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Gas. Uh And thank you so much for taking time out of your evening to join the event tonight. I really hope you find it interesting. Um So the paper that we're having presented tonight is um really interesting one and it's looking into something that touches all of our work every day and that is the global supply chain in health care. And specifically, it's looking at what are the costs of some of the objects that we're using day by day. I think it's a really um interesting area to be considering in the context of global surgery and global obstetrics and anesthesia which our organization is interested in. Um I think the supply team really came into the focus during COVID. Um But this is an angle that I personally have not heard, spoken about a lot. Um But I think is really kind of an area that is necessary for us to consider. Um So I'm not gonna talk more about the paper. I'm gonna leave that with Jasmine, who I'll let start shortly. Um But before we begin, just a few things. So first of all, the event is recorded and it will be available for um uh at metal on demand for anybody who wants to watch it afterwards. Um So just to be aware that it is being recorded and if you have any issues with that, you can reach out to our events rep. And then the second thing is so Jasmine is gonna present the paper and then we're gonna leave time for questions to ask your questions. If you just look up in the right hand corner, there's a little chat, um, note chat notice. So if you type your questions there at the end, I'll moderate and kind of um pick out whichever ones we wanna go with. All right. Um So that's all the housekeeping. So I'm gonna hand over to Jasmine to begin. Thanks Carrie. Um I'm just gonna share my slides to begin with. Brilliant um, Carrie, can you see those? Ok. Yes, looking good. Perfect. Um So, yeah, just to introduce myself. Um So I'm currently working as a clinical fellow in sustainable health Care, um at one of the hospital trusts down in the south of England. Um This work that I'm presenting today is uh work that I have done prior to that role. So kind of un unrelated to the, the work I've been doing in sustainable healthcare um currently around inhalers. Um But I'll be presenting the, the paper um that I've worked on over the past few years. Um Just a note that I thought that this worker does not represent anything of, of the trust that I work for. Um And additionally, and this is the paper that I'll be presenting and obviously everything. Um that's outside of that paper that I might talk about doesn't necessarily represent views of all the other authors. But I'm really excited to get into this today. I think it's a topic that there's really low awareness of um within our healthcare environments and something that is really, really important that we think about. So just a bit of background to this issue. Um we know that there are some really serious problems with labor standards within our um healthcare supply chains. Um So surgical instruments is one of the areas that has one of the first areas to be highlighted is where this wasn't an issue. Um So what you can see on the left is just one image that is an example of this. So this is an example of a workshop er based in Pakistan where you can obviously see that there is a manufacture um occurring using Children and all of the piles of instruments that you can see are just simple steel surgical instruments. Um and child labor is not the only issue that has been highlighted um in this area. So actually, Pakistan produces around two thirds of the world's steel surgical instruments and we know that um the the National Health Service has procured these instruments as well. Um And there's a range of issues that have been highlighted through some quite in depth case studies. And this includes things from precarious working um to just unsafe working conditions. And we know of many examples of workers receiving injuries at work as a result of inadequate um protection. Um One problem that is um particularly arises in this region is that a lot of the work is subcontracted. So what that means is instead of being um produced directly um sort of in house by the, the main um manufacturer that the suppliers will be purchasing from, it actually gets contracted out to various um workshops, which can in some cases be in home based settings and obviously, that um produces a whole environment where it's not really possible to regulate the standards of labor conditions in those settings. Um And a lot of this is driven by the drive to lower down the the price of the manufacturer. Um And obviously, the, the demand for the low price comes all the way from the other end of the supply chain. Um and just gets pushed down and, and this is the consequence that we can see towards the other end. Um This is just one example that we know about. Um another example is one that you may have seen in the media. So this is an article produced um in the Guardian um a couple of years ago that was highlighting this issue that PPE was being sourced from companies that have repeatedly been accused of forced labor and there's been a number of reports demonstrated produced around this. Um and all of these have have involved collaboration within various organizations within the UK. And this highlighted a whole different range of issues around the the working conditions that our um medical products are produced under. So, examples were um well, in, in this particular case, a significant amount of um the manufacturer of gloves is produced in countries um in Malaysia and um a lot of the uh workforce that is used to, to do that manufacture um are actually coming from other countries. So they're immigrating into um M Malaysia. Um And it's been highlighted that there have been recruitment fees that are extremely high false advertising of what the actual roles will be and the remunerations that workers will receive, we know of um instances of um workers having their passports retained by the companies that they're working for. So they actually do not have the right to leave that that location. Um And workers um essentially being given uh a list of debt that they, that they owe to that company that they have to repay through things like for example, um having to use the accommodation that is provided for um by that company, not having a choice to stay anywhere else, but also having to um pay all of the um money associated with the that accommodation and their food and not having any other option to go anywhere else. Um So we ended up in situations where people are essentially being forced to stay at work and working conditions again, have been demonstrated to be unsafe. Um There have been um these reports have showed that there is a really concerning level around workers having received threats and intimidation er to not talk about these topics so that prevents any kind of organization from the workers themselves to be able to improve the situation. So these are obviously really concerning we have really good evidence um in particular about these two cases, but also about some um other products that we know have been produced under conditions of forced labor. So that leads us to the questions, what is the risk of labor rights abuses within healthcare supply chains? And are there other products that are high risk that we have not yet identified? And what we know from those two case studies in particular is that those are two instances where there is a very large volume of production of product and a very significant risk of um labor rights abuses and poor working conditions. And this is obviously a really um awful ethical um position because what we are trying to do within our healthcare systems is to improve the health of the patients that we are seeing. And it's obviously wrong for that to result in harm to people that are trying to produce the the products that we need in order to produce that. So that's where this research really comes from, is trying to understand what actually is the scale of that problem. Um And if we can identify other high risk products, then can we focus our efforts on improving those supply chains? So the aims of the aim of our study was to try and quantify the risk of labor rights abuse in the manufacture of medical products supplied to a high income country based on data on medical product, country of origin. And I'll come to talk about, I'll come on to talk about why we're using country of origin within um this study as our um metric for risk of labor rights abuses. A bit later on within that, we wanted to identify what sources we have available on medical product, country of origin and then utilize country of origin data to identify the overall risk of products supplied to a high income country and then estimate and compare that risk overall and then per product type to data from other high income settings so that we can see um if there are patterns that we can see that whether this is generalis or or not. So we looked at the risk um of labor rights abuses within uh a data set from Norway um utilizing country of origin data. So the reason for um using this data was because it was an instance of um high quality data on country of origin that we were able to access. This is actually uh very limited. Um And this is something that I'll come to on to talk about later about how this impairs our ability to make these risk assessments. Um But in 2015 to 2016, it was actually mandated that suppliers to the southeastern region, um healthcare authority within Norway, um uh that the suppliers uh provided information about country of origin um when they were supplying products. So we have this data set that had over 23,000 items within it and it should, it was mandated that the country of origin was supplied within that. And that data also enabled us to look at the the volume of products that was procured in terms of the comparator data sets, we had three different sources. So um there was an audit that I completed at Cambridge University Hospitals in England um looking at the financial year 2018 to 2019 and that was an evaluation of the top 100 items by spend and it was looking at different data sources around country of origin. So it was actually about physically examining the product itself to look for statements of country of origin and comparing that to an online search to see if there was any additional information or if that corroborated with online information. That was obviously a relatively small dataset. The larger datasets that we were able to look at were first of all, the un contra global trade data this is data that um anybody is able to access online and it enables to see the export and import data. However, it only contains information about eight medical consumer consumable medical products. And therefore doesn't enable us to do an assessment of the whole of the the healthcare products sector. But we um utilize the products that were within that to compare them with what was in the Norway dataset. And finally, we looked at the um Federal Drug Administration in the USA, they, they have a medical products register. Um And within that, um all suppliers of healthcare products that are intended for use within the NH within the USA sorry um have to register with the FDA. And that register again, is accessible to anybody online that does not provide any information about the volumes of products that are being traded or imported, but it does provide the country of the location of the different manufacturers of products. So we're able to see for the different products. Um where are the manufacturers that are registered to supply within the US. So in order to analyze this data, um the, the first step with the Norway data was to actually categorize the the the products into product categories. Um This was quite a um labor intensive process as we had to review all of the products within that and assign them to product categories. And we then assign those product categories into more broader categories. So grouping things together based on the similarities in their um composition with the assumption that um similarly composed products are likely to have similar risks um of their um a similar process involved in their manufacturing and therefore likely to have similar risks. Um So once we had those products categories um to compare with the um other datasets, so to compare with the FDA dataset, we picked out those categories that made up more than 2.5% of the spend in the Norway data to be able to locate, to decide which product categories we should look at in the FDA medical products register and then identify the codes for those products. So once we had the country of origin data, how did we then go on to do the risk assessment? So for all of those uh data sets, we are matching the country of origin data with the risk of labor rights um abuses on the International Trade Union Confederation Global Rights Index for the, the year. Um that, that dataset was relevant to. So as you can see from this map, so this is from the, the 2018 Global Rights Index. Um most countries um have a risk allocated to them on the um risk of labor rights abuse. So this ranges from um one which is a sporadic violation of rights up to five plus, which is no guarantee of rights due to a breakdown of the law. And this um uh method of this categorization. Sorry comes from um both an assessment of the policy and law in all of these countries um surrounding labor rights and labor rights abuse risks and modern slavery. Um and also comes from reporting on real life instances of labor rights abuses. So this is a proxy measure for labor abuse risk. Um And the reason that we have to look at this in order to do an assessment of the whole supply chain rather than um working out how many instances of labor rights abuse exactly are occurring within different products is because we just do not have the access to that data. This is obviously something that is underreported. There is no um sort of database of all of these um instances and obviously many of these instances will not be reported because um workers are in vulnerable positions and there will be various reasons why, why that can't be reported and um and addressed. Um So, um so once we have um matched all of the, the countries of origin to that um risk, we were then able to, to pull this into um more broader risks um for the datasets that we had available. Um I should say as well that this um method around uh using country of origin is a very well established method within the um ethical trade um methodologies that are utilized by um companies in a variety of different sectors. Um Companies use us to assess their own supply chains and um evidence from um sex, which is a, a sort of consulting organization which helps companies to make those um assessments of their supply chains in terms of the um environmental and um social um responsibilities um has demonstrated that using country of origin as a proxy for risk of labor rights abuse has um quite good predictability for the actual instances of labor rights abuses. So, while it is obviously a very um non granular um measure, um it is something that we think is, is a, a fairly predictive measure and obviously the best that we can do with the data that we have available as it stands. So, what were the results from our study? So, first of all, looking at our primary data set, the Norway datasets and the Cambridge datasets as the as these are the data sets where we could do an overall assessment of risk given that the UN com and FDA data sets only gave a, a very selective snapshot of certain products. So the Norway dataset, as I said, contained over 23,000 items. Um And the first thing that I'll draw your attention to is that even though the country of origin was mandated to be supplied by the supplier, actually, 43% of products within that data set once we had excluded out of remit products um er was unavailable, so had not been supplied by the supplier. Um We do not know the exact reasons for this. But it it is likely that the supplier either did not know the country of origin or there was a reason that they chose not to supply it. Um This is compared with in the Cambridge data set. There's actually a a different uh difference obviously in the methodology of how the country of origin data was brought about. But in that data set by value, there was 27% of data unavailable. After two out of remit, products had been excluded for actually being capital items. Uh sorry, 2% of of products by value were excluded for being um capital products. Um So that 27% of data being unavailable meant that it was neither available on the product packaging itself or on a online search. Um Comparing then the rest of the data where we did have information available about the product, country of origin, we stated that a product would be uh what we considered to be high risk of labor rights abuse if it ranks in the I TEC ratings at four or more. So that's systemic violations of rights or um up to no guarantee of rights due to breakdown of the law. So within the Norway dataset for products that we had information about country of origin for 49% of those products by value came from countries that were at high risk of labor rights abuses. This is compared to the audit at the er, in the Cambridge dataset where 60% of the products for which we knew the country of origin for, er, came from countries that were at high risk. So what happens when we look to by products? Well, we um categorize the Norway data into 294 product categories. And then that groups goes into 17, what we called super categories within those super categories. There was a range of missing data. Um So while I si said um on the last slide, that 43% of country of origin data by value was um missing, this ranged differently within different super categories. So the the lowest amount of missing data being 20 point point 9% up to 86.9% of the total value. The the level of risk within a different different super categories also varied. Um So where country of origin was declared, some super categories had as low risk as 6.9%. Whilst other super categories had a risk as high as 71.6% of having uh products from countries at the highest risk of labor rights abuses. We then compared um byproduct to the UN comrade and FDA data sets. And there were eight medical products that we compared with the un comrade data and five medical product sets that we compared with the FDA data. So there was one product that we were able to compare between all three data sets. So this is a pacemakers and implantable defibrillators. Um And what these images demonstrate is the proportion of products where we had known country of origin that came from the highest risk countries of origin. So an itu rating of four or more in the Norway data set, the the risk was 100% with the only um country of origin listed being the USA um but this varies with the um other sources. So in the er UN contra a set, um there was obviously a much as you can see from this image with the red representing the um risk, the, the countries of origin from the highest risk uh ITC ratings. Um This was significantly lower and a very low proportion at all from countries from those countries in the UN con data set. And the top three countries that um made up the, um the total trade of those products were listed as the European Union, Ireland and Switzerland in the FDA datasets. However, bearing in mind that we're not looking at um product volumes, we're just looking at the number of suppliers listed by different countries. Um You can see that around 75% of those manufacturers were from the highest risk countries of origin and the top three countries listed with the USA Malaysia and Switzerland. I haven't listed all of the different products that we compared the specific categories for here, but here's just a snapshot of six of them that we looked at. Um And these were just compared one. So each of these categories was located within the Norway data set. And then we compared it to either the UN com or the FDA. And the point of this slide is really just to demonstrate how there was a, a varied range of risk by different products found in the different datasets. And some of them came up more similar than others. So for surgical gloves, you can see there was a, a similar proportion of products that were from the highest risk countries of origin and the top three countries of origin by um in terms of the value that they supplied was similar with Malaysia and Thailand, both being in the top three countries for surgical gloves, but then you can compare this to other products. So for example, needles, um the top three listed countries, um both included the USA but otherwise were different and the level of risk within those data sets varied. And this was the across the all the products that we looked at. We could not see that there was necessarily a consistent trend that we could identify to say that the risk of products that was identified within the Norway datasets would be the same in other um and other locations of supply. So what this study represents is something that um has to, our knowledge has not been done before. Um We know that there have been other sort of sporadic assessments of um risk of healthcare, um specific products and in some supply chains. And um in the beginning of this year, the UK government published a risk assessment of NHS supply chains which just focused on five products that we no ready to be at risk and of the results of some um supplier questionnaires. So to our knowledge, this is the the first study that has looked to try and understand the the the overall risk within the supply chains of medical product consumables. Um And the country of origin methodology enables us to do that um by having access to um the country of origin data for a variety of products and comparing that to the risk. Um within those countries, there are obviously significant limitations associated with the, with that. And um oh sorry, and with the, the data sources that we have used within this study, um the Norway A set is, is obviously only a snapshot in a single period of time. So in one year, in one region um of Norway. And so it's not an assessment of that whole country. Um And the Norwegian healthcare system will obviously have a variety of similarities and differences, both with other high income um countries but also will be very different to um countries that are from lower incomes. Um So, while we would expect that um many of the products are very similar to that, that is proc of the settings we don't necessarily have the um the confirmation of exactly how similar that is within Norway to in another country. And we don't know what suppliers are used in Norway that are, are used, different ones are used elsewhere, for example. Um And the datasets that we have used to compare with an OA dataset obviously have um a range of limitations in themselves. So the, the Cambridge data set again is a snapshot from a particular point in time. Um is looking at one hospital's um use of products. Um So the the supplier that they use, it is looking at the at the risk assessment for that supplier. Um and it's quite a small sample size as well. Um So that limits the ability of us to, to fully generalize this, the un contra um uh data source itself uh is only looking at a few products and there are limitations to the reporting of country of origin data within that is it is relying on the exporting and importing countries to um provide reliable data. And the obviously the biggest limitation around the FDA data is that it's not um supplying us with volume data um on trade. So we're assuming that each manufacturer is supplying in equal proportion and that is obviously going to impact the overall level of risk that we're assigning. Whereas it actually may be that a high risk country, high risk manufacturer, for example, may be supplying either a very limited proportion of the total supply of that product or actually a much bigger proportion as I've mentioned previously. And the use of the country of origin data to assess risk is a proxy measure. And so we, we do, we do not know exactly what is going on on the ground in the supply chains that we have assessed. Um a big limitation to this study as well is the amount of missing data that we had for the product. So as I mentioned, nearly half of the data in, in the Norway data, even though it was mandated that country of origin should be supplied was missing. Um So we can make assumptions around what the level of, of risk within that missing data might be. It could, we could say that it's likely to be similar or it actually could be higher or lower risk. Notwithstanding the limitations we felt in the, the analysis of this, that we have a large data set. Um It's granular, we have detail of over 23,000 products and the level of risk within our um analysis was high um at around half of the products. And this is using a methodology that we know um has a relatively good predictive value around um the real instances of labor rights abuse. I should also highlight that using the IT UC rankings. Um We can see that we have said that the highest risk countries are those with um a rating of four or above. But the ratings of three and below actually do also contain risk of labor rights abuses. So we're really only just focusing on the highest risk products given that we found the um the presence of risk in across all of the data sets that we looked at. So the Cambridge data set had a similar level of overall risk, but there was also the risk identified in both the, the single product level in the UN contra and um FDA data sets and the the UN contra data, as I said is global trade data. So that also has a significant size and value associated with it. We felt that this suggested that the healthcare products sector is overall at high risk of utilizing products that are made under conditions where there are labor rights abuses. And this means that it should therefore be considered akin to other sectors that we already know have high risk of labor rights abuses. I think people will be often familiar with the risk in the fashion industry that has received a lot of media attention. We also know about risk in the electronic sectors. And so our data suggest that we should also be considering healthcare products alongside those um other product categories as as a risk of labor rights abu and we should therefore be ensuring that our supply chains are are working to combat this issue and to ensure that we can eradicate this from our supply chains. One of the aims of the study was to, to look at the p product risk. Um, and I think what you can see from our data is that we can't, at the moment make, um, uh, we can't jump to conclusions about other products other than the ones that we have a case, a good case studies on. Um, let me start that sentence again. Sorry. Um, we can't jump to conclusions about other products that we can identify as being particularly at high risk of labor rights abuses alongside the ones that we already know information about. So this highlights that we need to do more investigation around our products. The fact that I've highlighted that there was so much missing data within the data sets that we've looked at as well suggests that there is a need for greater transparency among our supply chains because it is only by knowing where our products are coming from that we're able to actually locate the instances of labor rights abuses and put in the assurance systems throughout our supply chains that the risk of this is being reduced. So there is um there is lots to be done in this area. Um I think one thing that we have been thinking about um wi within this paper and the implications of this is thinking about well, what actually impacts the risk um of labor rights abuses within a healthcare supply chain. Healthcare supply chains are quite different to the supply chains in other sectors, just around the requirements that we need to have around the products and around the reliability of the supply chains that we need to have. So our healthcare supply chains impacting this risk in different ways to other supply chains. Can we identify aspects that increase risk and therefore come up with initiatives to combat that? Um And once we identify risks within labor, within healthcare supply chains where there are um problems with labor abuses occurring, what are the things that we need to do in order to um ensure that that problem is dealt with? Um So this obviously has a significant implication for um healthcare policy and research um within um countries and also between countries as well. Um So I'm just going to stop talking and I'm very happy to receive any questions and these are the references that I've um referred to just through um this talk, but obviously, there's the full list of references within our paper. Um And it's been a bit of a whistle stop tour through everything. There's obviously a lot of detail in that paper. So I'm very happy to take any questions either to clarify anything or go into any more detail or anything or just answer questions on related issues. Oh, Carrie, I can't hear you. I can see you're talking doctor. No, I can't hear, I'm afraid to carry. Um I don't know. Yeah, I don't know if perhaps if people do want to put questions into the chat and I'd be happy to answer them from there. It's great to see. Um, people have been joining from all over the world and I'm sure that you will have reflections um about how this might apply within your settings as well. Thank you so much, Jasmine. That's such an, such an interesting talk that really isn't talk um about or really known about much at all. I was just wondering, it's such a huge problem obviously on, on a global scale that how even if you enforce people putting the location of origin, he said that that was already supposed supposedly mandatory, but still places won't do it. How can you enforce something like that? Yeah, it's really challenging. Um So um so that was just one year that that was actually mandated for. So it's not something that is necessarily, it's not common practice across any other supply chain. Um So I think that there's work to be done around building the capacity. And I think if it becomes more standard practice that suppliers know that that is information that is required by procurers, then that is information that they will work to, to produce. Um if it's sort of a requirement for we only um accept um supply if you provide this information. So there's, there's, there's different ways around it in terms of you can mandate certain things or you can put in um stipulations that um this is something that is built up over time. So one thing that is within sort of the UK Modern Slavery Act is is almost er um expectation that companies will commit to improving their supply chains over time. So that the aim of the Modern Slavery Act is to put the responsibility on suppliers to say that they will not provide products that are at risk of modern slavery. Um And that they will be um sort of at risk if they do um provide those products within the UK. Um So it's, it's a mixture of, I would say sort of hard laws and policy alongside collaboration. Um and er coming to agreements between different um participants within, within supply chains, I think there's only a certain amount that um putting in mandates is helpful and it's working out, where is it helpful to do things that are mandatory? Where is it more helpful to do a more collaborative approach? And we don't know all the answers as well. That's a problem, isn't it? You don't really know to start and even if you did make something that was mandatory or even though it was done for a year, but if it was in the future, who would enforce that though, who is there, who would be the overarching body to hand out fines or whatever they're going to do to enforce it. So I'll be honest, I do not know the intricacies of sort of legal and policy frameworks. Um but that would have to, that would be, it would be dependent on the particular location. So it's, it's different, for example, in the eu they've been working towards this procurement policy and therefore the, the people that would be enforcing that and handing out fines um is actually um at the level of the EU bodies. Um So it might be something that's um done on that more kind of international collaboration level or it might be individual governments that would be responsible for that. Um Or it might be even something that I would be um what's the word sort of um given out to external um company or organization that would have responsibility for that? So there is no one right way is just working out about it where the responsibilities will be. Yeah, I guess also where a lot of us are clinicians, we obviously in a very microenvironment of using that one product on the patient. So I feel like we would, we have very little impact on something that is such a huge global problem and how, how can we be of use and actually, and tackle this problem rather than sort of just carrying on blindly, not knowing of this problem and using the products because that's what's applied to us. So we can do our jobs. I guess it's just people don't even realize, like I can't even tell you, I don't think I've ever looked on a packet and seen where it's from, or, I mean, you kind of do a fruit and veg because that's a bit more known about and about trying to shop local et cetera. But actually with products that we use every day, it's not even thought about. Absolutely. I'm, I'm, I'm really glad you asked that because that brings us on to what is the overall approach. And we've talked about policy and we've talked about law, but it occurs at all different levels. So I think we can think of at the one end, we have workers being affected. Um And we want to be able to build the capacity of, of people to essentially to be able to unionize and to be able to get the, the, the good conditions and the, the rights that they should have for their working conditions. Um We then need to look at what's happening with the manufacturers and with the suppliers. Um and then we come on to people that are procuring the um those products and going to suppliers and asking for products. So I think this is where clinicians come in because we are using these products every single day and particularly as um surgeons and anesthetists. Um You will already um it may not be depending on how far you are through that pathway. Um like surgeons and nieces already go to their procurement departments and go to um manufacturers to request for specific um er standards to be met for their products. So whether it's that you're, you're going for a clinical reason and saying I need to be able to do this kind of procedure, therefore, your product needs to meet these standards. Um And whether it's about the safety of the product, um we're already doing that. Um And we can also be um asking for environmental standards and for the ethical standards of these products. Um So what I would draw people's attention to is um if you look up the ethical procurement workbook, um there is a, a table within that which it aims to enable organizations to build up their capacity in um putting in standards in place for ensuring that their products come from ethical sources. Um That is something that as a clinician you could utilize, you could go to your procurement department and build a team to, to work on this if it's not something that they are already aware of. Um And I think that as you've highlighted, this is something that most people are not aware of as clinicians. So raising awareness is actually also a really useful thing for us to be doing at this point. And I think ultimately, we need to be looking at that um sort of having advocates everywhere, both within every healthcare organization and every level of the supply chain to make sure that that this is something that we are dealing with. Yeah, true. I think that's so true. Actually, if everyone, you know, everyone who's here goes and tells one person about this talk and about these rights issues that are happening all the time. Then just increasing awareness would be a huge benefit. And I guess talking obviously to more senior people because obviously we may all be trainees, but actually one day we will be the consultants asking for that equipment or that that particular piece of or medical device. Um So we can we will have a big impact. Um We do have a few questions. So we have Nora who is currently listening in from Saudi Arabia who's written, I understand this is a com competitive study. Um Could you please elaborate on the study design? Yeah, I'm not sure what you meant by competitively. I don't know if perhaps you meant to put comparative design. Yeah, so it's um a cross sectional sort of design. So we're looking at these data sets that were all taken at different snapshots in time. Um And so we have the structure of that was having our primary data set which had the the largest amount of products and the most granular data. Um And then as I talked about in, in the talk about we compared the overall level of risk within the, the Cambridge dataset because you know, we didn't have the detail within that to be able to compare by different products um given the small sample size. Um and then comparing with um specific product categories within the other two data sets that we identified. Um I don't know if Nora, you had any sort of more specific questions that you wanted me to elaborate on with the study design. II, don't wanna just repeat everything that I just said if there was something specifically that that wasn't clear or we'll, we'll wait for her to get back to us on the chat. But thank you very much for your question, Nora. Um Kerry has also popped a question down listening from summer on holiday. Um So she wanted to ask, do you know what the impetus in Norway for publishing the coo data and any push to do this in the UK, Ireland that you're aware of? Um, so the, the impetus um I believe was around this looking at the, the risk um within their supply chains. Um They have uh an organization that has been very active in terms of um assessing some of their own supply chains, um and has been quite effective at making some improvements. Um So I think that was the reason that, that they required that um I'm not aware of any push to do this within UK and Ireland at the moment. Ok. Right. Now, are there any other questions at all? I guess I just have one more, this sort of future for you and your research in this. What are your next steps? Um And what are you hoping to achieve? II don't know the answer to that yet. Um So, um my, my focus in terms of my research has slightly shifted away from the ethical uh side of um looking at supply chains um recently, while I've been working on environmental sustainability, but for me, they're all part of the same issue. Um So, one of the ways that we can um that we need to think about this issue is actually, and what are the systems that are producing the, the problem of um labor rights in our supply chains? Um And that comes down to what the, the structure of our supply chains is. And we, we know that the practice of the competitive driving down of prices is a significant issue. Um And so when it's that our supply chains are centered around price and they're not centered around the environmental and social value of our supply chains, then we're more likely to produce this, the risk of this issue. And it's exactly the same for environmental standards. We know that if um we're focusing purely on driving down price, we're not gonna be considering the necessary um factors that give our supply chains a high environmental footprint. So I see it all as part of, of one picture and I haven't been therefore looking specifically um at um the the ethical standards within supply chains at the moment. Um And um I'm currently working out where my next steps are generally in, in my, my research and uh eventually looking to do A phd um essentially looking at sustainability within healthcare. And II think about that in both in terms of environmental and social sustainability. So it's sort of a, a watch this space definitely. And a very needed area. I think an area that has never well often overlooked because the drive is particularly with the NHS to make things more affordable so that we can treat more people and get, get to as many people as we can. However, doesn't seem to be working. Yeah, absolutely. Well, within those issues, the idea of a circular economy where we're relying less on this linear supply chain should mean that we are um manufacturing less, having a less environmental footprint and also should be more financially sustainable as well. So I sort of see it as a triple win. Um and if we can actually focus, it's sort of the same with the preventative medicine and public health. If we can actually reduce the, the need for healthcare and the need to utilize these products, then we're gonna improve the, the financial environmental and social sustainability, the triple bottom line, which will hopefully enable us to deliver the highest impact healthcare where people need it. I think that's it. And also as we move more towards a collaborative approach from between countries, high income, middle income, low income, actually, it's about making it better globally, isn't it? So making sure that just because you can afford it in a high income country you're actually making the life and living conditions in another country worse. And actually people, there's a lot more collaboration and want to get the whole world to have better standards, people. Absolutely. Absolutely. Well, thank you so much for your time this evening. It's been really interesting and I will definitely be telling lots of people about this issue um towards the on demand content that will be uploaded to metal and I'm sure we'll have lots of people tune in um, when they can to listen. Um Just to everyone who's tuned in. Thank you also for your time and for coming. Um, there is a feedback link that will be sent around just to get your views and opinions um on how tonight when and how the layout works for you. Um to get your attendance certificate, you do need to complete the feedback form. So please do it. Um the sooner you do it the better because you will forget as we all do. But thank you very much for your time everyone and we'll see you at the next journal club. Thank you so much for listening, everyone. Thanks.