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Is the Senior and Global Health Vice president of the Royal College of Obstetricians and gynecologists. He's a UK based clinical director and a consultant. OB Gy and a subspecialist in maternal medicine based at, at University of Hospitals. He's a clinical director of Southwest London and Surrey Harland's Maternal Medicine Network and he oversees complex medical conditions, prepregnancy. Yeah, exactly. I think I'll be fine if you want to not, it's not necessary you. Thank you. Good afternoon, everyone. Thank you very much uh for the committee for inviting me and that's a fantastic program. Uh so well done to you. Um So I've actually been asked to speak on the um the oncologist for physicians and gynecologist. Can you hear me um in women's health or maternal health? And I actually started to move it a little bit more to women's health rather than maternal health because we always feel that the gynecological part of women's health seems to be neglected over the years. And I think it's important to highlight that. So I think one of the most important aspects we always find that where we look around and you can see today um in all the uh presentation that women that women and girls have been denied access to their human rights to help their life course. And I think that not only happens um in underdeveloped countries and low income countries, but actually also happens in the UK. Uh we can see from the um embrace reports. Black women are four times more likely to die. Asian women are 2.5 times more, more likely to die. Uh babies or black mothers and Asian mothers are more likely to die. So I think the inequalities are available uh uh for us to see all over the world. Now, if we look at the women's kind of uh uh health, that was life course you can see here that starting with HPV, vaccination and menstrual health, uh gynecological conditions and contraception and then their vital spin and gynecological cos. And I think of course, of course, the productive part of health is really quite important being pregnant or postpartum, but that's only part of the woman's life course. And sometimes we tend to forget about the other implications and possible uh inequalities that happens in the rest of the woman's life course. And I think this is really where we think we have a role, all of us who are um um wanted to do some excellent global health work is to work with uh with each other to try to improve these aspects such as menopause. Um I'm half Egyptian, half Sudanese and II will tell you in the Middle East, for example, um, the word for menopause is the end of life. That's what it's called. A and that's a horrible name. Uh But that's one of the problems you have. My, my sister works in UAE. I was speaking to her yesterday. She's a GP and she said it's very difficult to find any menopause clinics for women to access. So I think, um, let's all of us look at all these problems um all around the world. And then of course, there are general health things about climate change and wars and gender based violence. Uh it and, and, and all the other aspects that comes with life. No, we know that a woman's life is sometimes determined by genetics, but there is no doubt that socioeconomic factors as well as environmental factors will play a role in changing outcomes. And we, we know, for example, by having early menopause, women are more prone to chronic diseases uh by having um um kind of uh uh low birth weight for the babies, they will have later pregnancy compli uh later life complications, uh et cetera. So I think it's really important to understand that um um force. So I'm gonna start with maternal mortality, but I'm not gonna spend much on maternal mortality. And we, as a college, actually, we made a decision not to engage a lot with maternal mortality because there are a lot of big players and a Royal College of Practic and gynecologists will really be a small part of 11 can deliver. And I think if you look at the work with the UN and the WH O and other big organizations, we feel that if our focus really should be around gynecological care such as contraception, abortion, menopause, et cetera. Now, we had targets uh by the S TG um uh by 2030 to reduce the maternal mortality rate to less than 70 to 100,000 birth. Now, we are currently around 220 100,000. So we expect another 11 or 12% reduction over the next six years, which are is possible. But even the best of countries with good examples have just managed to achieve that. And I fear that we're not gonna be reaching that target at all. Of course, COVID um has played a role in reducing at that time and people focusing their care more towards the complications and vaccinations, et cetera. But we still need to do a lot of work to reach where we want to, to, to achieve. So what are the required actions now addressing inequalities? And I think that's really, really quite important by ensuring universal health coverage, comprehensive interpro maternal newborn abortion care, post abortion care and addressing all causes of maternal mortality and strengthening health systems. Because that's one of the problems we come across is that there is no infrastructure. We just had some said uh about what some of the complexities that one would come across when you're trying to set up health systems and of course, ensuring accountability. And that's one of the major problems I find when we do any work abroad is that trying to get that accountability built in within the work that you want to do. No early menop very well known that can increase risk of type two diabetes and cardiovascular disease In later life, early menopause can cause increased ischemic heart disease. And of course, um surgical menopause can also cause other problems. So, and I think these are some of the areas that we feel that we can actually do some work. Um on what about climate change? Well, gender equality and sexual reproductive health rights, climate change issues are in uh in linked and that it it increases social and gender inequalities. Global temperatures, of course, dryness, dehydration, high temperatures that all will lead to problems in pregnancy and outside pregnancy. And it will have a negative impact on maternal health health. And if we see here that for example of maternal health, the rising temperatures that can I increase heatwaves and droughts, rainfall, variability, how to access food, how to access water. Um and getting a reliable drinking water and dehydration. We know directly linked with problems that um and birth increased maternal risk of anemia and eclampsia and climate change also associated with increased in vector borne diseases uh as well at least, for example, malaria, um uh it can increase the malaria um um anemia and lead to complications DVD and, and early marriage. Now, one of the problems you find with um climate changes were in wars that invariably girls and women usually will get that blunt of um the majority of the complications such as rape, um such as gender based violence. Um at the moment, for example, with the war in Sudan, there is huge problem with rape and gender based violence. Um um II recently spoke to some um young ladies from there and they now assuming that when they're trying to cross the border, that they're gonna be raped, that kind of almost 90% of them assume that they're gonna be raised whether they are a young girl or a or a young lady. And this extreme kind of wars and problems that happened in Africa together with the, with the weather events would actually make things even worse. Now, neglected tropical disease is not an area that we deal with at the college, but it's just I know some of you have covered it today, but it's important to remember that uh tissue soys and, and DHS are common problems and sometimes we even see them here in the UK when refugees and asylum seekers enter the UK. And it's really quite important to remember that you look for that and, and earlier on, um uh one of the speakers mentioned that uh they kind of find a high percentage of that in women. And we know that one in three women in Sub Saharan Africa are infected with and anemia, of course, will have a direct impact both on complications of the pregnancy, but also uh increasing uh post um postpartum complications such as um postpartum hemorrhage. So, what are the college priorities at the moment? So at the moment, we have certain projects we are working on, I'm gonna go through them. Um one by one. So I'll start with gynecologic uh um the Making of Ocean State project. So this is the project was led by um our previous president name Leslie Regan, where we had a five year project looking at um um advocacy and abortion in um several countries in Sub Saharan Africa, including Nigeria, Rwanda, Sudan, Sierra Leone, and Zimbabwe. And actually the project was a great success that has led to a development of lots of training toolkits. Please do access them that are available on our website free of charge, but not only that, we managed to create more than 60 champions advocates in a lot of these and a lot of ministries, for example, in Nigeria, a adopted the change and and made abortion much safer for women in their countries. There was a struggle with a couple of countries, one of them was Zimbabwe and that's due to political problems there. And then in Sudan because of the uprising in 2019 and then followed by the war. So that's kind of an area that we didn't really do as well as we would have hoped. We just finished the project and we had a fantastic evaluation uh with really good outcomes and we seem to be quite happy with um with the uh with, with the independent evaluation, making sure that we're using those advocates in other projects, but also to continue and sustain uh the changes that we wanted to achieve gynecological health matters. So this is one of the areas that our current president has did when she was Vice President Ma Tucker. And the idea behind it is that what we want to achieve is that allow health workers. Um So general doctors, as well as nurses try to do something simple for gynecology, things like taking a smear, taking history advice about contraception and basically teaching uh those uh healthcare workers basic gynecological skills. And that seems to work really well when we started with Bangladesh and we started with two districts and now that has expanded to 20 districts because we have a buy in from the government that one of the most important um areas that we look at with projects from the Royal College is trying to get a binding from um governments and health ministers to help you to facilitate and sustain the work. We were also lucky to get a, a grant from F and that's what we already started that in Nigeria a month ago. And the same donor who gave us the Bangladesh um funding has now given us the go ahead to do a similar project in Rwanda. And I think this is a really good project, uh uh simple but very effective. Uh and, and I really encourage you to look at our uh e evaluation report in our website. Now, as I've said to you, uh at the start, I come from Sudan and Egypt and F GM is a big problem in these countries, but not only that medicalization in particular is a huge problem in some countries. Egypt is the leading country in medicalization where more than 80% of female genital mutilation is performed by doctors in Sudan. More than 8% is performed by traditional birth attendants. So what we wanted to find out is what can we do to reduce medicalization? Thankfully, if you look in Egypt, the rate of F GM started to come down but the medicalization is going up and there are certain countries are renowned for medicalization apart from Sudan and Egypt and that includes Sierra Leone and also include Malaysia. So I went to a conference in Malaysia last year. And the first thing that struck me when I was driving from the airport to the hotel is that there were adverts doctor's adverts for F GM. Basically, they call it, they call it clitoral piercing for babies at the age of six months open. You see the adverts on TV, you see the adverts everywhere and that's absolutely acceptable there. So there's a lot of work that we need to do with regard to medicalization now. So what I thought about, let's start with Egypt and Sudan because I know the area, uh we have easy access with the war in Sudan. We really focused our reps in Egypt and we did a survey and we really wanted to find out why doctors perform such horrible, horrible procedures as a, as a clinician. And actually, I can summarize them in to answer some of them. They believe it. I think it's the one thing they should do either for their personal beliefs or they think it's related to religion. The second group, they do it for money. They said it's a money earner, especially in peripheral clinics in upper Egypt and other areas where they get paid as a general doctor because you're the only doctor there. You do the appendix, you do the Cesarean and you also do the F GM. And the third one is community pressure. They feel that if they do not do it, the community will not trust them in such villages and therefore they will not bring them to actually sick people. So what we decide to do is that what can the Royal College do? And really, our strength is mainly around advocacy, learning and education. That's really what colleges can do. Um And we're not gonna get into community work and so on because a lot of NGO S are working there and doing a fantastic job, but we wanted to target medicalization. So I've created an, a workshop where we tackle ethics, we tackle physiology and pathology and we tackle religion and we tackle law. Um Sorry. So what we did is that we did a um uh uh um a pilot in Alexandria last year. And then this year in March, we did another three workshops, two in Cairo, one in Upper Egypt and basically trying to address the issues. Uh And you can see you have a really good number, number of people attending um in a lot of uh um in, in, in several of these um cities. We are so lucky because the both the president and the chief executive have joined us. And I think that's really quite important just to send a message that the college is quite serious about this project and that was really well uh received. No, what we have done as well. We got um representatives from UN FDA to come and evaluate the um workshop and their evaluation was really positive. Looks like we need to do a little bit more with the training, the trainers course, but the basic course I think are passed with flying colors. And I think we are now strengthening our training, the training course and really, really positive. And I remember one of the candidates uh from last year she was, oh, we chose her as a training as a trainer when she joined us this year. She said to me, I remember last time you said that you use the opportunity every time you see someone advise them against F GM. And she said, every woman who delivers in my hospital with F GM and go through a horrible birth. I remind her and I say to her, you have a daughter now don't make her go through the same experience. And that seemed to really work and she keeps in touch with them, et cetera. So I think there's a lot of work that we can do um to reduce that. Now, what are the highlights of the um of the project? The highlights are that we need funding to continue doing. And this uh and um these projects because there are about 20 different um sectors in Egypt that we want to address um and go to in particular upper Egypt. And at the moment, what we're doing is we are collecting all our information, the evaluation, writing up a paper, a concept paper and going for funding. And hopefully that will give us an opportunity for us to work together. And if anybody is interested uh in working with us on the F GM uh do let us know when I came to office 18 months ago, I found we have this s consult status. So one of our previous um administrator in the office was very hard to get these stages, but we just have the stages. It didn't mean anything. We just have the name and we talked about it, but I really don't know what to do with it. So I then went and had a look and it's some of you have looked at the Economic and Social Council of the UN. It's quite a mixture of social care, health care. Um um as well as a group, human rights. It's a mixture and we really wanted to know what is the value of such a privileged status and what are we gonna do with it as an RCO G. So I've written a vision paper and I've now shared it um uh about three weeks ago with our global health trainees and our Global Health Board to try to get feedback from them and then um formalize our vision and how we use that status going forward to have a such an important seat in such a privileged organization is really, really important, but we need to make use of it. And at the moment, I don't know what it means apart from that. We have S FO status, but I always say charity spons at home. So I think global health and I was really interested to hear earlier about the issues we have with asylum seekers and refugees and, and II work South London SJ and 10 years. And we have also in Surrey area where there's a lot of refugees um are kind of un entrapped into an asylum seekers into the health system that actually does not speak to the home office system. Um Community midwives tell me that they go and see a woman for her antenatal booking. And then four weeks later when they don't hear from her, they found that she has moved to Manchester because that's what the home office decides to do without telling the NHS system. So it's a mess of what we're doing here to our asylum seekers in this country and refugees. It's really, really bad. The Embrace Report. I don't know some of you know about the Embrace Report. II know some of you are obstetricians here but we are lucky in the U in the UK. We have this report that looks at each maternal debt in details by a group of experts and we analyze and we come up with them and we do that every three years, but I am sick of hearing every three years. The same out ethnic minorities don't do well and all we do in my opinion at the moment in lip service even today. I don't know if you, some of you have heard the news today, there is a, a AAA report coming out from the parliament about how women are treated in uh maternity. Um Few weeks ago, we also had um issues about translation services, et cetera, et cetera. We're not doing well. We're supposed to be a leading country in our care, but we are not doing well at all. And if you look at the embrace report, the last one was not dissimilated. The one before or the one before or the one before black women are still four times more likely to die than white women. Asian women are still twice likely to die than white women. The O NS report shows wide ethnic inequalities and perinatal mortality continue still high even recently from the um pediatrics outcome. Again, higher incident uh uh among women uh of ethnic minorities and the theme that comes out almost consistently is that are language barriers in London. We have more than si 600 languages and violence 600. Some of you work in London and you can see how difficult sometimes even to do a reasonable consultation. Recently, I had this couple with AAA baby with a um a fetal abnormality uh from Kurdistan and we prepared the interpreter. We were already and when they came, they turned, they turned out they speak surrounding and the inter is not although he was and that's the problem. So we need to really start rethinking what we are going to do. I know in some A&E s in some we're using some flash cards, some readymade kind of um um uh information leaflets in different languages, but not enough. And how many of us have found ourselves in the middle of the night with a serious emergency that you want to explain why you're gonna do such an important intervention. You're not gonna be waiting to read language line or getting an interpreter at three o'clock in the morning and we don't have that time. So we really need to rethink what we're gonna do about our language barriers. And it is clear that and this fact, um risk factors with language barriers are related as well to deprivation, refugee and asylum seeker status as well as homelessness and mental health. There is a big gap in communication, a big gap and I don't think we're doing well. So the RCO G recommended that women who have difficulty reading or speaking English should have access to high quality interpretation services and that commissioners should make that available. So I would urge everyone working within the NHS to make sure that your hospital for now at least provides the right provision of service really, really important. We are lucky in our area because we have a fantastic group of midwives who work with us in South London who take this issue very, very seriously. But I know in a lot of other hospitals, that's not the case. And there's a lot of high profile death recently made the news mainly related to language barriers as simple as that women die because they don't really know what's happening to them. So what I think we should really do is provide a comprehensive and anti um and an education I am really not keen on this slash part and simple things because I don't think this will address the issues we have. There's a lot of funding going into NHS London to provide that and you'll find a group doing something, another group doing something else. And actually a lot of that has already been done by a lot of fantastic emergency doctors that you will find information in different language. I think we need to start thinking about um technology and artificial intelligence and how we make that reliable. Um Of course, because that's really where the problem is, is reliability. And, and currently I'm working with the RCO RCM and NHS London and England trying to come up with some kind of agreement of how we address the service. Now, one of the things when I came as well found that we don't have actually global health training in women's health, believe it or not changeful, all other specialities do excel women's health. So some people have to get their families and travel all the way to um use it um to get some sort sort of global health experience at the moment and go out of program or do it after you become a consultant at the moment. We don't. And I'm now in discussion with our global health trainees together with our education BP, my colleague, Ian Scal trying to have um global health training within the curriculum. So people don't have to go out of program, they can do global health within that. And um um at the moment, we're looking at different job descriptions from other specialities, but also from Global Health Post uh within um us, try to come up with um several programs and, and I know a couple of um uh head of schools uh uh in England who are interested to work with us both in um in um self extent and sorry as well as leads. And I think that will really be helpful for us if I can do that before my term ends. Uh Next year, we're also discussing with our global health um um trainees because we have trainees, we have a new committee uh looking at uh a global health conference, but it's very difficult to beat conferences like yours. So we need to think about how we're gonna do something different uh uh for women's health uh as well. I think I'll um I'll stop here. Um But Professor Mahalah passed away a few months ago. He's like um a leader in sexual health. Um um um um in, in Figo. And what he said is really, really resonate with our experiences that women are not dying of diseases, we cannot treat, are dying because societies have yet to decide that their lives are worth saving. He was great. He was a great Egyptian doctor, very humble from Upper Egypt and realized very early on that the inequalities really affect outcome. And I think that women get a bad deal when it comes to health care. Thank you very much. So, thank you so much for that talk. Um I'm gonna start with two questions that came in earlier before this conference. Uh The first one to go first is looking at women's access to sexual and reproductive health care in neglected conflict settings. Um, much of the work that we um have heard about Africa and in conflicts that aren't as highlighted as others in the years. So we can start with that. And I think you're absolutely right. I, one of the problems we have is that conflict areas always creates problems for us. Access. That's one of the problems as an example, we want to do our FG MTK um project in Sudan. But because of the conflict, it can really difficult for us even to access, even myself who was originally Sudanese to try to get to somewhere that you can make a, a difference. Obviously, you also have um issues with um accessibility in Ukraine and um uh in, in, in other countries in uh Asia as well. So that's always a problem. And colleges like us and I'm sure they agree with me as well. When you look at oncology, physician, we are not, we are of pediatricians. We are not really equipped to go into areas V MSF and other organizations. We don't have that experience. Um believe it or not, I was going to South Korea tomorrow. And the Royal College has to do a risk assessment for me and the president to go to start career. And they sent me the document this morning about the do s and don'ts. So we kind of it's really, really complex when it comes to insurances, et cetera. So I agree we should do better in conflict. And I know a lot of work is currently being done in Sudan, for example, in um through Port Sudan, I was speaking to one of my colleagues there who actually went from Cairo to Port Sudan to do some work, but it is not easy and there is also risk to one's lives et cetera. So um obviously, the area that was most worrying um at home is Gaza and we have our colleague Deborah Harrington in Oxford before we don't have. So Deborah went to actually Gaza and worked within hospitals there. Her, so back in uh in December, but that's a really personal intervention from her with a group of doctors. Um It is difficult for us. We get a lot of emails um for advice and what to do with what's happening in Gaza which is horrific uh at the moment, but it's difficult for us to do anything apart from giving learning tools, giving advice. Um uh I'm currently co authoring with the trauma uh group, uh uh uh a book on how we deal with trauma in particular in women's health. So that hopefully will come out next year. That may be an educational tool that will help people who are able to go there safely. Thank you. Um One more question from online before we move on to in person questions, what change can we implement on the ground as front line clinicians to ensure that the same community with these outcomes are treated accordingly to ensure maternal deaths can be avoided in our future practices. Equality, that's the problem, accessibility, strengthening the health systems. These are the problems that we face in a lot of these countries. Um So I would say that in my opinion, you need to work together with other organizations, you can't work on your own. Um You, you work with other royal colleges, you work with other health organization, a lot of NGO S and that's the way forward. So the, the reason our um Bangladesh uh project in the health kids worked because we work with other organizations. We work with the Canadians, we work with the Americans, we work with the local NGO S. You have to work together, you cannot work inside. So for me working as a group, number two, try to advocate and influence um governments. That's one of the strengths we have at the Royal College. Some of you may have heard about the situation with the F GM um law in the Gambia, but at the moment they are trying to reverse um uh F GM um as um uh a procedure against the law and what we do. Uh We work very hard lobbying our mps who then managed to lobby a Gambian uh government. We still don't know what the outcome is, but that's kind of the role that we have advocacy both locally and internationally. That's number one, number two, try to influence governments that both locally and abroad. Unfortunately, as you know, the current government has cut down um the budget for um uh global healthcare dramatically and that has influenced a lot of projects. So I think our role is trying to do that and educate the college has um 18,000 members and fellows around the world, 50% are within the UK and Ireland and 50% are international. We have more than uh accessibly to more than 100 countries. So we're a very privileged position and we use our position very well through our educational tools and through our learning tools and, and I think that's the best way of doing that. Um We'll go through some questions in the room. So as always, if you could raise your hand. Yes. OK. OK. And, and that kind of another way that we do it and it's great to have flash, but so often in between, you know, who might be to, there's gonna be loads of that have been in, in, in and what would you say would be vision by not taking, but as part of the training in how to take. But what we do see is very good question. Thank you. So I think there are three areas we're looking at. So one of them is research and development and I think there are some people are researchers and I think we can, I see that we can very work very closely with other colleges and with other institutes like London School, for example of topical medicine. Um So that's one area we look at the other area we look at is is clinical work. So what we, what these clinicians would like to do so give them flexibility if somebody wants to have um a a an experience that they can go abroad and then some surgical or clinical tools. But at the same time, don't underestimate the experience we gain from other countries. So I'm really quite keen also to bring expertise from other countries to the UK to help us, for example, with things like, you know, Placenta Accreta where if you go to places like Egypt, uh where the C section rate, unfortunately, it is almost 70 or 80%. And therefore the experience with Placenta Arita is very high. So someone can go there and learn from them. But at the same time, they can also come here and learn from us. So we have actually currently a pilot where we are actually giving opportunities for doctors who are abroad to come here, not empty ISIS but post doctoral and they come here and then specialist services such as maternal medicine or urogynecology, et cetera. And then the third area is really more kind of, um, sexually block health. Right. And I think that's the kind of the areas we're looking at. So we look at an R and DSR HR as well as, uh, clinic. So that's kind of the areas I'm going to see if I can get up starting with the three kind of jobs, uh training models. I'll be very happy. We've got a question as well. And this question about your medical, how would you mitigate the risk of they have? That's a very good point. And thank you for asking that question. And that's one of the main issues that a lot of people do practice F GM U. We're doing it because we're doing it in a nice safe clinical setup rather than let them drive it underground, absolutely dangerous if we um accept that. So I think the law is very clear now, if we look at currently what happened over the last few years because of the obstetrics and Gynecologist society within Egypt, for example, started to really give good talks and training et cetera. What happened is that actually there are less gynecologists doing the procedure, but there are new, new players, we now have GPS and surgeons going into that area of practice because there is always a demand. So the the the aim is really to reduce the demand. So the patients or the prospective families do not find anybody else to do. And one of the areas we're working with is that we're targeting. Also, I didn't mention that in detail, but we're also targeting medical school. So in Egypt, although it's against the law, although it's supposed to be in all curricula in medical schools, only two out of their tens of universities teach that module, the rest of them they don't teach you. And actually I know in one of the universities, I'm not gonna mention that Dean is a complete advocate for FG A and that's why he put a stop to it. So we need to work at medical school level at the moment. We're working with the post graduate. But currently we're also speaking to the undergraduate processes that and see if we can work with that. But I really see where you're coming from, but that's what the excuse that they use. But I think working together with NG OSU N FDA um save the Children, et cetera. I think we will get there eventually. Thank you. Um We've probably got time for one more question if anyone has any last questions. So your presentation and I wanted to ask a question about which was talking about the and, and, and of course they problems which include problems um having that in, in, in um and also different per around um it medicine, I, we were talking about talking about international endeavors but Um What do you think is the, what's, what's on your agenda to help um help in the UK with the immigration that we have. I'm gonna speak at Hassan, not as the vice president of the Royal College. Um I think at the world will have a horrible government. I think the way they treat refugees and asylum seekers and overseas um people really badly. Um We know for a fact that patients cannot access uh health care because they're worried for example, to be asked to pay. So there is evidence to say that patients are actually ending up with really advanced cancer or advanced uh critical complications in pregnancy because they're worried that they go to hospital as a leader illegal overseas patients because there are some misinterpretation of the law within NHS hospitals. If I tell you how many times I had a um a difficult discussion with our overseas officers in the hospital about women and sometimes partners being dragged out of the label because they want them to pay and say to them go elsewhere. We are not really doing well. And I think the current rhetoric that is provided by the current government is actually seeping down to some of the workers in the NHS. And we have lost compassion, we have lost empathy and you are the wrong audience, but we are a minority here, a lot of the people out there. They don't give a damn. I can tell you that And unfortunately, you're absolutely right. We see that in a lot of hospitals and I can tell you that's probably happening in my hospital today that people avoid coming to hospital because they're worried about the immigration status. They're worried about um how they're gonna be and manage that. And then add on top of that, the language barriers, the lack of interpretation, but also the inherent discrimination within NHS staff and system, which is absolutely a reality. There is definite, definitely um inequalities and how we accept this and until this country accepts that it's become a multicultural country, we will come back in three years time. If I'm, if we get invited again, I will say again, the emb report is showing that black women again, more likely to die than white women, Asian woman doctor. It's the same thing this has been happening since I was in sho it hasn't really changed. And when I asked NHS England about the funding for interpretation services, et cetera, they, they haven't even appointed someone to leave on that. So we have a problem, a big, big problem. But it's people like you, the young generation who are coming up and not accepting this will make a difference, I believe. Sorry, sorry. Thank you so much. I just want to be around the