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they're recording has now started. This was going to be a way of seeing where people are sort of joining us form. And here is a current volunteer. And if you listen, But actually I think there's only a few people if in a chat you want to just put whether you are already with us as it went on its you're interested in getting involved, that that would be quite interesting. Just no, uh, don't worry about scanning this cage just that better, dear, Uh, And then, for those of you who are joining us just a little bit about us, some your seasoned season names that are recognizing you already know this. But essentially the voter doctors has been around for over a decade now. We're going to hear from you about it. So it's our genes instead of what we need to just to start it up on. The whole idea is connecting isolated, isolated healthcare centers where they are quite limited in terms of their resources, with doctors on which is predominantly a tailor the moment. But the long term plan is for me not to take over, so it's a suspicion system integrated into it. into a zombie in healthcare system. Um, and we give it must occur. You advice us that many do. You are on, I guess. The main thing, like in so many countries, it's, you know, we sometimes complain about getting a doctor's appointment, but actually, we're very lucky with this statistical. 1 to 360 people when we compare it to the figures in places like some of us, are vastly different. Andare name's really to just promote better care for patients on but in a sustainable way on. So the fact that people continue doing this one's working in the air. It's best Jobs is really useful on hoping to reduce unnecessary referral tops of that spray quarter. There's gonna be some cases where they can't reduce referrals on a lot of it is really about helping clinical officers with their personal development on don't make me feel less isolate because that often complete their basic training and then go out to dinners, health centers, where they, you know they will deal with that much anything that comes through the door. But often it's a case of not having that same support network. If we can help it able that that's really useful. And the idea behind you know, someone comes in with other sweet woman arrows. With that, we can advise them and then that here, learning to get cascaded down to to their colleagues on. And like, I was saying, also, we want it to be a sustainable system. I'm just gonna look in the chat about to see. So that's come on. Don't care. Recently joined on tears. So then radios, even 10 urology sometimes stick gp psychometry to start is about debt accident on Don't know. What about some artists? Great. So you probably noticed that that so they're supposed looking at the the past year in review. So it has been I went I've been a challenging yet or bad, too. Probably when we had the last conference. Just a 12 months yet on the clinic, numbers are fairly similar. Um, so we're still, uh, came for a wide section off the family on we aren't it around 4000 cases in 2021 which is just really good thing. Case broke down is, um, get fairly weighted towards General Is, um, on that partly because the clinical office is the one to select which specialty gets chosen the bad taste. So I often come to your general Mestinon general practice and actually get Realitatea that maybe was a lot of cases also go through Teo dermatologist ically when they've been taking appropriate pictures of the skin rashes. Or sometimes I get into pediatrics, infectious diseases, gynecology and things like that. Um, yeah, I won't have passed you boy. Sometimes see the f. C e o underwent Teo changes on in the last little while and unfortunately, that head upon there is budgets. Granted, things that we had in the works, which was ashamed, made things quite quite challenging along with Okay, this sort of affecting. So the mass participation events, which we sometimes get get a bit of our friend into that that has been a bit challenging on. We'll hear from the board and maybe here in a bit more detail about how we kind of come through that, and that's been exciting. Projects kind of feeling forwards. Um, volunteer numbers have some used it on down a little bit on. I think that's just, you know, a few reasons I think on our system we have got some historic volunteers for a while, and this would have been working out who has long gone when? So if you haven't signed on for a while, please is doing if you have any colleagues we think would be interested in getting involved in while means please, respect with it. Um and I suppose otherwise that No, I've been attending a few conferences there. Is that just to pick your hair? The world, actually, a medicine conference where I was talking about the two doctors were trying to get more people involved, which is really nice experience on then, looking towards the future on down here. Get interested in a bit more detail. Really. Um, but I suppose it's what What comes next? Where do we want to be? A few years time, and so we're sort of looking about expanding into Malawi. So as you may or may not may. We currently have six clinics in Malawi and had until of doctors on a separate system. Uh, you get cases from long way, but we don't have a huge amount, and the plan is to roll out of it more on. Then we need to think gate. What is our long term plan to meet in sustainable in it Zambia's Well on. There's a whole strategy in place to try and look at our tea, which is currently done by volunteers. And there's a lot of ideal things would like to achieve with our diet and our systems about how the APP works as well as the bath and works for us when you log in. How many of balancing against Ms Ms Reality and being a charity basis on then finally, as your air from grand from the board, we we have a new CEO so huge owns his own on the cold will ask you, uh, is the founder on be outgoing CEO who has a huge amount of work with about two doctor today They're stepping down on, but James Fear is, is joining, and so there's lots of changes, but it's also a very exciting time to be passed off the Detrol doctors, I think, on down just going to show you what the generalist for the rest of the meeting will skip. So basically, we're going to hear from from Doctor Martin Dedicate. Surely here is the colon is one of our infectious disease specialists then we're gonna here in a bit more detail about Hughes. Jenny, I'm from working as a safari. Guys, they're setting up to the tune up. Please on. Then we get ahead form. What about medical offices? About his experience. There's a kind of a status helps on. Then, after it's S O but short tear coffee breaks, we will have, uh, and listen to So what's done by my who's one of us? We 1st, 1st time in a virtual student electives. We had two students joining us. Uh, this is looking at some of our data as the things like that So motivated. Audit, along with David, one of our planet is looking at antibiotic use. And how about is, uh, maybe slightly differently in Tampa and Poppy, And then one of our student's going to ask me about what you eat, even elective on. Then lastly, Gram, our chairman of the board will just say hello and there's lots of faces behind the scenes. You you still do a lot that they're necessarily on get knowledge. So that's quite important. Is what I meant. A chance to have any. Any questions at this time table is, is a bit fluid. A swell I But I thank you for you for your heart yet. I, uh Now get hand for two martinis If you should be able to share your screen if you if you dont. I just turned off nicely in sharing me. Say hi, everyone that Thank you, Daniel. So you can all me there and I'm gonna trade. Not showed. Complete technical article incompetence. So I'm not going to share my screen. Say, hopefully Hopefully you can see some slides there and hopefully you can hear me something. A thunder from Daniel. Thank you. So, look, I really like being a virtual doctors volunteer, so I'm going to be a little bit playing a bit about my background and I'm going to mention too, really cases that rest by the clinical offices. And I'm gonna show you what I think. I should have been the answers. They weren't the answers that I gave. In retrospect, I could have tried a bit harder. I looked through a few more resources and hopefully you'll find some of this interesting say I'm infectious disease consultants in boom again. We also work for and what used to be called p h E p is now UK HSA sayings I don't think it's good having security in the title of public health organization, but that's that's what the government decided to call. It's and I've been a virtual doctors volunteer for three years. So I mean, burning a couple of pictures and burned again back grains and prayer toe Working in Burma again was in. So that forget, I mean from the UK but works for a decade in South Africa in this part of Africa, which she's inquisitive. Tell on this parts of Africa, which is improper. Martin, your your slide down to about advanced. You been to the spider red? Um, just a little one at that bottom. So I'm insulation in midstream. Maybe just called on this. Yeah, we're just getting Maybe it Maybe I'll just scroll down because it's always back. Start burning him. Yeah, maybe do that. Yeah, way up to South African. Is that any that's working area? Okay. Sorry about this. So when I went to yeah, I was a medical registrar, and I thought I'd be like, this chap sitting, get a destined some very important, very high powered medical work, but the people in charge of the hospitals. South Africa are the ladies on the rights and they have different ideas. There's a medical registrar at this is what I did for most of my time. Um, obstetrics, delivering babies, fixing bones. That's his background, say on the cases. And please tell me this is not advancing. First Case is off a 40 year old man who gains the clinic coughing up blood for two weeks, and he been on treatment for several months on a low, a sensible circus that's keeping taking his treatment and haven't really been having any problems. But for two weeks prior to coming to clinically been on treatment for two months, he had been coughing up blood and just feeling absolutely awful. So what action should be taken now? I should be aware people who are volunteering Sometimes the the case presentation can be a bit thin, and you need to ask some more questions, say the medical office concerned, actually had really filled this case incident where you have to ask me more questions here early. And it was it was it was a chap, it and taking a good history of examine the patient. You managed to get an X ray, and I think that's obviously not available everywhere, and you've managed to turn off some other tests as well. So what I had asked him to think about it was the check initial diagnosis. And I'm certainly from my experience in this country and certainly from overseas. If someone comes coughing up blood, use of the right background will be in in the right setting. It's very easy to say, but it's just definitely TB. Start TB treatments and just think that that's job done. But I was frequently surprised in South Africa in people who are on TV treatment to turned out to have lung cancer or composes sarcoma or some strange parasitic infections that make me cough up. So it's never wrong toe. Go back to the patients and look through the history and see what were you right in the first place? And that's a direct rates or friend. This is a This is not saying people make mistakes. It's saying that, uh, sometimes you have to change your line of thinking, go back and re examine what you've done. I'm checking treatment. Endurance is obviously importance, and, uh, greatly observed. Therapy is great. We we use a lot of video observed therapy in Birmingham now, and I think that's something that well, pretty become worldwide. With time, just fire. What's AP? It's very cheap. It's secure, and you can watch the patient swallowing. The nurses watch the patients were in their treatment. Vira small, emailed across or apt across video, looking for resistance. This is a scourge in a problem, but we we know that or TB cases were dropping rapidly pressed, the Cape of Pandemic and 40 things have gone the wrong way, even when they were dropping the words a rise in resistance and raising more tricky cases. And I'm gonna go through a little bit about what is possible in Sam. Be a to the best of my knowledge in looking for resistance. And that's the focus on the expert machine, which was approved by wh show around 16 15 6016 has been Wadley roll dates across Absorbed Africa and many other countries. There's two other techniques that available so lame prove essay, which will be available in reference hospitals and urine culture. And before we get through that I think it's almost it's important to remember, and I'm very bad at this because it's done by the nurses in this country. Teo Ask about contacts So if we've got some with tuberculosis that we're treating with someone that we suspect talking to. But police is remember that contacts of that person might be eligible for treatments as their contacts, or they might actually have active disease. And that's especially important if the, um, index case the person with the disease has a contact is a child or a contact who's HIV infected? So I usually forget to ask that, but very important to members. Ask it. So what? What machine was talking to about? Well, this is, um, game changing machine. It's a machine that, um can give you a diagnosis of tuberculosis and see if the resistance, but closest within 45 minutes. When that this was first roll day, it was pretty skeptical. But my and my sister in law, who's a nurse in South Africa, she runs one of these machines and one of her the cleaner of her clinic. Usually the person that runs this machine's a very high tech molecular machine, which is super simple to to run. It's, uh, gives you an answer in about 45 minutes, and it is better than, um, I cross the best and much cheaper than a microscope ist. So some statistics compared to, um, standards, culturing bugs, it's, um uh, very high, um, sensitivity on the very high specificity. It's a good rule in test, really not quite so good a rule out test. It's being game changing, but there are problems with any new technology. This is certainly a massive jump forward, but it's not. Not without limitations. And there there are some issues and I'm gonna show you a paper from Zambia just from a few weeks ago, which has shown one of the major limitation of this test, which the medical offices should be aware of, so that the cartridge in the tests that I want to be too technical issue has changed. Its name is good and ultra cartridge, and now it's, um, it's being changed, is much more sensitive, slightly less specific. You can get more spit into it. It looks the different targets in TB cost the same as the previous cartridge governments do. We deal with the company so So they wear them in in huge, great numbers, and it's pretty cheap than what's what's, um, on there and it's sent it to the places where it's used. It's been shown to be m um, that the new cartridges non inferior to the old cartridge. So people have adopted it. And, uh, I think Zambia started using get, from 2019, the new cartridge that works in HIV infected patients. It works in patients who have got meningitis. Sensitivities. Best fist. He hadn't changed. It was two slight showing that that's, um and it's it's been for for TB meningitis B patients that have had a little blubber puncture. You can put their CSF in the in the cartridge. Your help with diagnosis is well, but it is no or good news, and it does have false positives, and it's very tricky to use this in people that have already had TB. So we see this in the UK well, we don't use it so much, but we do use it and you can see that it stays. Then that cartridge, when you laid up with someone sputum who's had tuberculosis in the last five years, meet me here in the last eight years, it was still give a positive signal. So if someone's been previously treated for TB, that this is not great and can cause a lot of confusion, it does detect that bacteria so you can use it to monitor patients. So this patient I'm talking about you came back. If you use the cartridge on him and he had TB, he would still be positive. It might tell you he's got drug resistant TB, but it would. It wouldn't tell you he was cured or he had something else. And this and studies is from Zambia. But the family has been a 44% increase in patients diagnosed using this system compared to older systems. That sounds great, but it probably means that's quite a few people that don't have TB that being studied on TV treatment, which even more reflects back to the first case. Because if that chap we're talking about had another cause of hemoptysis, maybe had bronchiectasis maybe had lung cancer, and we've got a positive call on this tests. That's what he's definitely got. T. Because his test was positive. Just cause the new shiny test is positive doesn't mean you don't have to think about the diagnosis to in the patients on brief E. What else could it do? Well, with the raising resistance around the world, The cartridge at the moment. Told you if you've got TB, yes or no on it Totally fits resistant. Three families in the most important drug in typical OSIs. Yes or no, but nothing else. There's new clutch is being launched. I'm not sure how they will be rolled oats across the world and the studies being done mainly, mainly sadly, in Ukraine and Russia. So, uh, may not be completely trans, uh, what might not be completely the same as other situations with the use. They have been used quite a lot in South Africa again in big centers. Maybe Janice book. They can detect other drugs. They could tell you the patient had multiple medicines. But grace is obviously a big, important Teo, uh, to individual patients, and that there's a study showing that there so that they read to be sensitive for the other drugs that we rely on ice and ice It The quinolones injectable agents are kind of my same case in which we don't actually use so much anymore. But when they were developing the test, they were still sort first line drugs. It's a tiny bit on TV. Another case is this case is any It was. It was this week, actually. Well, last week, a 42 year old man came up to the clinic with a very severe headache. He was names have HPV infection and you was on interaction viral therapy, but probably not taking it. He was on TV treatment and thought to be taking his TB treatment. Um, you've been sent for a chest X ray and had lots of cavities on it, and it had a lumbar puncture. And the sample was cats. Positives. That's cryptococcal and Jim positive on the actually sure if the test is is every other card test or a lateral flow test? But it's, um it's a antigen test. Um, and they're quite good. So what should we do? We think this person might have cryptococcal disease well and well, I I often forget, tell the medical office is, is that there's some really, really good guidelines, So the same. In consolidated guidelines for the treatment and prevention of HIV, 2020 and the Ambien TB guidelines. Which should I put it the bottom of a previous slide? Auras? Because text books and I think some of the guidelines produced in September in African countries are under utilized and underappreciated. How good they are on my way of guilty secret, I'll admit to you, is that I actually used the Box one and medical formulary as a medical textbook in the UK because it's better than any infectious disease disease textbook. But, you know, so say they don't don't forget to recommend people look in these girlfriend because all the answer that you can read the answers yourself and seem very clever. But a lot of answers are Think it's page 67 for the answer to this question. Say, there's this patient that the standard treatment, the treatment recommended, where the guidelines is intto have terrorists, insulin, injectable agents and fluconazole put in brackets flucytosine because that's recommended. But I've never actually come across the country that can get hold of three slices in that maybe maybe it's possible to get in the same area, and it's going to be a two week course of treatment that that's awful. So two week of intravenous treatment is very hard for anyone to sort of tolerates. Well, it is effective. And so a little update, which isn't in guidelines yet on um hopefully will be soon a recent trail done in several steps or in African countries, but not samba. So I think it was about Swarner Malawi, South Africa and possibly Uganda, um, where they looked to give it a single dose of em for terracing on. Where I'm telling this is because what often happens is, um where is difficult to give intravenous treatments, people resort to just giving or fluconazole, which is inferior, the amphotericin, and that the reason for that is cause seven or 14 days of injections is just not really practical in many places or for many people. But if you could just give one days, it will be like a, uh, treatment for syphilis or something. It weakness with a single dose, ever have a powerful antibiotic, and then some other things with it. So that's what this trail looked at. They plan was to give a very high dose of amphotericin ones with fluconazole, and this this is super tiny, say, uh so if you got to see that. Uh, so they looked at giving a single days about for terracing 10 mg per kilogram respect 10 times higher than those things that we use in the UK and certainly for five times higher than basis that recommended in sending guidelines once with or or flu site seen. That's a problem, because I don't think exists in many countries and or fluconazole, which does exist versus the stand it, which is the seven or 14 days of amphotercin plus minus free Cytisine. And the findings that study was it was a noninferiority study, and giving a single intravenous dose of amphotericin was not inferior. So that was great news, actually. So it means that these patients and you know, in theory we shouldn't have these patients. There shouldn't be any one with. It's called a meningitis Night, because if people got an HIV test, got answer. Powerful intellect, viral therapy, normal developmental communicators. But we know in practice, um, this is not an uncommon disease, and it's a devastating disease that if you don't need to death leads to severe neurological disability so secretive get rapidly is important, and hopefully this will will help with both. So the summary their study was that they're single dose was not inferior. Teo, the current gold standard, which is seven or 14 days of intravenous treatment, I think is great. Say that's it gallops free. This's my one trip to Zambia. This is when we're still water. There is This's actually my honeymoon 20 years ago when the same beam was full of water. So thanks very much happy to answer questions. I think claim means that will be on to the next session. Thank you. And I'll stop sharing. Thank you very much. Started. That was it was really interesting. I really enjoyed that. Does anyone have any Any questions for months? Otherwise, Ankle. Uh, so I'm not I just I just wanted in your experience off cancer in cases on. Does he recommended medical officers get experts? Do do you find the most clinics? Have them win. The prize is awfully. Try to update what clinics have what or do you find out there's a land they have to send a sputum sample off somewhere more centralized and things. I just wondered about that. That's a good question. See, I did one actually start thinking I have the exact figures, so there's three situations. They got it. It's working. They got it and it's not working or it's nearby. So you're usually people can get it, but they seem to be sort of stock. It seem to be not uncommon from from, uh, the last year of cases. I think that's interesting, I guess. But I guess paradises like supply chain issues, it's kind of like accepted with my my other question about, um, honestly, you know, you may have someone who's has MBI TB or it's a certain treatment regimen. Honestly, I think this exercise, that is what you need. How often do you find his name will? Actually, we don't have a certain component that is needed. Is that is that common? Yes, see, So I'm very cognizant of that. And the way that the deputy organizes MDR TB treatment is is a green light committee, and only certain places were allowed to have the drugs. So I've made the assumption, maybe wrongly. But no one that I'm advising will have those drugs. So if if if it sounds like it's an MD, our case of just, um So I tried to respectfully suggest that the patient is referred. Teo um, an MD or sense? I mean that that's what happens in South Africa, this one province. So I assume it's a similar sort of thing because I think one of the issues is, I mean, the drugs in the MDRD TB regimen. A really great, and they're really great for other things. So you just don't let anyone get the hands on them. So they kept just in certain places. So there's a big issue some years ago in a sub Saharan Africa country where the quinolones in the MDR regimens got into general clinics and it pretty drove cholera in that country. Guess enough. That that's the difference is not taking as well. Sometimes I mean, it sounded like that little case. You you were saying that the clinical lobster gave, you know, a decent history and examination findings. But I suppose one of the challenges sometimes it's getting a bit of a limited issue, thinking this might be going on and then you don't sort of in a very big contributing to joke resistance things I left the most really interesting. That's that's the other thing. I was also wondering just in terms of family more sort of thinking a bit more, more broadly there. Do you do find that we did? And lot of cases compared to your UK practice off people presenting with much later They're a surviving illnesses books one in what sort of thing you tended to come across. Yes, we do. You say so. I mean, actually be, as you know, is not a huge problem in the UK Now, in Birmingham, we have two forms of late presenters. And there, um, intravenous drug user. You've stayed into the radar, and this's awfully busy or older men who maybe being to Thailand or life. So I'm boda and not really thought for the better. And then 5 to 10 years down the line present with unexplained illnesses, this or two later groups of people we see interested and I don't know, you've got your hand up from done. Thanks for that, Martin. And I'm sure I heard your voice a few years ago in Birmingham. Good to hear it again. And I wondered you mentioned people tested positive on the expert ultra following completion of treatment. So from a practical point of view, then if you're a clinical officer in a peripheral setting in samba is the assumption. Then the best option would be to collect a routing sputum sample. A good example is he can and then send it for normal microscopy. Yeah, they're sending it again. Or experts. Yeah, that that's that's actually the right thing to do. You see in that cartridge that the redesign countries they put in two targets Which Russia? The targets that you use for detecting microbacteria DNA in modified remains so they can detect t being Peruvian skeletons from 6000 years ago. Say, detecting a bit of damage DNA in a patient that had TB four or five years ago. This is not uncommon. So it's, um it's Z a great test. But you do have to think about like that. I think in really high instance, settings where people are catching TB over and over again, they lose utility. Yeah, that's fascinating. About 6000 year old nothing's I guess it. It's, uh so is that I guess you may have positive one and then actually, like you're saying in in your talk to another cause of hemoptysis, maybe, you know, at risk of potentially looking, I guess. Fantastic. And And I think, um, I just put in there in the chat with you can there at the name off box one is sidelines. Let me find useful here with a piece of paper. So great, that was really interesting. I think they asked many more questions, but I'm conscious. That's there Way are sort of running out of time a little bit, so thanks, Martin. Then we'll there now. I just switched to our next talk on which is from Mr Huge and say, here is the founder of the Virtual Doctors. Um, and he has been in the studio for about 15 years now on he's put so much happening and they're waiting for starters, which I'm sure you agree is there's a really wonderful organization to sort of volunteering on. And he was just going to talk us, know that his his journey from his work exam the excess sort of present day and say, Oh, yeah, over to you. Thanks a lot. Daniel thinks that kind of structure, and I see everybody and meet new people, and the master thinks that's superb. Uh, he is Well, that's pretty interesting. Yes, as I was. I would normally if I do it, talk to the conference like this. I would I would have a much doctors go straight into the virtual doctors, but Daniel twisted my arm. It's anywhere we wouldn't hear bit more about how you got out to Is Amber in the first place in the background. So I to share my screen could bring up my, uh, give me a second of stuff. Get my technology. That's well, right? So But you're so manic. Your main issue huge owns without fat under the verge of doctors, I suppose. Why? Background is now about 30 years. Um, more than 30 years now. It was working in Africa. Million. Sandia. I first had the opportunity to travel Deserve you're 1989 Onda uh, Zambia Night and 89. Very, very different place. Geopolitically, the whole reason was very different, Of course, getting of historical context. Kenneth Kander is unfortunate. Recently passed away. Actually, he was the very first president of independence and Bs or exam. Be a cream independent. 1964. Kenneth Kanda was the first president and he was still president here in 1989. There he is on the top left meeting Fidel Castro and in Cuba in 1989 um that the neighboring countries off Zambia particularly Angola on, uh, Mozambique. We're going through a very harsh civil wars have been raging for many years. They could see Jonah seven be at the top, right? There were famous character from the unique to Angola on days remaining proxy wars. Nothing really changed throughout history, but the you had proxy was really in Angola, Mozambique. It was in Mozambique, Renamo against Fremaux Onda with African support for an arm. Oh, on breast and light support on water pack countries supporting Fremaux. And then they gain in there in mango that it was the same you had. You need to support it by so Africa on the Western alliances. And then the Warsaw Pact country is supporting the N. P. L. A. And as a result, huge numbers of refugees poured into same and there's a lot of them actually established very stable communities. And there's this day on, then way to the south. Beyond this, about where borders of Africa the apartheid system was very much still in place. Nelson Mandela was was still imprisoned. Then And then, of course, you know, later that year, there were other world shaking events in other parts of the world you had, you know, Tiananmen Square, and then the the fall of the Berlin Wall actually was actually the fall of the Berlin Wall on the collapse of communism. But that was actually the final death. Know for a part of it on gum it the chapter on the left FW clerk really have no choice but to make peace with the gentleman on the right. Of course, not a Mandela on the rest is history. But that was the sort of that the Zambia I I arrived at in 1989 and geopolitical just get a bit of background there. And I had the opportunity to I was invited to work a sort of a safari guys at, Ah, beautiful, beautiful National park called the South Long but National Park. I don't have anyone who's visited Zambia. Uh, the South longer is basically the very bottom end of the great Refer me. The great Rift Valley has, you know, pretty starts in Lebanon, and it it runs away down through East Africa. And there's a peters out near the October and go delta, but on where, roughly where. Zambia, Malaria and Tanzania meet. The great rift splits on the eastern split forms. Lake Malawi. Absolutely gorgeous place on the Western splits forms longer belly. Here's the longer river. You see that blue line right hand side there and the flow is basically from the top of the splits away down the valley, having the northeast down to where it meets the's and easy river wears of our way. Mozambique on Zambia Ulcer meat on There's no wonder, really that it's got a sore several national parks. It has incredible wildlife. So this is my is what Daniel asked me if you use this happened, but it history. I wasn't Safari guide. I was invited to work in a camp called the called Cooley and the Ginger, which sits right on the banks of Of the longer a brother. It's incredible place rich and biodiversity, amazing wildlife really worth a visit. If you ever get to Zambia on Diced and a lot of my years were here exam be over, then I'll be right across the continent. It worked in Tanzania uh Malawi, uh, Tanzania. 10 years of Africa loose you too, and some viral way. But it's Ambien and the people who live in the same and the longer really in particular always have a brace on a special, uh, place in my heart. I really love going back then and being with the communities there. This is my very first and great. That's a very dodgy foot for 1989 this is my first accommodation. That little heart in the left hand side was my home for sometime my help to build it. I learned how to make a thatched grass, and the commute is then and still do to some extent, use a lot of grass thatch in their accommodations, and it's really amazing stuff. You get this school elephant grass is a species of consent, see, And you you packet, you get some nails and you pull the grass through the nails, and it kind of clears away that the traffic few, like in your packet together makes Ray strong walls and a very strong Rufus. Well, you can sometimes use them boo. In contemporary times, people have sort of switched to using at l a million roof you sheets, which quite cheap to buy makes it been easier to put on the roots. But actually, Grass is surprisingly effective, keeping the heat of the day when it's getting very, very hot. You could walk in there to be quite cool. And then during the rainy season, you get one down flooring of rain. The grass expands and sort of seals gaps, and he quit waterproof. I got a couple of Daniel sort of say, Well, put in a couple of funny story. I've got some stories to tell you about some high a high enough So we gotta use a little wild life a cup doing And there's no you know, uh, vents to the national park. Get lions and leopards and buffaloes going through. And we used to keep up. Ah, so deficient without without little metal, Bishop walks with a wash our face and shake it outside the hut on de every night. This high in your sky needs to come through and steel or so and eat the soap. So we thought, Well, it's not keep the soap inside our hearts. So one night I was lying in my heart and I have my head quite close to the fence, and I heard the sniffing sounds on this line. A shop, his head right through the brothers took my so and started the chew on the soap. What's staring? Be right in the eyes so dribbled over my head and then and then retreat. It's that that was quite an interesting experience on because, you know, we get a lot of guests coming to stay in these camps, and there's sometimes a little bit nervous. And I got a couple of stories to tell you one later. But one was strokes is quite quite striking. We have this couple from England staying. Margaret was from Scotland. Bravery, tall, athletic woman, very strong instead of breaking. Ah, Short lived in your husband with with Mark and Margaret, and there were little bit nervous about staying in the bush. And on the first night they were there. A bridal line can't right through the camp and started calling and then a metal line for the sport. Right class. The hearts. We found his tracks the next morning when lion call, Um um, it's a bit of a distance to it's quite incredible. It's exhilarating when they're right next to your heart. you can feel it vibrating in your chest. And then he heard this science after that, the line we're calling. And suddenly we heard this Margaret telling going to husband Mark Mark, push, push on The poor, old poor old mark the LDL me that I would go on their honeymoon is Oh, dear, Oh, dear. This is been Barisic, and we could check it here in this mark. Pushing or not, they're not there. That's it. Keep pushing on on and on. For ages of you was thinking I said, Mark, for goodness sake, push anywhere the next morning. Not as bad as you think of breakfast. We said we did. Everybody sleep well on Dmard? Yes and no, I didn't see it all. Well, I thought the lien was gonna break into the hut, so I got marked to push the bed and they had this. We used to have these very, very heavy book Where wouldn't be a a big double bed. So it's four chaps had to push this huge. Wouldn't bad with the mattress on it and his wife Margaret, hiding under the Dubay against that over a sort of a nerve floor is the heart wall. So that was That was quite funny. There's a hyena, you know, the good old high, you know, with with the, uh, eating a side dish on. But it is an incredible place. You get incredible wildlife there. It's full of elephants and buffaloes, and, um, you could see it. Her development crossing the Long River and the dry season. Uh, you've got some sacred IBIs there. Um, and absolutely gorgeous. I present like a salesman for longer belly, but it's got You can see these animals in the far right is a giraffe. These are actually unending mix species and draft called the 40 Crossed. You're off when you found in the longer belly. Um on the top left there. That's carmine beaters. The Carmine's come down from the Democratic Republic. Congo. Uh, during the dry season, September to breathe and the burro These on make falls in the side of the banks of the river. So you get this incredible color the's birds congregating on the banks, the rivers. It's absolutely incredible. As emperor there we see a lot of left. One is one of the best places in the world to see to see leopard while doke. And then this is crowned cranes. There. Now I put a frog here. This is a very interesting species of frog. This is a a gray foam. Ah, a gray foam pre frog. The reason why I did this is I have another quite humorous story to tell you is well from used to get clients coming into the camps. But I specialize in walking safaris on drumming these little for the Bush camps and sometimes agents with some people who really shouldn't probably have come on a on a safari to Africa tool. And we have this American woman who's first worse mutual arrived where I read that, like in sex, I don't like reptiles. I really like like amphibians on. She'd come in the rain, You see you and we thought, this isn't going to go very well. And, uh, if anything, you have being Teo part of the world. You haven't get these little pre frogs which will sort of be often be found in bathrooms on they like to go and where it's cool, dark, damp. But they also seems to congregate quite close to where the lights. But they're little insects. They often sit on toilets. We call them in porcelain frog. So they could be quite, you know, white like that. They'll match their backgrounds on. But this one had gone off to the toilet. I certainly hope this screen was sitting around lunch. I heard the screen, and I went back into her where, you know, went to her heart door. Not from the door on it, is it? Is everything okay? She's at night. I'm in big trouble. So I went in and she was standing there. What happened was one of those little frogs had jumped into her, enter her trials. And so she sat down to have her blue shin on the Frogger jumped into her trousers. You pulled her trousers up in this frog was in her. You can imagine it was an absolute It was very funny. Not funny for her, but funny. Funny for everybody else. So that was the, uh, the the environment. I I worked him. Um, but of course, it was last I was working in Sandia that I built up some very strong and close relationships with the communities, lived in in these areas and witnessed many of the challenges that they faced particular and access to primary healthcare on I suppose the genesis of the charity really drives from those experiences. So I want to start with a little story so you can see here by the math and Zambia's and be a sort of central Southern Africa. And many years ago I was driving down very dusty, bumpy track in a remote area quite close to the longer body. And I drove down this track much like one you can see in this photograph. I started to see you drops of blood and I get going. I saw him or more blood. Now I thought, perhaps because I was so close, the park, the line or left. But it kills new animal that may be dragged it up the track because I came around this big bend, I said, Man, it was like in his bicycle with his wife, sort of sitting on the handlebars, resting against him for support. That's a pretty common site in that part of the world, particularly then and still. Still, people carry amazing lows on their bicycles and for transport, but in this case, that woman was heavily pregnant in the blood vessels coming from her. So I stopped the vehicle. I helped him best I could. And as I drove by acid man, you know what had happened on? He's taking his wife to the health center, just outside little bleach where they lived. There were no doctor's able to help him. Um, you know his wife? We needed emergency. Kirsch need to get the hospital, but there was no ambulance. T get in there on. There was no motorized transportable. So that man really took the only option available to him. And that was to try to cycle his wife to the nearest hospital. And that hospital was a good So the 60 miles away, it's like trying to cycle from. So we'll that right into lung a very long way on. When I picked him up, it was in November. It was in the in the sort of the period you builds up just before the rate he's seizing. It's very, very halt, very, very humid, and she lost a huge amount of blood, and as we drove, she just very quietly passed away in the back of my vehicle. There was absolutely nothing that I that I could do about it? No, I have to say there's not a lot Italian medicine could have done to save that woman's life. But there are the sort of events that could take place in our lives that actors a sort of, ah, catalyst, I suppose, to make us want to do something. And that was the catalyst for me, at least. So as the years in the spring, like I shared this story with friends of mine, I knew a lot of doctors in the region of the doctors in there, in Zambia, in Malawi. And I also talked to a few doctors I knew in the UK And the interesting thing was, they always expressed the same design, and they all want to help. And for free. The room wasn't None of them were, uh, based in rural Zambia. What could be that? It would have a reason. And so the Christian must. Well, how come he connect all these wonderful doctors like yourselves to a rural health center and zombie like that? That was the question. How come you connect that? That was the sort of a challenge. And so I started to talk with some colleagues to the district Health Office is that time? I mean, we knew we had spoken to genital officers. Who said to us, Look, we really want to be able to communicate with the doctor. We just don't get that peer support. If we could talk to a doctor, it would really help us the better Treat our patients. And then eventually we got permission from the Ministry of Health. I could get my, uh, slide shows work to set up a pilot off telling medicine in a rural health and to call Chenango, just down about 60 kilometers south of blue soccer into three district and then every year or two weeks and back to five pilots sites, five rural health centers for Interfaith District, one of the socket district. And then we pile. Is it a whole with or of different types of technology? Miunori? No, we need it once. Just try to make something work. Eso We started with the sac satellites you can see here on the top left is two gentlemen are setting up the satellite dish on the Receive the units Engine. Yeah, yeah. Uh, and we we we use desktop computers because he had the right there for to run the platform. And then we had a commercial tempting to commercial telling medicine software we bought from India on be part of this. But they all have different problems. I mean, the the sacked was very expensive to set up and very expensive right on. Also, we had other problems, like, for example, where she's quite funny. I again I I shouldn't say this is funny, but we thought it's got a funny at the time was a service. These gentlemen, it set this dish got, oh, the kind of the technical detail of trying to synchronize it to the satellite. When they left, there was a cheek. It'll Jordan running around and they tend to climb up to the roof of clinical is often what sort of center? The community. And they thought this was a great thing to do some pull ups on. So they were swinging on this, uh, on this dish. And of course, it put the dish out of sync. Uh, so rather funny Objectively, they're not really great for our access to Internet, but we have to wait two weeks of these guys to come back with that cough, reconfigure the satellite, their satellite dish to the to the satellite desktop, computers in Sandy, your nose and your worlds. And it's very heavy. Reliance on hydro for its electricity was any two major sources. That's the comfrey damn and then the cream. But down in the South and invariably taking the dry season low water, there's a lot of loadshedding for the minds of an industry that's a lot of power cuts in here. So they would offer render the desktop useless, sometimes for hours, eat days, even, um, and telling medicine software we had was just very complex. It would timeout regularly, and it really wasn't fit for use in a low result setting, like like Zambia we've entered in trying that books. I explained that in a minute s O at the same time, the mobile phone revolution was called really kicking off for the region, sort of mid 2000 late two thousands. The networks. We're going deeper, deeper into rural areas, and it was quite funny. One day I was standing at the injury and yeah, I was looking at my phone and suddenly overnight I had signal and data just just like that, where where did that come from? And Matthews, they don't accept. They put a tar up. Uh, no. Greasy. Put a towel in stone. Live about 11 kilometers from here. So suddenly, overnight, there was a mobile phone that this is a major paradigm shift of what we're doing actually made us completely rethink everything we were doing to went right back to the drawing board. We're back to the 10 o'clock asses. We try to reassert what would help you make best use of the service like this. And I reiterate they demand came from from them. Forest. It wasn't are saying this is a great idea, you know, you did. They say we want this. We want to be out of communicate with the doctor, is how we do. It is the question. And to the important things came out of the conversation is the more the kind of research we did first day. They wanted something very easy to use and easy to learn to use. Something could fit in during the very busy consultation pers of the day when they maybe have 8200 and 50 patients coming up to see them. And secondly, they said, Why Don't you just use smartphones or tablets? You very jerky piece, that kit to use. But we all know how to use them. Any of us have them and you can buy them here. And then we went to the bonds, ear doctors. We had a time and amongst other things way, you know, we said to them, What's the band? Minimum of information that you require as a doctor to be out of four rays and putting on diagnosis? And they're not for treatment of ice that's essentially created. The system that we have today is very simple and easy to use. Android that we use phones like this. This is these are some some J fives you some some j a 10, they relatively inexpensive, and you can buy the exam you but essentially allows the train o'clock until, like Kennedy Milenko can. It is in the wary raw Health Center in Losartan District to communicate with doctor Simon Gazlay and Simon is a GP and Bingley just outside branch fluids for diagnosis and treatment of ice for his patients. So ask them, it's very easy to use. It works well. We need still a bit more work on it to upgrade it. But that's the system we have now. Some of the slides I got to go through now. Daniels already gone through. But I'll reiterate, so we're very lucky at the moment to have about 250 last volunteer doctors, including yourselves, were extremely privileged that you are supporting the work we do exam, be a on, has a huge impact for the clinic drops. And the patients, of course, on a great diverse city of cases. I mean, we put about 25 specialities. What? We're hoping it should kind of dropped. Victor's going to speak soon about about some of the support he has had, but they clubs or through the aptitude is what special actually they need. And you can see here some cases. The top left is a baby with a very bad burns. That was, Ah, you can actually see the insurance for on the skin that was a cooking pot on a fire on going all over the baby on the actual house collapse on the baby. I think that the mother popped off to get some water left a little little bola, which is a lack of brasier burning with a machine report on it. It can see what's happened there. There's little girl. They're seven years old with HIV. If I HIV complications and a very nasty skin rash. Gentlemen, the middle let proceed. And then on the fly, right, that's Ah, snake bite. That was a path ago. The bits that boy on his lower leg And you can see I mean, a puff out of sight. Cytotoxic Brennan extremely painful. And you can see the necrosis there. And he walked in and was late like that intense pain, you know, rate brave little boy, and then the boss of left. If we got any orthopedics watching, that's osteomyelitis. It was a 13 year old boy passionate football that he had had what? Not like a trauma on his leg. Of course it wasn't. And they've been giving him antibiotics for a year. Not really sure what it waas and they were able to get into a hospital had ah x ray machine. And this This serves the innovation between the closest because if they can get a patient to the hospital that has the equipment, invariably you may find you got a really radiologist That's a radio prefer station there, but no radiologist to analyze the slide. So what they'll do is a lot to take a photo bell with you at the hospital if they can. Well, maybe that the patient will bring the slide back, and they cannot low that attached to the case on DA This was observed by radiologist in the UK and and the orthopedic surgeon. We both said this needs to be Hey, news to the operator immediately, always in front of his leg. And we I think we did find out that he was able to get to the mission. Hospital bites most the Limbus Alka, run by an Italian orthopedic surgeon and the operation save his leg. So it's a very positive outcome. Daniel. We showed you this, you know, great diversity of cases. A lot of the moment for general knowledge INTs, sexual health on dermatology. Pediatrics needs that some of the health centers be support were originally set up 233 but not 197. Now. Been a reduction beauty because we've had some issues with devices or perhaps lower usage, and we're trying to reallocate devices, but we're still in about 35 districts across Sandia. Many of these health centers are built with very, uh, quite old built with very simple materials and breeze. Blocks nearly always rally milium on by specialists. Roof sheets with no insulation underneath. Um, and you can imagine trying to work and 40 degree plus heat in the building with Make with a Million or aspects operations. With the insulation, it's exasperates the heat. It makes it really hard for the health workers working there, but also the patients coming in as well, you could imagine. So they're quite rough. Ready places, right, dusty as well. The top left actions because insulin longer district, which is very close to the rose and beaks about we border in the East. There's Matthews that Junior was the very first health center we supported back in the day, and he's using the richer doctors at to consult with patients. And then there's the the right. That's Ah, uh, cream for your health center. Down was about border late cream, Uh, where the damn is, um, with the senior nurse at mid wife at the health center and that gentleman there. His name is James Period, and he's taking over for me. A CEO. So I set the charity up 15 years ago. I stepped down recently, and James is, uh, Azam in, based in the UK, has been living okay for many, many years. Ah, very strong backgrounds on day. I think you'll meet him at some point. So he's often come out with me two sample when I hurt my visits, uh, and then the being back, generally a Z. You know, when you're a volunteer doctor, you have the ability to recommend that they genotypes that closes the case. When you felt they've dealt with it, I believe referred the patient with the patient's being discharged, it brings back a little bit of, uh, any some questions for the clinical office to answer. Did you, uh, help improve the patient symptoms? I did? It prevents a referral hospital. And did you find educational generates quite quite positive. Well, we do lots of more comprehensive them any way can talk about later. And then, as they don't have brought the sides up, And once it kind of just reiterate the what are our AIDS? Uh, I suppose that that's the ultimate aim of the charity. If you look at Our theory of change is to improve primary healthcare off the country and Zambia. The moment also Malawi. But then so freeze key Sabates. Firstly, we want to help permissions treat more patients in their communities. Mess now the vogue universally actually, uh, secondly is to reduce unnecessarily girls to hospitals now exam via the onus often falls on the patient in the hospital. Very rarely will you find an apple. It's a luxury of transport to get to hospital. And if the distance is a great variably are and there's no transport and they've really well, they gotta have to walk a cycle. They're just very unpleasant. If you're brown, well, we're gonna have to go, you know, 60 60 miles. And so the hospital be when they get the hospital, there's no guarantee they can see. A doctor may have to wait several days, so it's more costs. They're gonna have to incur money. They just don't have, um, they'll have to find accommodation of weight, thio and food and so forth. And if they're very unwell and they need to have family members great with them to help him in the hospital exam is very much a rural based economy. It's a lot of people rely on subsistence farming for their for their livelihoods. So if you are taken away, your family's taken away because you're ill to a hospital and you you're missing the planting season harvest that can have more but more pressure on already limited finances. And then thirdly, for the most important of all is is to be able to, uh, improve the skills and knowledge off more Healthworks chemicals in particular, to the point that they will be able to deal with a complex case next time it presents because they've learned through doing. And then finally, you know where we now is, the way we've historically set up. 233 health centers we are do plan to set up some more of that with this year, but that covers a population attachment about four million people, and we're also the largest provider free, probably telemedicine services and Zambia by far. Um, and all long term Amos, always bean to hand our service over to the government has a charity and assault charity. Should the question should be, how do we have you put ourselves out of business. How did you get the job done and won't want to do insanity In every country we work with, this is build up model. It's taken a long time to do that exam here because it really is understand what was going to work on the grounds and build a spoke system for the uses. The people in the field using our service were actually right now transitioning it to an institutionalized. So that's that means handing it over in the sand in government being take control of it. We step back from day to day running in Santa, focus more on malaria, which we're doing. But we continue to support them with the technology, be immobilized their own doctors onto the platform to consultant cases locally. But they're always going to have knowledge gaps. So the volunteer your your cells. In the UK, there's always an option that make the cases will be able to come to the UK if they don't have expertise on the ground. In Malawi, we've been we were invited to a lot about three years ago to do a pilot. We've we've finished the pilot is that the Malawi government like it and they want us to expand to 56 health acidities in central problems this year which we're going to be doing and then long term, we want to do a lot more to improve our technology. We know that being eaten proved froze from the years is end, but also from the UK side yourselves, When you're saying earlier, I think some of you share that, that you don't always get the feedback and information needs to me and inclusive or data fields in the at what's improved the monitoring evaluations we can more readily measure impact on. But also we have gotten of interest in other countries outside of malaria. Exactly. We've had probably interesting really. Every country north of the Limpopo, South and Sahara in Africa, but also other reasons of the world have interest from countries in India. For West Pap hour, Columbia so got abroad interest more of the world. So we're a keen to see what we can do in the future. But this year next year we're very much focus on trying to handle over inches apnea and then expanded Malawi. That's the end of my presentation. Hope that was interesting and I'm I'll have back to Daniel and see that was, uh was fantastic. And those photos of got me wanting to go on, uh, on a trip out there, But I will stay away from from the porcelain frog and various same. Some of other things may No. No. So that's under here about your journey, as has been really interesting. And then we'll have any any questions with you about, um, you know, something from his talked or comment from Harry that to you. You are amazing. Really. Thanks. Sorry. Yes. Next we we should be having Ah, Victor. But I think he he was just having some trouble. Uh, essentially logging on a little bit early. That's while I've It may be that we we start our coffee break but early, um, and then we will get hopefully get him safe. If we can now have a break or suggested he coming to coming. Let's so let's less of a break. Mouth. Little quarter to, um stretch your legs and things and hopefully we'll we'll have victory here to tell us, um, bit about what it's like from a clinic officers perspective. So see shortly. Think somebody. It's just a question about, um, deep people that actually worked in Zambia. Jeff Experience of, um, culture, pain syndromes and symptoms that don't translate into English that we might be advising. Going where it's actually something else, thinking of the all over body pain type, things that might getting some cultures. So I haven't worked in some bit, but Donald seems to have since a month. I'm over a year and a half, I suppose. But one of the thing, which was interesting waas Asians of what initially would appear like a seizure or perhaps the postictal phase of seizure. So apparent confusion on be very limited communication, which not often but on a Cajun after a day or two way would realize, because of sort of inconsistencies in maybe the behavior that something else is going on often. What would help most waas the arrival off some form of spiritually dinner so it could be the local priest? Or it could be the chief of the village or a representative from the chief of village on Do it made us think to include that in our routine history, taking going forward particularly for often the younger generation between the ages of 15 and 30 you are presenting with quite over symptoms that might might fit with a seizure. And after we've given the has a problem with no effect, only to find two days later that a 15 minute prayer at the bedside on often at this question about some of the background which could have been something in simple. As you know, this individual had a fall out with somebody important in the village, and this was their manifestation of that sort of mental anguish. So that's really interesting to hear it. So I have been keeping you going. Yeah, just gonna say similar things we can impact of a local society and culture, Um, presented in a lot of different ways. I guess what we would maybe level is kind of functional symptoms and presentations. Yeah, I was going to say, Actually, getting the chief of the village involved was often very useful, and and the converse is probably true Well, and a lot of people and presented with a studio M, which, well, actually would quit off Internet to be quite complex. Psychiatric presentations or even neurological presentations were sometimes labeled, particularly if people had seen traditional medics as a kind of history when it didn't need to be taking more seriously and it's got a pass of care. Thing is, well, if you're in that culture really one of the most difficult things and I'm a intensive care training and interested in pallets of care and I found it quite difficult to take that approach with and patients and Zambia when I was there and I think faith and was obviously a massive part of people's life in which were maybe not so used to here. And I think sometimes that was I don't want to use the word bad here, but almost a pad here to go on down palliative care of it. And and similarly since coming home and I'm in Glasgow would have made quite a few families and recently from his MBA, a hymn was on beacon things and had similar kind of difficulties there. So it just needs a very sensitive approach and just taking it. Have faith in your main goal times. If you're trying to go down that route still showing that that's that's very interesting, Yeah, misplace. And we know certainly in the UK with necessarily is, has opened up the stashing sort of wear a little bit medicine. So what makes less pain is is it's not. That's interesting. I think we've convicted a smidge to join us. Um, so about the trouble with the, uh, with the meeting. Um, can you help me? I guess, is you're connecting to order. Just on me. And second, Okay. I've been taking the Harry. Okay. Really, We can't you know. Hello. Can you Can you hear us agents in it with It's a okay. Oh, yeah. We can can see. You know, times I said, um, I think there's a bit of a delayed in there Was in the reception going to have you join us better. We would just Maybe you could just tell us the best how the virtual doctor service has been a year and how you've experienced that. I spent it impacted on your where Okay, you know? Yeah, we can We can hear you. Okay. So it's maybe she's going to drop, drop the camera. Maybe without the camera. Maybe if we try just would be with the audio that that might help a bit faster instead of if we turn your camera. Okay? Okay, maybe this way. Oh, yeah, that's much better. We can we can. It was just breaking up a little bit before I wish is a shame because it's it's nice to have the video on see you, But it would be nice. Just it. I suppose if you could just tell us a bit about yourself from on. Don't suppose how how the virtual doctors has kind of impacted on your work and things. It's It's really great. And you've been able to join our soil. It was a bit of a problem with with disease. Okay, so my name's a victim. Y you I'm a clinical so general in Eastern Province exam. Yeah. Which is the ah, Southwest. Ah towards Mama. We we have mom with district. That's where I'm located and in particular at school or a health center way have where people are coming patients, especially what coming from distant places 30 kilometers to 40 kilometers away from this jail facility. And, uh, really, I joined the picture doctors team That was in 2020 20 and, uh, I didn't appreciate it has really helped me. And the only thing I was looking at at the beginning, I was looking at the property help that it can't be channel to my clamps, my patients back. As you know, it's sending the case to a specialist in that specialist rate on it may take two days or 48 hours for the eight hours or 24 hours, even 72 hours to respond. But it's it's very helpful because at the end of the day, even if we refer the patient to the next level off care, we have that backup that does not that we get in the land through. If the similar case comes, then we know what to do next. So it's zillion helpful in that way. And I personally I would appreciate it. And I've been interacting with my colleagues from various places. Enzyme Yeah, and, uh, wait, did I Where did I put shit your help? It's really good to hear. Um, yeah, I'm sorry. It sometimes takes it a bit of time. We and we aim for 24 hours. But sometimes I think the technology someone's means it takes takes. It takes a bit longer, but it is great to hear that. It's it's sort of benefiting sort of with your learning. If a similar case comes in, sort of the next time on, do you find that the advice you get is sort of appropriate? So for where you're working, do you Do you think it's kind of a mid at the right level, given some of the resources you haven't been? Yes, it is. It is, uh, kind like, because way I am It's very different from others, you know, in the knee. I don't know if you have been to Africa before you now three constant and parts have network set in parts. Do not like where you were from. There is. There's four time natural, and, uh, I don't really have struggle. I don't really have a struggle. It's just conducive the devices, Okay, but I had a cry from other people where they are. It's a big file from the network for them to start the network. They have to go to a center and they go to one prom meter away from the facility for them to get there the next week you saw that's kind of being a challenge, but as for me, I don't have that challenge. Makes a big difference doesn't it? Former, I suppose if you put a very busy clinic and do you having to walk a kilometer or for that, actually send a case that that's, uh he has Strict. Yes, on. But just like we've got them, we put a handful of our volunteers, so listening to a swell assume some of the board a swell. I just like to see if if anyone has me any questions that they're, like two aspect er it's great to have him on Ms or Miss School. Feel free. You are welcome. Sure. Donald has got a question. Yes. Say your man when I asked that one. Hi, Victor. I've seen Teo something next in rural Zambia. I was in Connecticut, in Eastern Province. I'd be grateful to hear more about your clinic. What staff do you work with On how many rooms have you got there On what sort of things can can you test for? Thank you for that question. Saw Doctor. Ah, one thing. Is that you as we have rules. Ah, the MCHAT departments, my child health department. And we have That's his connection. The Libre want an M c h a kind of one big room or hope it's demarcated Onley. And and that is not a condition for, uh in The mother was very very in. They share the same room. This department is here. The other department is next room. So we it's just, like confined in one area. And yet when they come for Internet, okay, and they were supposed to be oh, on the other side. But they are only within one room, so that's a bit of a challenge. Number one, number two, we have another room for screening where we do this screening. And, uh, where we do the straining there is a man. It's there is another room for a V M m A C voluntary medical mail, circumcision. And then we also have a room for female one which has got two beds and male lot, which has got two beds and then we have a dispensary and then we have a pharmacy and then we have one room for a a t. Those are the rooms we have now the services that we offer, like testing. We test for HIV. We test form Arabia, off course malaria. We don't do uh, m ps. We don't have a microscope. We use, Ah, rapid tests. We use rapid tests and then we We also collect a viral. But we don't have a machine for viral. Do we send? So where we where the hospital is Comotto Mission Hospital. And then come out the mission, Or is it also will be able to forward it to spatter Central Hospital? So those are the services Really awful. And that was very interesting. And what our specialist kind of links in. Earlier, we had a talk from Doctor Martin dead. A coat is one of our infectious disease specialist. And he was telling us all about TB and Gene. Expect testing. What? So what would you do if you had a prospective to back? You losis patients generally testing ability? Or would you have to send some sputum off? I don't have I don't have a testing ability what we do with genetics, but all microscopy, we just get the patient. It was It also takes time when we correct sputum, it'll take time for the write that to come It depending on the season when it's Renaissance's on the road network is so poor. So the driver would take some days off. Suppose it's rending three days consecutively from minded toe. Wednesday says that they will be off waiting for the road, at least to get dry, and they get to us. So instead, what we do, we get the best chance drip today. And then they collected from there so that we avoid that spending suasion off, not knowing the diagnosis of the session instead of helping the patient. That's what we do. My sons. They sensible yes, on does anyone else and good question. Boston. Yes, Okay, I picked her since my synthetic it here, one of the the volunteers. Can I ask you with regard to malaria? Sure. Do you have much problem with drug stock outs, or do you always have a constant supply? A. That's that's part A and part B. The question is, could you tell us about malaria nets? And what? What's the situation in your area? Thank you so much for that question. It's a very good question in the diarrhea. I appreciate it. Ah, where I am, it's first over. Malaria infested the area. It's in dividing, and we have a program off my labia and ammunition, starting right by my area in the valley where it's Maria prone everywhere and it does. We have testers off severe Meridia and we find them to the next level. You find the child has come with convergence. You test for the t, you'll find it. Say it's my very opposed to However, I can never complain off Maria Drugs being in shot for There is no time that we had the shot for Maria drugs where Where you work from leaving the day they random tests The air adity testing kit We never had such a shortage because we have a supply from the government of Zambia. We have a supply from charges Chechnya with Association of Zambia. We also have a supply from Ah US President Initiative My area all those. They come on board to supply to us so I don't know. I'm speaking from my area I don't know other areas because our area has been chosen as easy. They sent out where these these tried trials off in a minute in my area should take place. We also have a program every August off every year that is called inside. There is your spreading so they come and spray a Marie, the time and spray or the house. Is it throughout in August? So Maria, in shot, We don't have strategies off my Arabia drugs. I think that answers that much. Especially thank you. Thanks for Victor. I just wondered. Obviously, it's Zhar to sort of have medical discussions these days with that sort of thinking about Curve in 19 in on Bennett. I just looked it on. What sort of challenges you you faced in an example, with regards, Stand on a. So the folks looking at some of the data that it's been controlled pretty well with you, But I just wondered how it had affected the area that you have off course if I covered night 10. Govern 19. Care with him. It's the feelings or people. People have feelings that it's another system. You know, we we we have really just people. They have a different interpretation. Some people, they declined. The fact that there is called did they say no, it's There is no coveted previously the way of blaming the government, saying the government is trying to make money out of it, blah, blah, blah and all of a sudden, this time around. People have come to understand it. And, uh, yeah, the previous month we had massive, massive, massive vaccination against covet and people were coming in masses. They were coming mass is making cues and were vaccinated. Currently a sweet tests we like. Last week we tested, we had the 14 tests, but nine was positive. So currently we don't have more positives scared. And I said, Yeah, it's interesting about what you were saying earlier on when there was a lot of skin and just add on whenever you have, I have tested somebody and find the specialness positive. I look at the severe Little Ridge. If if it's not severe, I wouldn't send today to the hospital. Ah, I just I'll just advised or know how they have to keep themselves. F keeping wearing my This must avoid contact with other people, especially true Drin. And, uh, it's manageable with in the villages in the confound orbs, they asked themselves, Just like that yourself. Quality is what we advised because otherwise you'll find the horse because I have no beds. Yeah, that's, uh, that's very true thing is that there's a question from Bonn. Samantha's Well, Okay, Victor a sounds like you're doing a really good job. I just wanted to ask, and we always try and answer the Casey's as quickly as possible. Sometimes, as she said, there's a bit of a daily, and I'm just wondering from a practical point when you ask a question, Do you have somewhere? Just the patient wit O. R. If they go on to the hospital, is there any way that you consent and a message with the sort of advaced with the patient or to the patient? Or I'm just trying to think about how to kind of target my advice, knowing that sometimes I might be asleep when the case comes through or there might be a daily Yeah, thank you for that question when, like, I have a kiss right now. Suppose I have a A case right now What I do. If that case is not manageable by me, I don't have facilities to manage that kiss. I refer to the hospital immediately, but as well as capturing the information of that tests and extend it so, virtual doctors, the now wait for Richard doctors to respond, and as they respond, we the hospital, they away I have refund. I have to make your follow up, either by physically being there or making a phone call. So if I make a phone call to the person who is attending to that person, we engage each other we discussed. And then with the notes that I have received from Detrol doctors, I'll be able or so to share. I would say, Look at this may be dyskinesia help us. Why do you feet? And at the moment it did help us some. Some of the things you send to us, they are very practical. Or you find maybe they're being used there on the hospital. And then when the pressure comes off course, some advice that I get from from you. I also share a patient has been discharged because it's given with the statin. Note by the doctor was attended to how him she or he must pass by our facility toe Endorse that this pessary is now distract now, as they passed by this passivity, how engaged myself and depression into a dialogue scattery, and I'll share what I got from the actual doctors how to go about it in case off any anything else. Well, that that's really interesting. Thank you very much. Yeah, that's very interesting. I didn't realize that you had that, but the cases would get discussed with with the, uh, with if you prefer someone on, so that that's really, really good today. Yeah. Any other questions from from the group? It'll it's been great happy, have you? I'm glad we got you on. It's been fascinating talking to you. I just wondered if that if you had any questions for funny of the volunteers that are listening. Yeah, I just want I just love one Christian. Yeah, friend. Yeah. There was a group that was created. Do we said that doctors brainstorming group and ain't Asian of the group was that we should have, at least on orientation or one day workshop on a certain topics. And we suggested topics that we may have refreshment courses that veteran doctors will be either grouping us in one district and then ah, they're trying or by zoom in getting toe us and give us some information. Some lectures on those, So I don't know how flight as God. Or has it been a dropped and I know what you're speaking about. Yeah, I remember that. Basically, it hasn't been dropped, but it has been known cause due to various sort of logistical issues, it's not something that we've sort of phone out is where it's something that we we just need to have a bit of space to think about it. And I work out it be really nice if we if we could do something like that on, because obviously we, you know, we've got the Volunteers with lots of knowledge on it would be nice to do. I guess it's just working out logistically. And also, I suppose, some of the barriers with the technology and things are and working that out well, it might be. And so before we've had a podcast. So it may be that we could do some similar things to do that, or maybe as as Webinars on. But might be that band up having to be pre recorded say that because getting people sort of aligned with technology and getting everything working is sometimes if it difficult. But it's certainly something that we can sort of child revisit. Over the next 4 to 6 months or so, we can maybe follow it up and have a chat with with self stellar and things like that. Yeah. Okay. Thank you so much more than that. Now you're welcome. It's been really great. I'm glad you cuter to join us. So that was a bit of a problem with Zoom to start with first, then having repetitive your day and thanks a lot. Thank you. Thank you, Victor. You all comes out. So that was That was great, that we could have victory join us on. Do, um, So now what we're going to do is is have have another talk on former are other student who joined us for their virtual elective. Um, so this is moving most of sending, right? Nobody My best back and no, she said on also David Hatful, one of our volunteers on may. They have to know if they're looking a history of that antibiotic use. But I thank you very much for me today. Can you hear me? All right. Yeah. Hey. Great. So it's not sure on my screen, So I was really August as dark. I explained I was very lucky to do my left, uh, last time, uh, with but I just on during my time. I did some research with the team on. We were, except for all presentation, a national conference recently and this basis, sort of a summary of the what we did that we presented at the conference. So just a background information, as you're aware on my resistance, is a huge issue on Currently. Was this infectious came in. It was 700,000 lines each year and it's estimated reach 10 men per year by 2050. Really, humans have lost 100 trillion USC in the comic outfit on learn middle income countries of predicted to be effective disproportionately in comparison to high income countries with clinically on financially, uh, obviously effective antimicrobial stewardship straps she's are dependent on the standing current practices of the drivers in appropriate antibiotic use to design interventions on to measure the impact. Uh, unfortunately, there the understanding the drivers behind on to my cover assistance particular middle countries is very limited. It's a special sir and grill clinic. First amount of data got our income been impacted by the resource coordinator of the Sessions on Murder Studies in the middle income countries. Having card on inpatient settings on very little is known about primary child with most patients actually received healthcare. Eso prescribe practices on epidemiology disease, obviously very massive between the little concussion. She's across the road. So my pleasure. She waas, um, to focus on substance on Africa specifically on to carry us. It's not to review the bottom or Asian specific understanding caps. Crying passes a specific clear. We try to understand the frequency it a choice on a lot of prescriptions. Other indication on their purview nous and any first contact cast that you went and bought it super sore. At the same time, there's no aspect my project, which was using the actual doctors day space to analyze patient consultation records on compare the final smoke it to records to contact provided by This is a matter of me that I carried out and, uh, same time. Let me explode the Post. Use the time medicine and promotion on microgestin ship in these locations. So again, just to re emphasize there are two components and studying the systematic review on the retrospective analysis of the virtual doctors data to start you on the systematic review, um, I won't go into the details that essentially I used uh, the cold. I used a basis as well. Assay a specific day basis on these towns. The variations of antimicrobial Asians. Profarmer kept describing, um Onda cute. Okay. On for the retrospective analysis using virtual doctors data, uh, we use the patient connect data on weight. Retrospect. We analyze data from January 19 to drink 2020. Importantly, we excluded non adult patients on. We only included cases which has been Curtis infectious disease. Respect your medicine, old medicine, German. Because we feel that these were the case. Is that almost like me to be associated with infections? Schools is on antibiotic. He's onto the results. So this is just a prison guard round of Strattera review that I carried? Uh huh. Yeah. On finding 29 as well. Studies ordered five from nine different countries. Um, majority of the studies were on the taken and of settings on only about 40 then, uh, we're encompassing rule settings. Interestingly, Ethiopia, uh, represent a disproportionate number of studies included and a systematic review. Uh, this is ah, the results of ecology assessment. Uh, some rides brief. The most studies were full quality. According to you know, a lot of us has been criteria that have been used this and less studies previously. So oh, 29 studies I don't from. Because the nine countries the prevalence of antibiotic prescription ranged from Brooks May 33 to 84%. The most common indications were perspiration. Giant urinary infections, the most prescribed antibiotics with each elections through primary amoxicillin, Thank you know veins and metronidazole in that order on the only two studies actually assess appropriateness of prescriptions. And there is a wide variations from thought into 36 to 7 country and appropriate now on to the doctor Days it so 502 cases or abused from 101 science across 22 district. The time consultation. Find the one that sent for receiving Want to three antibiotic Asians already on most described agents for metronidazole amoxicillin, which is consistent with the systematic review findings for the consultation. Importantly, uh, 53 patients it time send patients were initiation antibiotics on all those already receiving antibiotics. About 62% have antibiotics, rationalized or stop base level, and his advice approximately half of complications did not specify. They antimicrobial Asian Eric condition. So this is very difficult to assess appropriateness of recommendations provided by the Lantus. So what does this will really mean? Um, I'm like, fastest limitations of study. Obviously, they're studying the project that I did is quite limited. Um, with respect to six month review on the respect announces. So with systematic every, um, I was drugged after they they're over possession number studies from each country on also from each setting on population as well on, um, roles unable to retreat. Full studies that were initiated, identified and suited on were included in the abstract screening stage of start people. It couldn't of a contact the the initial authors or they didn't respond and tells the expected announces, Uh, the data quality is limited because of the information on the presentation examination findings on diagnostic information on the antibiotics used within the connection. Um, it could be that the oncologists renal specified because wanted deliberated, not specify it based on the nomination local treatment guidelines. Because if you got oh, it could be that there was incomplete recording of exchanged information, be excluded pediatric cases or presentations. I fell outside of the three specific Kurdish Kashgari. So very limitations in mind. Um, I do some conclusions based on the findings. So the matter Really, Uh, sure that they're high rates. And I microbes in the middle country itself start Africa on a significant portion is inappropriate. The data is very limited on maybe from obsessing on from a town medicine data about doctors days. Uh, I think the key take a message is that 62% of antibiotic prescriptions were actually rationalized through telemedicine based approach on. This'll provide opportunity for a long time educational days on my address, involuntary knees education to twice for responsible scribing in maintaining patient safety, we can, um, kind of treat the antimicrobial started ship. Efforts on this should be addressed as a priority on these references. Thank you very much. I'm if you have any questions, please. Do you know, I like to give particular thanks to grab on David full supervising you from this project and for every try to for giving this amazing change your body eventually much. But I was on. That's fantastic. Talking really interesting, Teo to hear about Sam the commencement. Some of those figures, actually, and it it took quite a long time to look because obviously lots of people here unaware of how our data is exported into a horrible Big Excel file. You know that That's that's really good. I just I just wondered, I suppose in terms of there, you know, looking at the data things Did you find that a lot of the time? Um, did you look at sort of the same and spotty guidelines and whether or not the choice fans, but it's sort of a pre a pretty tall. So that is what I set out to do. Initial methods. But reality waas because the quality and the completeness of the Connect Asia list there limited. Um, I couldn't compare it to the guidelines. So, for example, if there was any information or limited information on the presentation of the patients is difficult for me to consider what the diagnosis could be. Honestly, if I don't well, diagnosis could be contrary. The top of the specimen antibiotics were perfect. Well, the hand, even if they did have presentation and diagnostic information, if they haven't specified down to microbial agent, if they just said antibiotics advise that I can't really assess whether it was black guidelines. That's very interesting. And I guess they did The other thing is, uh, supposes is thinking off, Um, that might be an ideal and body, but then it's that supply to let you know whether or not they're actually got that, that everybody stops. Sometimes, volunteers will say, Well, if you've got to use this one, otherwise use this one, you know, a sort of plan a plan B type strategy. As as, well, does anyone in the group of the questions for me about have you sent? Oh, well, thank you very much. Money on that was really interesting. Um, on, but hopefully the first of one of many studies to kind of come out off of our data because it is really interesting looking at on some of these so trends in in global help decrease from Mattel a medical perspective because there's there's not a huge amount off research out there. It's great to use some of the the data that we gather into your charity. Well, coming towards the end mouth on. Sorry. My Yeah, I just want to say on doctors isn't a really neat position that you have outrage exile, places that most people don't on it is on potentially incredibly inviable data stools. So if you could somehow improve the quality and completeness of data input, I think there's a huge potential producing significant contributions to the literature. Yeah, I completely agree with work the next day on the Actually, it's on the action plans on I guess that moves us quite nicely onto, um, Mr Grand Fesi. Is that germinal off our fair to doctors board on here is just going to sort of say hello and give us a better Not great, I guess because there's a whole bunch of we've been looking at, kind of clinical stuff on a distance to live in. In fact, these anything like that. But there's a whole bunch of old sort of non clinical brain storming and planning that goes on behind the scenes. Say it even here and various joining us from northern France. All right, How you doing, everybody? You know him? You're right. Then you okay? Okay. Thank you. Hi. It's a real pleasure to you to join you this afternoon. Uh, whenever I hear what we do is an organization on the technology, it just amazes me every time the the impact that putting expertise and knowledge and there are ability to expertise and knowledge anywhere in the world. Team proof people's lives. This is amazing. I want to start with a few Thank you. Without, um the, uh without you guys, uh, finishing your busy day jobs and then logging on to our app on reviewing cases, We would not be, uh we're not able to do what we did. Like like year my volunteer. I I'm not a medical professional, but I d specializing trying to get money out of people eso to feel what we did. But you feel like this organization to on Daniel in team work very hard. Ta help you do your jobs better. So this massive, massive we appreciated. Um, we're just in a in an interesting world right now, Aziz. Well, no. Um I guess what we're looking at as an organization is after Zambia after Malala we? Where do we go next? How do we How do we put this amazing gift on adventure? We've had so far, which is two have the ability to put people's professional knowledge anywhere in the world into any situation? Say, right now we've changing to put that into Zambia, Malawi, But as human often tells me weigh. Haven't ever longer list off. People sank. And you do this here. Can you do this in this situation? Um, and we've had some fascinating conversations. Um, with people are new and World Food Program. He said, actually, when we when we set up a a refugee camp on the, uh the medicine, some frontiere or relief organizations go in and do their job. Actually, there's a there's often avoid of medical knowledge after that, you know? So we're having some interesting conversations about where we go next. Uh, but always that always we need funding to do what we do. Eso We're working very hard at the moment. See to fund three things at the moment. One is Teo. We have people that believe that health inequality is not right. We'll just around the world. So that's one of the ways that we traditionally get money in people. You go. Actually, why is a health care system different and why in different parts of the world and we're increasingly seeing climate change as a way of us? Accessing funds on the theory is pretty simple. The carbon emissions off the western world are impacting uh, parts of the world where they didn't admit the carbon. But fundamentally, the world has changed for them in terms of floods, onda natural disasters. So we think we play a key role in, uh what the what the climate professionals would talk about, which is climate mitigation, and I that uptake shins say I I think anecdotally. And it's always in the data we're starting to see things change on a simple example when I'm talking to, ah, climate on environmental funds to try and work with thing to feel This organization is, uh, snakebites is a really good example. We anecdotally know that snakebites are starting t o things medical done, which I would do good bye. But the rainy seasons are changing on the risks or population around. Climate change is changing because the when snakebites happen is changing. So we think there is, ah, a tap of money that we should be using to fuel are service, which is about climate change mitigation. And I'm really interesting. The last thing is around technology, um, without without good technology, ah, way would not be able to get your expertise on D your advice on export that to when you were in the world. We've done amazingly so far with the landmark team to build what we built and not surprisingly, in Cove it quite a few other organizations of built technology, um, typically video based telematics and services, but they've all got the same. Problem is band with Onda. He's done a amazing job off. Uh, some interesting conversations with the end 50 Network on and 50 is basically an Intel on tec driven initiative, which kind of accepts that in any country in the world, particularly developing countries on technology cannot reach into the deepest, darkest parts of those countries despite their being a really good mobile network satellites often too expensive to get into those places. So we put our first device into the hands of a clinical officer exam, be a two weeks ago, working with and 50 which is basically Intel on a few other tech companies in the U. S. Because they're starting to look a different ways of cutting up data, cutting up data in and they're like chefs. If you like, they're cutting it final and final final and trying to get into some harder to reach places on working with them to women that your voice, your advice can go into those places that traditionally cannot get to the 333 technology networks that exist already. So So we're we're working on Liza The moment, Um, yeah. Help health inequality. People who believe in that climate change mitigation on. And how do we get your voice from wherever you're sat, providing your advice from whether that's in the hospital you work in or the clinic you're in. How do we get that to the deepest and doctors callers of off the world? That's where I definitely have a massive implant. Yes, we're trying to do that. It's, um it's a cave. It has to us that, uh, telemedicine really matters, and we've been doing this for a long time. So a lot. A lot of other people have caught up on that fact, particularly the commercial world's climate change is playing out. We think that's a massive opportunity on deviously this stuff going on in the war going on in Eastern Europe is also it's difficult. We have a job today in Africa, we've been asked, Can we don't? But what we do into into Ukraine? Um It's really difficult. Is an organization to kind of say yes or no on that. But what we do know is that we've got people to serve in Africa right now, and we've got a lot of anti easy. As, um, you guys say, um, the good thing about that is that people realize that our technology and what we do really works and impacts people's lives. I just want to say massive. Thank you. We would like to come back to you guys at some point to pick your brain's on where you think with care is going in the world in the next 5 to 10 years, where you think we should be going after a zombie on Malawi on what you think your petunia teas are. So we would, uh, we just, uh we just answered those questions is a board which we talked to this week with Daniel involved and he. But I'm sure you have a view to you know, you you see healthcare play out every single day on but way want to know where to go next, and then we want to go and get some money. So fund where we go next as ever. What we did say massive. Thank you to Daniel. I'd like to thank you. Assuage. Huge. I hear. Told her told her already. Good. Uh, experience and story today you use changing what he's up to. Four is, um we've got a James period coming in. Is our room interim CEO on July? Things forward on Danieli. This's any questions? It's ah, volunteer. You know, I'm trying to make sure that, uh, what we plan to do, You know where we plan to go, way deliver, don't get it done. It's an impact peoples' life. So So, yeah, I haven't got anything else to say, but I'm really happy on, sir. Any questions or No. I know you've had a long time on the thing today. So you put the sink? Yeah, like man and nobody questions. I guess I have a grand myself, You know, Uh, anyone else told him otherwise, there's a few just quickly onto the ones in the group that popped up, I think a swell first off from Alison, I think we're dialing on back off. Most all does this in the case, we should record our data slightly differently and future to capture this information? Um, probably the the thing with data recording that is one of the things that we are trying to kind of brain start when looking at. How can we make our our tech matter one of the things that we're hopeful we have quite a time frame best get. But it is, too, is to get some sort of either I CD, 10 based coding or the 10, which would be done by by the volunteers or symptom Kating. So that would have almost like a I said they put in chest pain and it's coded chest pain. Or, like put it in a billion left. Is it towed? That said, it will be much more searchable. So, yeah, I think I think there's a lot of tech that we can harness that would maybe do some of that for us and that we would be able to just, you know, write stuff and then have a database for the flag things up. But these are all things that yeah, that it's one of us to kind of think about Harry. Is your data collection done on Cobo? I don't know what copay is. If you want nights. It's done essentially through, um, alot of the data. So every case feel that gets filled in, um, on the afternoon, and that comes to to the volunteers. When we did a really long in and stick a statin at the moment, the any way that we could get that data is it gets exported into a C S P file in Excel. Then if a familiar with them there very basic. And so you should have a column for each data on that goes assay. Huge documents. Its since the system went live sits there, which was 2018 or something like that. So it's it's that so just a huge amount of numbers on data, and it's very tricky to look. Then it takes a little time. Eso yellow in your eyes Open source. Data collection tour? Uh, no, but it's maybe something that we can. You should look into it so I'll make a mater. Thank you. You know, too bad. And any other questions from from anyone else, it's well, otherwise you're a lady gets It's been a long, well, good three hours. I think it's been useful. Most certainly been nice to kind of gather. Get people together again. And I need some people went able to join us because it was about the state, which is is a very good reason to be there. So we will put put this on line of people who were planted I/O. I had any connection issues we'll put online with the next week or two. But otherwise yeah, thanks for giving up. You know, after names. And like you and Grandma said, we may be really do appreciate you volunteering d on, but yeah, it's nice to sort of see a few friendly faces on, but if you do have any ideas in over the next weeks or months about like I was saying about about two doctors or suggestions, then we always little toward to him. If you just stop drop your email or your grandma and yeah on and hopefully next year really name. We might better do You do this face to face where we'll keep our fingers crossed, Um, and safe. But otherwise, yeah, thanks for joining us. Thanks. Everybody I be doing was great to hear from victim, please. We got more. Actually, that was excellent. And enjoyed that. More done. Daniel for hosting. Excellent job. All right, take everyone. Thank you.