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Thank you for coming back. Uh We're going to make a start with our first session of this afternoon. Um So Prof Michael Marks is a professor of Medicine at the London School of Hygiene and Tropical Medicine and an honorary consultant in infectious diseases at the Hospital for Tropical Diseases University College London Hospital. He works across the Pacific and Africa with a particular focus on neglected tropical diseases and sexually transmitted infections. What you do, right? Do I need this? I'm I'm really loud. So you, you, you project. Yeah, I'll take it great. Uh Thanks everyone. Um I mean, the topic is sort of huge uh for those of you that don't know wh O has this uh list that they made up about 10 years. Well, 14 years ago, now of neglected tropical diseases which have nothing in common whatsoever with each other. Apart from that, they're on a list at wo um and there are 23 of these diseases which is far too much to try and get through one talk. So I'm gonna focus on um one specific area which is um this uh uh area of neglected type of disease that's involving the skin because this is something that wh O is really pushing in its uh next 10 year vision of how er this space will move forward, right. Hopefully. Great. So, uh I'll talk a little bit about entities and skin entities, uh what people have been doing on sort of burden estimation uh and uh then sort of care pathways for individuals suffering from these conditions, right. So, uh this is, well, actually this list is wrong. Now, the the this changed in March, but they haven't got a new list on the right side. But this is wh os list of neglected tropical diseases, Cerca March 2024. Um If you went back six years, the list looked a bit different to that. And if you went back 10 years, it looked a bit different from that. And if you went back to 20 10, the list didn't exist at all. Um And conceptually, you'll see that essentially there is no unifying factor for any of these diseases. There are some viruses, there are some bacteria, there are some protozoa, there are some helminths. Uh There are even some non communicable diseases. Uh since snakebite got added uh in 27 A wh O I is a, a new disease which is the 21st or the 24th depending on how you count the numbers, which is noma. Um an even less clearly defined entity which is probably some combination of microbiome and micronutrient deficiencies. OK? Uh and these five diseases, the ones highlighted in red, these are probably the ones if you've ever heard anything about a ectopic disease, uh, you've probably heard about one of these five in red cos, these are the ones where the mainstay of the strategy has basically been community mass treatment. So you go to a community, a series of communities and you don't test, you just treat everyone on mass in one go. And these have been supported by, by traditionally the British government until the cuts in aid. Uh the US government er and the Bill and the Melinda Gates Foundation and supported by huge donations by pharmaceutical companies who are of course, normally the enemy. But this is uh one area where they have made major contributions. Um Merck, for example, have donated more than a billion tablets of ivermectin over the last decade for um onitis. And these are the really the ones that people have ever paid any attention to. Uh But there is this other group that people have become interested in in the last few years, uh which is this category uh which are those diseases predominantly manifest as changes uh in the skin. And this is really a marketing exercise on one level uh to bring attention to this group of the DS that have got less attention than the others. So they sort of neglect within neglect. Uh And the idea is that rather than having er individual programs focus limit to these diseases. Perhaps you can bring them together in a more sellable package. Uh So here are some of the diseases we're gonna hear about today for early ulcer in the top left hand corner, this is caused by mycobacterium ulcers. So this is very closely related to mycobacterium marinum, which if you know anything is the one that you get from putting your hand in a tropical fish tank. Uh Mycetoma, this is uh an implantation disease. So, there are two versions of this depending on whether or not you get a bacterial or a fungal implant that effectively you get a puncture, wound arterial fungus get in traditionally into the foot. Uh And the fungal one is highly debilitating and basically unresponsive for treatment on ESIs. People think of as river blindness, but actually at least half of all the disability adjusted life years due to onis are due to skin changes. Uh Yours aid and Tenuis is a relative of syphilis. The morbidity of lymphatic filariasis. So this mainly manifests as uh hydrocele and uh lymphedema cutaneous leishmaniasis. Probably you think maybe from time to time about visceral leishmaniasis. But there's far more cutaneous disease in the world, scabies added in 2017, the most common of these diseases, probably 400 million individuals affected uh annually each year. Uh And then let us see, uh which despite being declared eliminated as a public health problem still has about a quarter of a million cases a year worldwide. So just to sort of give you some sense of uh what these diseases look like, er, and, and sort of how common they are, these are all taken from uh wh O data. So be really, also runs at about 1500 cases a year in the world. Uh of which about two thirds are in West Central Africa. So really spanning from Liberia down to um Cameroon and D RC. And then there's another very, very interesting focus uh in Melbourne, Australia, which is related to the possums being infected. Uh And then it's completely different to the um Borreli ulcer that's going on else in the world. But if you ever wanna go and work on possum two, I strongly advise you move to Melbourne and work on Borreli ulcer uh Mycetoma. Uh You can see that no one really knows what's going on with Mycetoma cos they've just made up a number to put in the official wh O report and they just say that there are at least 10,000 cases. OK. Onchocerciasis. You can see here, people like to prepare uh give different numbers. So there's not 238 million people with onchocerciasis, but there are 238 million people living in an area where they need treatment for onchocerciasis. This is because this is a, a disease treated predominantly through mass drug menstruation. Yours, about 90,000 cases, nearly all of which are in the Western Pacific uh lymphatic pleuritis. Again, this is a number of the proportion of people who uh live in an area requiring MDA who are very high. Almost a billion people. Uh In 2020 lived in an area requiring treatment for this and then cutaneously men. More than 200,000 cases. Oh, but hands off. If anyone else this runs seeing a case of cutaneous leishmanin, that's not bad. Four people, five people, I mean, there's quite a lot of leash in the world. You come to H TD, you see a case of leash every month, for sure. Ok, scabies, er, 200 million people probably affected at any point in time, 400 million people, probably a year. Uh, and then, uh leprosy, uh you might say, well, Michael said it was a quarter of a million and said only 100 and 28,000, but that's 2020. So it was obviously the first year of COVID and you, people just stopped looking for cases of leprosy, which is a very effective way of making the number of cases of leprosy go down uh in the world. And is, is actually what happened at one point. Wh O declared they were going to eliminate leprosy. Countries were strongly incentivized to uh not find any leprosy. Uh And so people did less case searching and of course, when people looked again, it turned out, the lep hadn't gone away, they just stopped count. So that's to give you a sort of sense of, about, of these. Um, and the skin is really important. I mean, I'm an infection doctor, not a dermatologist. So I, my dermatology colleagues sometimes, you know, have to remind me that the skin is uh important. Are there any dermatologists in the room? No, dermatologists here to do global health. Tragic. You know, the skin uh, is probably the bit of you that you care the most about. You might like to think that you're really worried about your cardiovascular health or you know how well your liver is, but the skin is the bit of you that you see when you wake up in the morning, it's the bit that is important for attracting a life partner for communicating for homeostasis. It is fundamental to your very sense of being. And so diseases of the skin have really outward uh impacts on people's sense of self worth, ability to interact in the world, ability to go to school, lots of things, you know, far worse. Um And you might otherwise think, ok, so where has this sort of idea come from? Just to give you a sort of brief timeline since uh 2015. This is when we first started thinking about the idea of that I'm a skin D person and I was very jealous of all the people that were just giving out tablets and getting all the money. So we, we put together some symposiums in 2015 and a series of opinion pieces in 2016, 2017, uh which culminated hopefully uh in in this, which is sort of uh putting the idea of neglected topic diseases of the skin into an official wh O document. So this is uh taken from a document called the roadmap for neglected topical diseases. This lays out what wh O thinks should happen over a 10 year cycle. Uh And so this is from the 2021 to 2030 roadmap. Uh And for the first time, uh skin entities got their own section, recognizing them as one of the 20 leading causes of ill health globally. And in the top 10 causes of nonfatal disability, actually, skin diseases are the fourth largest cause of das worldwide. The number one cause is back pain, much more interesting than any other global health challenge it would appear. Um And they, so for the first time they set this target saying that between 2020 to 2030 they would go from 0 to 30 countries which would develop an integrated strategy for skin diseases. So this sort of emerged from a concept of a few of us being a bit annoyed all the way through to a policy document at wh O over about a six year cycle. Uh and that was then followed by this er specific document. So the roadmap is a sort of overarching document tots across all 23 of the diseases. Uh and they subsequently published this, er, specific document on skin related diseases. Uh And last year at the first Skin MPD meeting in Geneva. So that's the sort of policy backdrop that's, that's got it here and I'll, I'll talk in the uh last two sections about some of the work that people have been doing. So, um, measuring things is basically all I do for a living. I'm an epidemiologist. I just go to places and I count stuff in sort of increasingly sophisticated ways. Um And you know, burden estimation matters because that is how you convince people that the disease you work on is important. You know, people give lots of money for worms because uh 300 million people a year get worms and that's a big number. Uh And then they say that that results in 500 million disability adjusted life years. And that's a very big number. And if I turn up and I say my disease affects six people, it's pretty clear who to give the money for. But you get in a sort of vicious cycle, which is if you don't know how much disease there is, you can't convince anyone to give you any money. So you can't show how much disease there is and you just go round and round in this cycle. So this has really been um a focus for uh these diseases trying to understand where the burden is. Ok. These diseases are quite hard to measure the burden of for a number of reasons. Uh They predominantly affect very rural, marginalized populations who have limited access to health care. They're quite difficult, costly and time consuming to treat. And it's not ethical to turn up, measure something and not be able to provide care. So for example, if you're gonna go and find cases of leprosy, you need to have people who know how to look after the cases of leprosy that you find when you do that uh they are hard to do. There are no dermatologists in the room. Most of these are complicated diagnoses to me. Um You're starting from a position of ignorance, we don't really know what the spatial determinants of these diseases are. And as I said, they've had lower investment in research and development. So I'm gonna show you uh one example of uh work in this space conducted in collaboration with the Ministry of Health in Liberia. Hopefully everyone knows where Liberia is, but this is on West Africa a bit along from uh Ghana. So Cote de Noire there to the East Sierra Leone, to the um to the West uh and really focused in this, in this one area uh of Maryland County. OK. Uh So just to sort of uh zoom in. So the capital is up here on uh on a good day. That's about a six hour drive on a bad day. It's about a three day drive. Um Just to give you some sense of the sort of logistics of the worker. And Maryland has a population of about 100 and 65,000 people. So this is, you know, a smaller city, right? This is like somewhere you might go to work at a district general Hospital, but over a much, much larger geographic area. Um And we really wanted to measure how common skin ent Ds were because we suspected that the routine Ministry of Health data was essentially rubbish because the routine Ministry of Health data relies on someone presenting to a health facility that's probably not gonna happen because that's uh time consuming expensive. People live a long way away. A diagnosis being made, that's not gonna happen because none of the staff at the facilities are uh trained to recognize the conditions and there's no access to diagnostics. So there are lots of reasons to think that the routine data is basically highly unreliable. And so we used an approach uh called C random sampling. Um So you make a list of all of the health care facilities uh in the whole of the county and you basically identify the communities that sit with each of these health facilities. So you can imagine this is like a host of one or two nurses working at it serving three or four villages. OK. Uh And then you can send out a community health worker just is an untrained member of staff effectively and they go round their village, uh, and they will screen to try and identify suspected cases. So not the thing you're looking for, but something that might even vaguely be the thing that you're looking for. And then you can send a smaller number of groups of individuals round after them to see which of the suspected uh cases really are. The thing you're interested in and you want to do that mobilely coming to the patient's home so that they don't have to travel to a healthcare facility. Um And so we said we would enroll about 60,000 people. So it's about a third of the entire district just to give you a sort of sense of the scale. OK. So, uh what does this look like uh in reality? So each of these red dots uh is a healthcare facility, there are more healthcare facilities that are not shown, but these are the 96 that were shown. Uh And you can see unsurprisingly, there are two more peri urban areas which have several facilities and therefore they're sort of over sampled deliberately. Ok. So if you're gonna do this, you have to start from the assumption that people need to be able to look at the skin a bit or at least the people who are gonna do the verification are gonna look at the skin. How many dermatologists do you think there are in the whole of Liberia? Zero? So there are zero dermatologists in Liberia, Ethiopia probably has the most, uh, dermatologists outside of, say South Africa and some of the northern African countries has. There's more than 100 dermatologists in Ethiopia population of Ethiopia's more than 100 million people and 85% of the dermatologists in Ethiopia in Addis Ababa, the capital. So even in African countries with quite a lot of dermatologists, they are always in the urban settings are not out where all of these diseases are. So we did a five day training program uh where we taught some basic dermatology and some common skin diseases. That's really important. Uh because you want someone to be able to say that's not leprosy because it is something else rather than just say that's not leprosy that doesn't fill you as a patient with any, um you know, sense of confidence and they have to be able to provide care for the people that have the other conditions if you turn up in a village and you say you've got leprosy, so I could want some drugs for you. You two have both got skin conditions, but they're not one of the ones I'm interested in nothing for you. When I come six months later, you will just tell me to disappear, won't you? Politely? So it's really important that even if you're particularly interested in a small number of conditions that you're set up to deal with all of them. So, uh we covered some common skin diseases, uh management of skin disease and then how to deliver? Ok. Uh And then what did screening look like? We had these amazing community health care workers, um many of whom had never used the mobile phone before. Uh And they were given basically a laminated flip book with lots of pictures of uh different skin conditions. The idea here is right, not to make a diagnosis. It's just to say does anyone in your house or anyone, you know, have something that looks vaguely like one of these photos? So it's meant to be very sensitive but not very specific. Uh And they would go round and they would do that for sort of 300 to 2000 people. And you can see people were very happy to sort of sit around and look at this, this was sort of activity. Uh And then we had a third physician assistant. Um So this is a sort of midlevel grade perhaps with people in the UK are a bit more familiar with now less controversial in Liberia, I would add. Um and they went door to door. So I mean, you can see this is not a healthcare facility, but the patient is having molecular testing, samples collected for beli ulcer and being initiated on appropriate drugs that we would normally only ever start in a secondary care facility. Ok. This was a research study. So we had a whole bunch of quality control uh checked in. So we wanted to check that the community health workers really did turn up at people's houses and didn't just come back and say, I promise I did a census everywhere. Um And uh we had the national program check the quality of the er verifiers. We did and we did everything using real time electronic data direction. And so we did this over four months screening just over 56,000 individuals and found about 3000 suspected cases. Uh And you can see it worked really well when we did our QC, 95% of people said, yes, community health worker really had come to our house and shown us the flip book. Um and most people 90% still had the ID card that we had given them. So that seemed pretty good. And what you can see now on the left is the um number of cases that have been reported for each of these diseases in the subregions of this county uh in the year before. So basically, you can see that if you lived in, in the year 2017, you might have had a diagnosis of lymphatic filariasis associated morbidity, either lymphedema or hydrocele. But basically, if you lived anywhere else in the whole of Maryland County, the chance that anyone was gonna find you and diagnose your skin condition was effectively zero. If you compare that. Now, uh on the right, you can see that in every region of the county, we were able to detect cases of skin entities using this approach. And most importantly, you can see there's quite a lot of variation in what the predominant disease was across the county. So for example, uh in Caloway two, we found quite a lot of yours. Uh In Harper, we found loads of um lymphatic go in, we found mostly leprosy. So this shows two things you have to go to the patient in this setting. They are not gonna come to the health facility. There are too many barriers for that. And secondly, there was real value in integrating if we'd done it exactly the same survey and we'd only looked for lymphatic filariasis, you know, in three or four of the regions we'd gone through, we'd have found nothing and we'd have spent a lot of money to find no cases. But by cross cutting across several diseases. At the same time, we were able to really add value just to sort of show that this approach really does make a difference for one of the diseases, for example, that we were looking at this is a condition called yours. So this is closely related to syphilis. Um And we found uh 24 serologically confirmed and 17 molecularly confirmed cases of this disease and this had not been reported in Liberia since 1970. It is clear that this was still being transmitted for the last 50 years, right? This didn't magically appear again in 2016 just for us to turn up and measure it in 2017, but passive case surveillance, which is what Liberia had in place. And Liberia's had a very tough time over the last several decades and a very uh weak health system, you know, just not sufficient to pick up these conditions and just to sort of show you what this effort looked like. We had seen 30,000 individuals in this study before we found the first case of yours. So, you know, if we're sort of serious about finding some of these conditions, wh O says they're gonna eradicate yours from the whole world, the effort involved will be substantial. OK? And just a little bit on the other things I mentioned um that a lot of you have to be prepared for the other stuff. So the key thing here is that most people we saw with a skin problem turned out not to have one of the diseases we had gone looking for scabies was the only other neglected tropical disease of any substantial burden you'd expect. But you know, if you go out looking for lymphatic filariasis associated hydroceles, what you find are a lot of uncorrected congenital hernias, right? Because it's very noticeable person has large uh you know, scrotum patients don't know what's wrong. They bring them OK. Lots and lots of fungal infections because they give rise to a large hypopigmented plaques on your skin. Get confused for leprosy, for example. And so this has sort of major implications. And I would say I've spent the last three years convincing wh O that they need to have an integration Skin Pro program rather than an integrated Skin NTD program. Because this is such a tiny proportion of all the skin disease that's sort of out there. I think they are now finally on board, but they have to tackle skin as a problem and not just the skin diseases that happen to be on their special list. Ok. So I'm just gonna focus in for the last few minutes um on the other bit that's going out and finding people uh or what about how to sort of manage their care journey. So probably no one in this room ever really thinks about their care pathway or their care journey because outwit the fact that it's very hard to see a GP apologies for GPS in the room, it's pretty straightforward in the UK, how you access health care, you know, you have universal health coverage. No one lives a very long way. Referral pathways are extremely well laid out. Of course, things go wrong. But in general, it's pretty clear how to access care and people are health literate broadly speaking in the UK, they recognize that they're unwell, they know that they need to seek care. Ok. That is not the case in many lower middle income country settings. And I'm talking about this from the perspective of skin conditions, but Jack could tell you the same, I'm sure for many non communicable diseases, other people could tell you the same for pretty much any condition. Ok. And so you have to start by believing that you are unwell. So there's some gap between disease onset and suspecting you're unwell. And if something's really common where you live, you may not identify that as illness. So, uh I used to live in the Solomon Islands. 20% of the population of the Solomon Islands had scabies. It is just viewed as a normal thing to have incredibly itchy skin all the time. It wouldn't strike anyone as obvious that you should go and see a healthcare professional for that because 20% of the population have it, that's just normal, right? So you have to identify that you're unwell, you have to get a diagnosis which means that you need uh to go. Uh and then you need to get some treatment and be prevented. Ok. So I'm just gonna touch a little bit on this uh project we've been doing the last few minutes, making sure I leave a bit of time for some questions, er, which is really aimed at the the box on the right, reducing the physical financial and psychosocial impact of these conditions. Uh And I won't talk to you for all of this, but the idea is really to fix the health system. It's a minor challenge. Uh But you know, we'll find cases we'll strengthen care pathways, we'll fix the supply chain. Uh and we'll do all the bits in one go. And so our sort of high level a hopefully walks me through this journey is you should seek care early, you should get accurate diagnosis at a single visit. So you shouldn't have to come and go and come and go and come and go and then you should get complete effective treatment without incurring catastrophic expenditure. Not something that most of us in the UK think about, but a major consideration. We did this by um putting together a variety of different pieces of work. Health care care records, reviews observations, focus group discussions, in depth interviews just to tell you the things that we didn't see because these are things that people often ask about. We didn't see that stigma impacted people's choice about where to seek care. People experience stigma, but that's not what determines where they choose to seek care. Uh It doesn't matter if you think the thing is caused by witchcraft or by a bug, that's not what causes people where they seek care. People have those beliefs, but it's not what determines where they seek care. No one believes that allopathic normal medicine doesn't work. Um Or that, you know, the health system wasn't good. I'm just gonna skip through a few of these things quickly. Basically, the thing that really matters is care is expensive. Ok? It costs to seek care because uh you go lots of times you have to pay, you'll have to travel back maybe for three hours, you have to stay somewhere, you have to have food. So all of those things result in direct and indirect costs of care seeking. Um And there you go, for example, you're o for three or four days at a facility just to get a diagnosis. And if you don't get the diagnosis on your first visit, you have to go back a month later and do it again. And that really puts people off sleeping care. And so I mentioned this already, transportation costs, wound costs and then the things we might not think about so much, all the opportunity costs a day visiting a healthcare facility is a day not working, not earning income. Whereas if you go to a traditional healer, which is what lots of people do, you can pay in a chicken, you can pay with a chicken in a month's time because that's someone that lives in your community. So they have flexibility about how they charge you and you don't have all the costs. We may think that on one level, this is a very irrational healthcare decision. But from a financial perspective, this strikes many people as incredibly rational. Why not go to the traditional healer? See if things get better. It's your skin. Sometimes things do get better if they do, you're financially better off. Uh And it's much easier for you to accommodate. So it is really finances, not whether or not you think something's caused by witchcraft that determines your decision to see a traditional healer in many, many things. Ok. So all of this is gonna feed in and we luckily I don't have the results of this study yet. So I don't have to tell you about them uh for this piece of work, but I'm just gonna show you uh what this will look like in the last 30 seconds. So um we've developed a series of pieces of work on community messaging. So this is um addressing population knowledge so that people are aware of the problem and they received care earlier. I have to say personally, everyone loves education. I'm not that convinced education is the problem. Most people know there's a problem, it's expensive. I think the expenses that is the main of you. But you um we, we have these um we have decentralized care. So we have developed a very simplified set of training materials uh and wound care that can be delivered at the level of the community, in fact, so that patients deliver their own wound care rather than they even from the health facility at all. Uh psycho social support so that people feel better, right? I've already said that your skin is super important for your sense of wellbeing. So we need to heal the mind as well as the body. Uh And then I've mentioned this home based wound care which is really key because it's the cost of buying dressing materials, the cost of buying your antibiotics, the cost of coming to the facility that drives the problem. And so we've put in place a series of, er, steps to try and address that. Ok. And maybe in 18 months time I'll come back and I'll tell you if it worked or not, I think making it cheaper will have worked, but we may make it too popular and then we'll run out of money. So, um I guess, I guess I'll conclude the, the the entities are moving away from these vertical programs, single disease programs to integration. Um And this is really designed to be aligned with universal health coverage. OK. So that's another big push. The idea that care should be available to everyone for a common set of conditions, your diabetes, your hypertension, your pregnancy care, your skin problem, you know, so skin problems are about 25% of why people go to see a GP in the UK. It's the same. Uh globally, these are one of the commonest causes of um ill health. Skin involvement is the most common feature of the NTD S. So I told you that 23 diseases have nothing in common with each other, which is correct. But uh at least eight of them do involve the skin. Uh And so that is a cross cutting way that we can try and tackle several of these diseases at the same time. But most people you see with a skin problem, don't have one of these interesting diseases. So if you go into this space thinking that you're just gonna work on leprosy for the rest of your life, most people you see won't have leprosy. Most people you see will not have one of the rarer diseases. They'll have tinea corporis, tinea capitis, p versicolor diseases that you probably learned about very briefly at medical school. And then for the GPS would look after. Uh but you know, these are common and important conditions that affect people's sense of wellbeing. You know, if you're a small child in West Africa and you've got large chunks of your hair falling out from tinea corporis and there is no treatment available. You don't want to go to school and you feel trapped and that preserves care. So these entities are really just the ent that's healthy skin for everyone. And lastly, as is made evident by the people that are in this room. There aren't that many dermatologists in the world. So we are not gonna fit skin health care problems in low resource settings. Through dermatologists. Dermatologists are wonderful. Some of my best friends are dermatologists, but there really aren't that many of them and they are not going to be even with the wonders of telemedicine and remote monitoring and mobile phone apps, they are not going to fit skin health care. So we need to think about how we can move to broader decentralize whole community based approaches. And so I think with that, I'll finish and hopefully those kind of questions. Thank you so much. Question mark. That was a really interesting talk about your Liberia um project was excellent and we've got lots of questions coming online um and ask the room as well. Um Just to go back to your Liberia project. Is that a one off project or will you be repeating that the date of collection? Yes. So um somewhat astonishingly in 2019, the UK government put 20 million lbs into skin NPD research. I don't know how they decided to randomly do that. It's the only time they've ever done it. I have to be clear. Um And so they, there is um there is an ongoing project in Liberia, I'm not involved in, it's being led by a team in Liverpool um which is um designed to understand how you can make those kinds of activities more sustainable. And we're leading an equivalent project in Ghana and Ethiopia. There's another project in Brazil and Sri Lanka. So there are, there are a number of those sort of projects going on trying to understand um how to move from something like the survey we did, which is very clearly a research intensive highly resource intervention to an activity um that the Ministry of Health can deliver on a rolling basis. One of the big differences for the uh neglect focal diseases where you do mass drug administration, it's quite straightforward. I simplified. But, you know, you go to a community once you measure that, there's a lot of ones, for example, and then you just roll out your intervention every year for the next five years. Cos you're treating everyone. So it doesn't matter if there are new cases emerging cos you're treating everyone. The difference with the skin conditions is, you know, six months after we left Liberia, undoubtedly there were new patients developing leprosy. So there's a big difference there where you have to be doing role in case finding for incident uh diseases. And that is much more challenging to understand how to sustain most of the evidence is that when the sadly that when projects end things go back to normal because the sort of incentives that are put in place to facilitate effective case finding on drug. Thank you very much. So we probably only have time for one question in the room. Um Is, is that your hand yet? Ok. So we'll start with you. Yeah, fascinating. I was gonna ask in terms of um the next steps in treatment. Is there any evidence around uh decreasing the cost of medication and increasing access versus giving these communities or families cash handouts? You know that that's a great question. It's like I planted you in the room. So what he's describing is called an unconditional cash transfer. I don't know if anyone else has heard of those. They are the single most effective intervention that has ever been designed. People know what is good for them. If you make them less poor, they make sensible decisions about their health. Um So if I was taking off my academic cap, where my career is based on working on these conditions and putting on like what do I give money to u unconditional cash transfers are, are the way to go, you know, and people will um improve their quality of life. They'll improve their standard of living. So they'll be less exposed to the pathogens that give rise to these diseases. They will have better nutritional status. So they'll be less at risk of uh some of these conditions. They will be able to seek care when they do. The problem with unconditional cash transfers is um effectively marketing. So uh hands up in the room if you give money to charity, just checking. Ok. So I mean as an example, I give money to Medecins Sans Frontieres. OK. I think they're a good charity. They're one of the people I give money to. If MSF told me that they had spent the money looking after panders, I would be a bit not. So the thing people like about giving money to charity is that there is a measurable thing that there is an outcome that can be measured. It's really hard to measure what is the outcome of an unconditional cash transfer? And my sense is that the big donors, you know, they like things where they can measure what Bill Gates likes to say, you know, I have vaccinated 500 million people this year against polio. I have given out 100 million do uh doses of treatment to treat oncopsis. They're measurable things which, you know, that, that has value and you can report back to people. It's so, on the one hand, I think unconditional cash transfers are much better than almost anything else that you can do with your money. Um But I think they're a hard sell because in general people um rightly or wrongly wrongly, you know, they want a ta a clear tangible thing that they get out of their investment. So that's, I hope that's, that's my personal view on the onset that it's a really interesting area of research, cash transfers. So we do have time for a few more questions. Kind of straight up. Hello, Jimmy. I just had a question. Is there a role in? It's like all these questions are planted? That's a great question. Also, um there are two schools of thought on this and I'll tell you two and you can guess which one I prefer. There's Yeah, sorry. The question is that um given that so many people go to traditional healers, is there a role for engaging traditional healers in the care pathway? II think that's a sort of fair summary. So there's been some beautiful work done in Cameroon, um where they um did try and bring uh traditional healers into the care pathway and it was very effective. Um And they became one of the major routes by which uh patients were brought to the care facility and you sort of strike a deal, right? You say, well, I'm here to fix their physical problem and you're all there to fix their spiritual wellbeing and both things are required for the patient to get better. You find a, you find a language that you can agree on that's worked. Ok. The um so I think that it definitely has been going to work. The opposite side would be to say you're in competition with these people on one level, right? They make their livelihood by looking after individuals. And you're saying, well, don't make your livelihood from that, bring the person to me. So there's some negotiation option to be done about um how you can bring them into the health system without them feeling threatened. So that's the sort of tricky bit. And then the counterview to Cameroon would be to say that um well, we don't want people to go to traditional healers like we want them to come to the health system. And we agree if you allow the traditional healer to be a portal to a accessing the formal health system, you are legitimizing them and they are not a legitimate part of the healthcare system. Uh So we shouldn't do it. And so that is a view that some people would articulate um in uh our work in Ghana, we pushed really hard to involve the um traditional healers. It seemed like a no brainer. The ministry was very concerned that that would legitimize them. Um you know, and it would put them on a part with formal members of the health system. Um So personally, I think it's a good idea, but it's obviously quite complicated how you do it in terms of, you know, not overstepping their boundaries, respecting the different roles uh doing so in a way that sort of works for all parties, but it's a give you something you can talk about. We've got one question online for you. Um It's is there any cost collaboration that can directly impact on the neglected diseases that we can actually? Yeah. Uh So, well, I mean, these are really diseases of poverty. Uh So you could all give more unconditional cash transfers. Um That would be the single biggest driver or you know, we could eliminate all debt uh to lower middle income country settings. These are the things, right? The the reason everyone laughs and no one does those things is because those are things that would really matter, right? All of the stuff I'm doing is window dressing because we can't fix the primary social determinants of health, which is poverty. So, you know, if you want to change the world in global health, I'm afraid we have all picked the wrong profession. The people that change the world in global health are politicians and bankers. You know, if you want to change global health, you need to go and work at the World Bank and cancel debt. That is the thing that will really fix things. Sorry. That's my little sort of political thing. But but that is that is the primary, these are diseases that are due to poverty under nutrition, not having the right clothing, not having the right housing, right? And these are not things that doctors are here to fix. We're here to ameliorate the symptoms of poverty, right? But the cure is poverty alleviation. Thank you so much. The thank you. Mhm. No.