melas subtle tinea, some, you know, subtle sort of post inflammatory hyperpigmentation due to previous sort of sweet syndrome, for instance, you know, so there is a wide range, but you're right, there will be challenges, but that's the beauty of picking up the phone where possible and talk to them directly as well. Thank you. And you've got a online. Um So the question is, how would you advise people to get their medical support? Um So that you can get involved in local projects, you get the support. Um I guess it is easy for me because I, that I have connections. Uh But also having um someone like Chris on the team is incredibly um uh helpful because he's so well connected internationally. So that's why we as a team are able to connect up the local healthcare workers with the international. Um But when we go out to Rain and Armenia places like that's through college and, and uh and networks and again, it doesn't just happen overnight. It's, you know, your sort of lifelong career networking and, and connectivity and my lifelong sort of in the east and, and uh and I think it's about, you know, if there's a will, there's a way and one more question from anybody else have another question. I, so I just have a question about the end side of things. So when getting studies in on the year, you find in terms of a, a risk factor and II know the gene diabetes, really great question about uh like, but in Greenland, the key pathology, as I mentioned was the chronic hand eczema and that's because of their occupation, you know, very um sort of a lot of manual workers there. The level of education is quite limited in women. Where else in uh South Africa, I think that they, the data is being actually digested but acne is the commonest. So they're both in skin conditions. Again, acne is due to local cultural practice where they have to use rather, you know, quite emer uh uh uh conditioning for that. And as a result that can block the sweat pores on the forehead. So they have this mild type of um uh uh more hyperkeratotic um on the forehead. So again, it's about education, recognizing what um is contributing to the pathology uh in terms of Armenia, it was um sort of, it wasn't an official skin disease survey that we went out to. And basically, Professor Alan is a, an academic colleague of mine and he's Armenian French. He went out there and he saw a lot of uh rare genetic skin disease as well as inflammatory skin disease. So, inflammatory skin conditions seems to be the common thing that different factors underlying that. Great. Thank you so much. Thank you so much.