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That's the last for um, injection. So, without I so consult position, he was a principal investigator of the study pregnancy and condition of disease in investigating the pre and risk factors of diabetes and hypertension in pregnant women. Got to two. Right. So we'll just get the sound cos I don't think I'm not sure I can speak right into this, but we have to make sure that people online can hear. So I'm gonna place that there and hopefully, can you hear me at the back? That's the important thing. Um Thanks very much for the introduction. Great to be here and to start off uh the day. So we'll all give different perspectives as the day goes on. I'm sort of at the end of ready start training and if someone puts consultant at the beginning, it means they've just CCT and they're very proud of it. Uh, but, you know, getting used to the idea but still see myself the registrar and now doing a clinical, er, phd at the University um of Liverpool. So the bulk of what I'll talk about, er, is in the, you know, title, er, of the talk. But because I was first on, I thought I would bring in some other themes as a bit of an introduction, perhaps for certain threads that I hope will run uh throughout the day. So firstly, it's a welcome, you've had one already. But to say that everyone is welcome in global health. I think when I was uh in the early stages of my training, I was thinking I should probably be an infectious disease doctor. And indeed, it was exciting learning about those things um in East Africa. Uh but now I share an office with all sorts of people in Malawi. I'm, I'm gonna give a perspective from the sort of clinical phd perspective. Welcome funds two lots. Uh probably more, but the main ones are in London, the create program um and Liverpool. And I'm sharing an office at the moment with an ent surgeon who's doing something about hearing loss and conductive er er um device that they're using um uh an intensive doctor who's looking at multimorbidity in older people. Coming into the emergency department. A fed who's looking at uh transmission of Campylobacter from animals to humans. We've got an ophthalmologist looking at retinal imaging in cerebral um malaria. And if you go onto the websites of these phd programs and just look at present and past fellows, you'll see a splattering of infectious disease registrars. You will, of course, but you'll be amazed about the whole other host of specialties that go through global health now because long gone are the days really that it's an English doctor teaching African doctors about HIV. Trust me, these guys know what's, what when, when we're talking about that. But all of the specialties that we do here, there is so much room for learning in different parts of the world. So, think about what you're interested in, pick your specialty, think about something that will keep doors open both in the UK and abroad and follow your passion. Don't become an ID doctor just because that's what you think uh you need to do. So um MCD S is a, is a funny, well, it's an odd description of a collection of diseases. Really. You don't often get a uh a name which tells you what something is not. And it's because so much research is about infectious diseases um uh in low income settings. So these four have been picked out, of course, they share some common factors in that they become more prevalent with age, they tend to deteriorate. But I mean, like lots of cancers are caused by infectious agents. Um They just happen to be the sort of four main ones that cause the greatest burden of, of mor morbidity and mortality um worldwide, I'm interested in pregnancy. So I particularly focus on diabetes and hypertension and cardiovascular conditions with chronic respiratory illness and cancer is not so common um in, in, in the pregnant population. Uh So I was focused on those really? And I suppose the first thing today is hot topics. Why are they not hot? And I'm really convinced that it's something to do with our sort of cultural histories. We, we humanly and intuitively understand the battle between good and evil and it is instinctively attractive to get into infectious diseases with the, with the good immune cells protecting you and the evil infectious pathogens trying to take over. Um A and working MCD S isn't sort of quite so exciting. Actually, it's all about maintenance of machines and homeostasis. Really. If you're writing a film plot, it'll be, you know, the superhero would make modest but sustained efforts and then the bad guys would never turn up and nothing would happen. That's, that's literally what we do in MC vs, that's how we can't success by things that don't happen, er, rather than clasping people away from the jaws of death due to some evil evil pathogen. And uh we haven't really had the sort of patient advocacy uh that infectious diseases have, I think there's lots of very good reasons that you see these kind of protests. You know, that's gon not only in Africa, but importantly in America as well. And that was part of the groundswell that led to the huge amounts of funding that now go into infectious diseases and fund those vertical programs such as Petar for HIV, and the Gates Foundation for Malaria. There's no worldwide celebrity who's got a bit of hypertension who's out there saying we can't have people dying of o oo, of, of hypertension in Africa that just, you know, you just don't hear about it. So there's just less funding and most of the work we have to do is through public health, uh, um, expenditure and a, a, I think we're trying to work out a way of piggybacking without disrupting all the good work that's gone into infectious, er, diseases, uh, as well. But if you go and do a ward round, whether it's in Kampala, in Uganda where I was or no. Now in Malawi and you go onto the general medical ward, the doctors you work with, they'll whip round the ones who have got stage four aids and they've got complicated malaria and they'll be sorted quite quickly. It's bread and butter. And then you get to the 34 year old man who's in DK A and he's been in DK A for four days. He's having one glucose level a day. There's no keto strips to blood gasses. He's getting some intramuscular boluses of insulin just to try and keep things going and no one knows what to do. You see someone else, a young person, 41 year old, maybe with a subarachnoid hemorrhage cos they've got uncontrolled hypertension, which is such a, such a big thing across the, uh, across the African region, particularly, no physio coming in for their stroke rehab and no decent antihypertensives compared to a diagnosis of HIV, relatively early on triple therapy, one pill, once a day free at the point of service. Rest of your life, you can live a long and healthy life. NCD. S are a massive, massive problem in low income settings, uh, at, uh, at the moment and the cancers are a whole kettle of fish completely and a whole other thing. But that's how the sort of cards fall on the general medical ward in an African setting. And so as we get on top of more of the infectious diseases, people are dying more and more of non communicable conditions and that's gonna increase. So if you're strategic about your uh career and you've got 30 years ahead of you come and join us in MC vs. And while there are, of course people on the streets talking about HIV, there is a groundswell in the public uh saying my young mum or my young dad or my brother and sister has died of this and just living in Malawi talking to the guards that look after the hospital or, or, or, or, or whoever you see in the shops, the, the, the, the the stories you hear constantly about young people dying kidney failure, not sure why. No dialysis, it's just constant, you can't believe it. So, you know, diabetes is an example, but it pretty much mirrors hypertension because they have common root factors and the metabolic syndrome. It's on the rise of course, the population is increasing hugely that partly drives it, but there's an increase in prevalence as a continent like Africa goes through a huge demographic and nutritional uh tran transition. So there's certainly work uh on the horizon and uh we would be foolish to think that these conditions are exactly the same in a, in an African population, er, than a Caucasian one. I mean, I was tempted over to Uganda, er, because of the team that was working on the different phenotypes of diabetes that we tend to see in people of Sub Saharan African origin. You might know this from your practice that someone in their young forties, slim bit of a belly, maybe who has this ketone prone type two diabetes. It goes into DK. Is it type one? Is it type two? Uh, not sure. So they were, they were investigating that and sure enough found that lots of people presenting in that sort of time of life, late thirties and early forties had that phenotype of, of reduced, uh, ba cell uh production, um, uh, of any step and it's very different in that it affects a different part of the population. Clearly, metabolic problems are, are, are a problem of deprivation, uh, in the UK. Now, er, quite the opposite across the African region. Actually, they are still how we used to call it diseases of affluence as people move into the cities and take on western diets, ultra processed food and the amount of sugary drinks that people are consuming an absolutely unregulated capitalism of ultra processed food companies is just sick, to be honest. Uh And people are becoming sick as a result and there's gonna be no shortage of it as time uh goes by. Um And this is borne out in the data. This is in northern Malawi. So you've got uh hypertension on the left, diabetes on the right. Uh The dotted line is in urban areas, the long way, the capital and Toga, which is a DSS, uh, in a rural part, um, as a, as well. So just moving to the city and taking on all the aspects of life that come with urbanization, er, seems to increase your risk of MCD which are particular p when you develop me earlier in life. Uh, and that's a typical care cascade oo of diabetes care in a typical Subsaharan African country. So there's all your people with diabetes, only half of them ever have a glucose test. Only a few of them get a diagnosis. Very few indeed, get some advice and even fewer still end up on any treatment at all, which has to come out of their own pocket as well and compare it and, you know, you don't want to be competitive with infectious diseases. You don't, you want to learn and understand how, what's gone so well in the global fight against HIV. But there's a typical care cascade of HIV, care And of course, we're going towards nine, 1990 for HIV. And look where we are with diabetes with, I don't know, 1520 10 something. Um, where we are, we're talking about two conditions, multisystem disorders that affect organs all over your body that kill you within 10 to 15 years. Just like HIV. None of the funding these forest plots show the kind of complications that people turn up with when they're first diagnosed. So on the left you've got uh diabetic retinopathy and on the right, you've got nephropathy. So when people finally turn up in hospital, there's no function in primary healthcare. No GP doing HBA1C. SA third of them have already got massive microvascular complications and the horse has already bolted in terms of um ii in, in terms of what you've got to prevent and the amount of people losing limbs due to diabetic infections. It's uh it, it, it's quite shocking when you see it uh on the wards and you see that in our setting, most people with diabetes die of causes related to it uh in their sixties. And above this is what we see and that reflects what you hear on the street, talking to, to the public that these are people dying in their twenties, thirties and forties, all sorts of barriers to quality care. You can't just go and train people and think, oh, people just need to know more about diabetes. There's all these other factors as Well, I mean, that graph just shows the typical cost of AAA month of Metformin would cost you a week or two weeks of your wage if you're a government worker, I mean, you're just not gonna put that money into some Metformin that may reduce your risk of complications. 10 years down the line when, when you've gotta put food on the table, supply chain issues, uh, hospital facilities and like all these things as you sort of zoom out, you realize that there are massive health system structural problems which prevent you doing with the good work and you go and do as many training courses as you like in diabetes care. But there are downstream or upstream, er, er, er, barriers um that you're, that, that, that you're facing. So how does this intersect with maternal health, which reports my area of interest uh, within it. So, er, I II was in Uganda and this was sort of a four called medical training and I was, uh trying to get some surgical skills up before a job in South Africa to do a Cesarean section and, and the basics that you need for a district hospital. And they asked me to audit the maternal high dependency unit. And so at least just counting up the numbers, uh, over a couple of months there. And what I found and I suppose with a physician's eye was that lots of the women in the HD U had complex medical problems in pregnancy or have got Hellp syndrome by them and really needed skilled multisystem physicians to look after them rather than quite surgically trained obstetricians in that kind of environment. And there was a disproportionately higher mortality rate, er, and occupancy of the HD U itself. And that sort of started my interest in obstetric medicine and I was pleased to find out that there was a growing small but growing niche in the UK. This is maternal mortality in the UK falling. It's already quite low. But in the UK, now more women die of underlying medical problems in pregnancy rather than direct, er, things related to the pregnancy, like postpartum hemorrhage or Clancy or sepsis. So that's good because there's a job there for me and there's a job here for me saying strategically, these are the things that you kind of need to think about as you're designing your portfolio career, as they say. Ok, so you've gotta get the one on the right, but I won't blame you if you don't get the one on the left in Malawi, who's the one on the right? Paula Radcliffe. I heard it. Mumbled. Oh, she's a National Treasury. She's be belting it out. Um, uh, and she's a marathon runner of course. And that's Theresa master who's a Malawian marathon runner, er, um, who did very well in the Rio Games. Uh, when he trained for a marathon. I know we've got cardiologists in the room size of the heart, thickness of the myocardium, weight of the heart, whatever it may be goes up by almost 50%. And the same happens during pregnancy within a few months. Quite a lot of it happens in the first three months. So it's not a huge leap of imagination to think why someone with impaired systolic function or why someone with a stiffened rheumatic valve might have problems as a pregnancy progresses. It's not just the heart, it's all the organs. The uh pancreas is working twice as hard pg fr needs to go up by 50%. So again, it's uh logical to understand why underlying medical problems cause all these different overlapping poor perinatal outcomes that we see in pregnant women with medical problems. Uh It's referred to as a stress test for life because you might be going along quite happily with a subclinical underlying condition. And then the physiological stress of pregnancy might put that into an overt condition, which we call gestational syndromes like gestational diabetes or gestational hypertension or whatever else it may be, which seems to dissipate after the baby is born but raises its head 10 or 20 years down the line. Imagine that crystal ball for almost half of the population who get pregnant early in life, telling you what condition, it's it the mind boggles. Why this isn't a much huger area. Imagine that period of life that tells you who's gonna get noncommutable conditions later in life. Giving you that opportunity to intervene early and stop those things happening, exciting as that is stopping things happening. And so, um the first study I was involved in uh in the African region was in, was in Uganda. A a and the study was designed really to look at the risk factors and the burden of gestational diabetes in five sites around Uganda. Uh three in Kampala, one and Tebe in a rural site in Osaka. And, and for me, it was just a AAA great opportunity. I did this as part of my academic Clinical Fellowship in endocrinology and diabetes. And it was a fantastic opportunity just to be part of a big research team and understand how, how, how it all works and a great opportunity. And thank you to my GPD who let me take that opportunity when it was something that he hadn't really come across or considered before. That's an important thing. Choosing a good GPD who's got your, who's got your interests at heart rather than some other uh uh uh uh reasons for allowing or not allowing trips abroad. Um 3000 women for a glucose tolerance test. They were really looking at the insulin curves and C peptide and all the rest of it. Sorry, the, the text hasn't quite worked on the transfer, but almost 10% had gestational diabetes. I mean, whenever my brother and sister aren't well traveled, but whenever I go to Africa, they say you can have enough to eat, you know, you're gonna be ok. This isn't the pro and, and so you would, you, you know, you might, you might imagine that conditions that are associated with high carbohydrate diets and that kind would be rare, but they're not in parts of the world. 10% is similar to, uh, to the UK. Um, they thought they'd see more of the slim diabetes. There wasn't so much it was more to do with the traditional risk factors of age uh parity. Er, and, and BM, I interestingly a little bit of an association with university education and private clinics with this condition of affluence rather than deprivation. I was interested in the maternal and fetal outcomes of these conditions and I resisted the urge to go into depth about my work. But the headlines were actually for the women with mild to moderate hyperglycemia, gestational diabetes. Her pregnancy outcomes were very similar to those with normal glycemic pregnancies. It was the women with type two diabetes that did a lot worse. Thank you. That worse, worse outcomes. But if you've got limited resources, you need to know whether GDM is a horse worth backing really. And, and that do, that doesn't bear out in the data. And I had a look at the mild to moderate hyperglycemia and mild to moderate hypertension. Uh tried to understand the, the um contribution of each of these different variables and it was hypertension and obesity that were coming out right on top, rather than the hyperglycemia a a as probably places that we need to focus our efforts on. And what we learned doing that study, I suppose, laid the foundations of my own study now, which is called the Prone study, pregnancy recognition of MCD S, early women who are prone to bad outcomes, but also prone to NCD S later um in life. And so I wanted to focus on overt conditions rather than these mild to moderate gestational syndromes. We had to consider all of these instead of thinking about conditions as a silo. And I really wanted to understand how we could detect these at the booking appointment as early as you can in the pregnancy. So you've got an opportunity to intervene but also early in women's lives, understand the broader challenges a a and really head towards implementation uh with a with a, with a local cosign team uh to think of an intervention together that would be suitable er for that er setting. So we are in um Southern Malawi in Blantyre where the Wellcome Trust has been funding our Center for a lot where it has lots of funders now, traditionally Wellcome Trust, University of Liverpool, Liverpool School of Tropical Medicine. Uh and it's a beautiful place and we have two sites. So one in Blantyre which is about 12 1300 m and you drive down the M one and you hit this plateau with this just amazing view. Over the lower Shera flood plains, which is down almost sea level of hot malaria for a rural uh uh and more deprived population. So two quite distinct populations um that we're looking at and again, instead of a slide with the protocol details and all the rest of it, I'm gonna show you some photos of the fun it is to do research in this part of the world and have a team. So we've got four research nurses that we work with two in each of the sites. And we've been doing training and glucose tolerance tests and urine dips and all things NCD basically and having our, you know, uh ethics visits and all the rest of it, uh just did the first placental growth factor in the larvae, which we're very proud about. So we're looking at some novel biomarkers, uh the L GF but also um uh glycosylated fibronectin, er, and the rural side, it is half an hour away. This was last Friday after work within 30 minutes in a game park looking over the Shire River and that's part of the fun of being in global health and working abroad and just seeing beautiful and amazing places that we're very lucky that, that, that Malawi has lots to offer uh from that point of view. Uh How long have I got 15 minutes including the Q and A? Ok. Well, I'll, I'll rattle through this implementation science and hear about it. But it should be part of everything that we do. Now, what is it? Well, it's actually doing the stuff instead of having the ideas and working out, they're efficacious in a very uh artificial environment. It's that extra step. If you've got a spare hour. Look at LS HG. On the last um uh Steven Lawn lecture. It's about the no do gap in tuberculosis, but you can talk about the no do gap in everything in maternal health. We know how to take women safely through pregnancy. We don't need any new stuff. We just need to know how to do it in different parts of the world and it's mad how much money goes into research and new stuff and A I is gonna do it. We're gonna have tablets in rural health clinics. There's not running waters in the main hospital. We just need to understand how we do the basic things well, and it's intuitive again to wanna do novel, exciting stuff. Boring. Just doing, you know, big sepsis is a big part of the team that I work with. They're doing a big hand washing thing. Is this really what I can do my career, a big hand washing thing and some vice work is that we're still doing hand washing, you know, as an intervention. So these are the basic things that have to be done well and have not been done and women die of infections now because people don't wash their hands uh so everyone wants this silver bullet, but Global Health is basically plastered with empty shelves of ideas that never turned out. And the reason is we've been doing it backwards. We have a good idea as me sort of caucasian with all these good ideas ready to inflict it on Sub Saharan Africa. It can be anyone if someone from the Global North having a bright idea here and then going to Malawi or elsewhere and inflicting it and saying this is gonna work. No, we've put too much of it, this is gonna work, this is going to work and it's a big waste of money because they don't work because you need to go to a place and you need to look at the environment and understand the context and understand what's going on and get people who live. You work there to really design your design, your intervention and be there to guide and bring the expertise um that you can. So all the funders now are looking for people to say, look, I need three or five years to, I don't know what the intervention is. I don't know what I'm gonna do, but we need to understand the context. And if you're gonna read one paper on implementation, it's the new MRC F framework for intervention er design bit busy like that. I know, but it's just saying you need to understand the core elements and then go round the circle of getting somewhere So for my phd, you sort of design it based on this a systematic review to understand what, what everyone else has been doing a cohort study we're doing, we're following 1000 women through and the qualitative work to understand all the stakeholders, to identify the key uncertainties, how prevalent in these conditions, who's getting them and then to either create or adapt an intervention and this and th that's before you then go on to feasibility and evaluation. So this bit takes three or five years and then the feasibility bit in another five years and refining it and you don't get to that thing that you wanted to do, which was the big cluster RCT and the intervention. How are we gonna reduce maternal mortality maybe until the end of your career? And I'm going through the process at the moment of work. When I did my first phd um application, I was gonna be testing a pilot intervention and see if it worked and all that kind of thing. I've been stripped down ever since and say, you know, hold on, this takes a lot of work. Don't waste your money, you waste everyone's time, do the groundwork, pick your thing and make a career of developing that over 20 or 30 years. Uh The biggest driver of an equity in global health is probably gonna be the climate crisis and you just cannot think of any of these, any anything global health without thinking uh about the climate crisis. You can pick any story from the last week. I tell you about Malawi. Last year was the most ferocious cyclone ever recorded in Southern Africa. Cyclone fre absolutely devastating Southern Malawi just had the rainy season. 1/5 of the rain compared to the last 20 year average, everyone's crops have failed. Both Malawi and Zambia have just announced national states of emergency because of the hardest been in the news because it's just common now, isn't it? Our nanny who borrowed some money to get the fertilizer at the beginning of the year just haven't got a single ear of man off. Her. People are really desperate and this is making it worse than I smoke. El Nino makes Southern Africa dry, makes East Africa wet. And I've got friends in, in Nairobi that are underwater and can't get to work because of the torrential flooding that's going on. This is real and it's happening in real time and whatever you do in global health, you've gotta think of this, a part of it. And there are two things I will mention on it. Firstly, you can actually think about strategically how this can be part of your career because all these research units at the moment are maneuvering to understand how they can be part of this cos they know that funders are bringing up money for it and they've got to keep their, their research unit alive. So if you're interested in this topic, go for it cos there'll be more funding coming on board. You know, it's a shame that my topics II wish it was more involved in the climate crisis, but MCD S attached to ultra processed food, unregulated capitalism. You know, there are lots of common threads about the direction the world is going, whether it's the climate or the diets that we eat. So follow that, I mean, this is just a couple of papers from the Gambia about heat, but look, welcome, announcing new teams to look at, you know, the kind of prices and maternal health. So it'll be cropping up in every part. That's Sarah be, you may know and she's just been suspended for five months to register for, er, protesting peacefully. Er, and everyone's very worried that we really shouldn't raise our voices as, as doctors because, er, er, er, er, er, um, we're gonna get in trouble. Uh, that's what the B MJ was saying. Er, it's 100 and 20 pages but I skim read it. My God. You can do a lot before the GMC gets involved. I've met Sarah. She's lovely and she's very grounded by her inhibition of goody two shoes. Er, er, she's been up, protest, being dragged off, things change to things, flying drones nearer airport or whatever. So, if you're thinking about keeping quiet, not talking to friends and the rest might get in trouble. Absolute b, talk up, inspire people. Talk about it. I mean, Sarah's retired. She's been suspended from the gym for five months. I mean, you know, uh, she's gonna, she, she's gonna be back out there and she'll be struck off and that'll be another big thing. But don't think we're gonna get struck off by talking up about this. It's the most important, uh, it's the most important thing of our generation. Colonial history. Here we go. No, I've got another hour at night. So I mean, the the biggest driver of, of, of, of poor health outcomes across the world is poverty and the way that the world works and functions, keeping poor countries poor. And a lot of that has to do with the history of the last 200 years. Here we are in Chelsea. What wealth that is really founded on the extraction of wealth in countries all around the world which we did industrial revolution, lots come from it. And we can say, well, you know, we had to do it to achieve what we did. Malawi can't go and extract resources from another country. Tiny GDP, the main source of GDP is, is un uh unrefined tobacco use. They don't even roll cigarettes there. And it's pathetic. Anything that's imported, exported, there are taxes across Mozambique to the sea. The whole global trade system is geared towards keeping you country and poor. And you know, we can go and think we're doing the right thing by helping global health outcomes and the rest of it. Tiny, tiny, tiny compared to what needs to happen is economic development. In the poorest countries of the world. There were no TB, global health TB teams got eradicated or not eradicated but, but got TB. Out of London, there was no global health that came and help us. We just economically developed and learned how to do it and didn't go away. Uh So this was a paper and she was a fellow, a few years above me, she was looking at cook stoves and if I've got two minutes, is it too small to read? It probably is at the back. What was nice in this paper is that she said before I go on and talk about my little special. Just let me recognize the main drivers of poverty in the place that I'm working and they are because of our history. Uh uh Not that we should go around just being terribly guilty, but we should recognize, recognize that and have some humility about it. Um In all, uh in our work, I would say the five key points of origin of global inequity colon process is fine colon influences on post colonial regimes and independent nations. The structural adjustment programs, recent international systems of trade, we subsidize the crap out of agriculture and all those things. These countries can't go through the steps of development that we did because they are held back by international systems of trade. Now, there we are trying to introduce Glucomet. You can't be too depressing. Many of you will be a student and you gotta be optimistic. You gotta look at the numbers and look, you can say Malawi's stagnant GDP and it's so depressing. But you look at that decrease in return of mortality sharper than anywhere else in the world even in the UK when our mortality, mortality rate was dropping in pregnant women. So we're making absolute strategy and it's fun to be part of that. Uh Actually success story even though it doesn't feel like it's sometimes on a day to day basis. So that's what I talked about and I've got a few minutes for questions. Thank you pretty good. Thank you so much for your and I think everyone will agree that with an excellent start to the day. Um We have lots of questions come in for you um before the conference. Um One particularly is about about point of care testing. You mentioned that patients often just don't get their glucose measured. So from your experience, um how much point of care testing or lack of it is there? Well, point of care testing is where it's got to be because the infrastructure and money that needs to go into central labs is too high and we need to do more before that. So you can get point of care testing for nearly anything. Even PLG F which is that a new biomarker? It's a near patient marker that, that we're having. But again, technology cannot just save the day. You can't flood subsequent afterward, point of care machines and expect that to make a difference. You need the groundwork, it needs to be upstream clinical governance and how do people use them? There are BP machines all over the place. There just aren't any batteries in unless you've got a good supply supply chain officer in your hospital and clinic clinical governance team who get batteries or get a rechargeable device, you can, it doesn't matter how many you've got. But if you're interested in point of care, you've got a career in front of you soon. All of the blood test we do and all the blood tests we're doing in our test with a point of care. So yeah, get on with it. It's a big, big field. Brilliant. Thank you. Thank you. If anyone has any questions and those two questions, can you just click it? Sorry at the front, at the front, I'll repeat it if people can't hear it as well. Thank you. I'll repeat it. If you can, I'll repeat it. If you can't hear me, just say it and I'll repeat it, just say and I'll repeat it. Ok. Um Was so OK. But yeah, good one. The key message is that it's got to start with a sense of uh uh of adventure, I suppose. Look, lots of us wanna do global health because we know we got one shot of life and you want to live and work in interesting places and understand other cultures and other people. But you can, this is the key message in your medical training. You are allowed to do whatever you like. The message from them is that you're not, they gotta fill the road. So you just gotta advocate for yourself and trust me. If you show the passion, you show the interest, there'll be a couple of seniors that spot you out and say we'll help you follow that and it is slightly different to the norm, but we've seen that interest and passion. So knock at people's doors, send emails. Every reply you get for a potential job, takes 10 emails where you don't get a reply. So just keep plugging at it and show that passion and it will work itself out. So the straight up just so that you don't need stretching at the back, far back. It's and and multiple health condition. And so I want to know, I, I'm so fascinated, I'm still on the clinical work. What we, what we are all losing are, are those general clinical skills which were so key to medicine when we were at medical school. And just before everyone's getting highly specialized, there is of course a roadmap to being more generalist. But it's the work that I've done overseas that I've felt really home by clinical skills. Cos you see clinical signs, you look after people before they've got the clinical signs for the most part in this country now. So you see that stuff and you can, and you can apply it back. One of the key things is you understand what really sick people look at. So, obstetric trainees in the UK, spend quite a big portion of their day looking after people in pre practice trying to stop them, having their or most, none of them have ever seen an Eclamptic fit or what it looks like to be really, really unwell from preeclampsia. And without that knowledge of where it can go, it's a little bit hard putting that passion into the, into, into spotting, earn signs and stopping what's gonna happen. So that experience of seeing severe disease shapes how you are, it means you don't need to overinvestigate when people are in very early stages of things. You can be a little bit more pragmatic and be confident and say that person can go home instead of erring on the side of caution more and more which is filling up hospitals and causing a, a huge cost to be as well. Cycling is round you if you have clinical experience to uh to not admit everyone you've seen because because you haven't done enough clinical time. Thank you. We only have time for one more question at the moment. Um So I'm gonna go to the back and yeah, so um so that will help um my main question is he tend to take medicine, I think. Yeah, that is amazing. So I actually come up with a lot of traditional, we tend to take a lot of these interventions to places like Malawi very medicine. And I think, although that is amazing, I imagine you come up with a lot of traditional, a lot of cultures and traditions and cultures. My main question is how have you adapted your practice to suit their traditions and their cultures? And what are the challenges you face with that and what you can and, and support what they're doing of local, you can it with any of your level and you just can't believe what it's doing everyone. This isn't right. Thank you so much. So Jack, thank you so much for your opening the day.
