 Good afternoon. Good morning. Good evening, everyone. From wherever you are joining us today. Dr. Masi Wanzhala, I'm a family physician from Kenya, and an executive member of the Wonka Working Party on Role Practice. I will be your moderator for the day. Welcome to the webinar, which is being co-hosted by the Wonka Working Party on Role Practice, and the Wonka YDM Africa region, known as Afriwan, Renathan, and rural Steve. The topic of our webinar today is on the role of young family doctors in rural health practice, and the role that we can play, knowing that one, about 50 percent or more of the world's population is the rural population. So if you're talking about advancing health equity, we're talking about universal health coverage. We cannot talk about that without talking about the population that live in rural areas all over the world. Just to start us off today, we have a privilege to have our Wonka YDM chair, Thanka Randini Kumar here with us today. So I'm going to welcome Dr. Thanka to just tell us something about the Wonka YDM, and also to just make a statement. Welcome, Dr. Thanka. Thank you very much, Mercy. Good day to all of you joining us around the world. Very nice to see you. I think it's a very, very important webinar, because as Mercy mentioned, rural practitioners are the heart of health care because in certain countries, sometimes 80 percent of the population lives in rural areas. So when I talk about rural practice, it's very close to my heart as well, because I started as a rural practitioner in Sri Lanka, and I was there throughout about more than four years in rural area, and still serving more or less to rural communities. Also in Wonka, I started my career as a very active member in Wonka in 2016, and joined Wonka Rural Working Party on rural practice in 2016 as a council member. So rural working parties also very, very close to me, and it has been part of my life for the last six years. So I'm very happy that everyone is hosting this webinar, because Africa has a lot of rural areas, and we have a lot of clients and our patients who serve in rural areas. So identifying challenges in rural practices are very important, because then we can address them. We can share the best practices, and we can probably learn from the others and improve our practices. So I welcome you all. I'm really grateful to Wonka Working Party on rural practice. Mercy on behalf of the rural practice group and Bruce as the chair, and also the rural seeds, the young Dr. Liaisons to the YDN. I'm grateful to Veronica, who was very enthusiastic about this webinar from the beginning. And finally, I'll say last but not least to Etan, our everyone here, who was the Liaison as well as the main character behind the YDN in arranging and organizing this webinar. So dear friends, be engaged and let's learn from our colleagues. Thank you very much. Mercy, over to you. Thank you very much, Wonka. That was Sanka, the YDN, the young doctor's movement chair in Wonka. So welcome everybody, just a bit of housekeeping. There is language interpretation available in Chinese and Spanish. So if you need language interpretation in either of those two languages, just go to the bottom of your screen and click on language interpretation and then select the language that you're comfortable with. So on to our program for today, we have our panelists here with us and I'm going to invite them to introduce themselves and I'm going to start with our everyone chair, Dr. Enwongo Etan. Please go ahead and introduce yourself. Soren Muten, hi everyone and good evening. As you rightly said, I'm Dr. Enwongo Etan. I'm a rural family physician working here in South Africa. I'm originally from Nigeria, but I've been practicing here in South Africa for about 14 years. I am, as I mentioned, a family doctor. I'm also an ER doctor and at the same time, I also am a household physician. And in my off peak periods, I also offer telehealth services to clients. So I do have a very busy schedule, but nevertheless, I'm excited to be here and part of this team. Thank you so much for having me. Thank you so much, Dr. Etan. Welcome now to Dr. Yong. Please go ahead and introduce yourself. Hello, good day, everyone. My name is Yong. I'm a family medicine specialist from Malaysia. Currently, I'm practicing in the clinic in Yusei Attan Chamo, which is a government clinic. Thank you, everyone, for having me today. Thank you so much, Dr. Yong. It's great to have you. Welcome, Dr. Natalia. Dr. Natalia, please go ahead and introduce yourself. This seems muted. Yeah, Natalie is there. I can see her. Yes, she should be able to unmute. Dr. Natalia, can you hear us? She could be having some challenges. We can introduce her, then, and there. In that case, Mercy, why don't you go ahead? OK. Let's move on to Dr. Guha. Please go ahead and introduce yourself. Yeah, hi, everyone. I am Dr. Jhajeet Guha. Currently, I'm doing my residency in family medicine from Delhi, India. Before this, I worked in a border district of a state in the rural hills. So I had an experience of working in the rural area for almost three years. Then, after completing my residency, I have plans to go back there and join. So thank you for inviting me. Thank you so much, Dr. Guha, and welcome. Just a minute. Let me unmute Dr. Natalia. Dr. Natalia, please go ahead and unmute. You should be able to unmute from your side. I've just sent you a prompt to unmute. Dr. Natalia, have you been able to unmute? I think she's dropped off. I'll probably just begin, and she will introduce herself as we go along. And I think I'm going to start with you, Dr. Guha. Could you share with us any specific challenges that you faced as a young doctor working in a rural area and how you've overcome them? Yeah, sure. I'll just share my screen once. So before starting my residency, after completing my MBBS, I started working in a border in the Uttarakhand state. So that is a state in the northern India. It has borders with China and Nepal. So most of the areas in that state comprises Hilly region. Almost 70% of the state is Hilly region, and a few of the 30% to 40% comprises plains. So I worked in a primary health center there, and it was overall well-equipped. This was the location of our primary health center. Almost 7,000 feet height was the height of the area. So actually, we had almost all of the facilities which are necessary in a primary health center, including three medical officers, two nursing staffs. We had an ambulance for referral. We provided OPD services, emergency services, as well as antenatal care. So what was the problems which we faced there? The most difficult problem which I faced that the terrain was very difficult terrain. Many villages were remote, and many of them were not connected by roads. Although most of the primary health centers were well-staffed, but a few of them in the remote areas were not staffed. So due to the, and some of the people are not aware regarding the health-seeking behavior is not there. Referral problems where the health center was far away and the people were not having jobs. So they did not have a good source of income due to which they were very times reluctant to go to the higher centers. And most of the diseases which were prevalent mostly were infectious diseases, warm infestations, scabies, fungal skin infections, snake bites were very common in that area. Anemia and non-communicable diseases like diabetes and hypertension were also prevalent. And there was a lack of quality emergency care also available in that area. It was not so much good. Plains, the areas which were in the plains were somewhat well, but still they had a few problems. The more problems which were there in, they were in the places which had tribal populations. There was very less infrastructure with less manpower and infectious diseases were quite burdensome in those areas, including tibial ocelluses. Sanitation problems were there and unemployment the same issues were there but which were more in amount. So I, along with a few of our medical officers, we made a group and we started doing something that we need to do something more because whatever we are doing in the job that is not sufficient enough to provide for the local population. So the problem is that due to the difficult terrain the people are not able to come to the hospitals. So then the other problem was that there was less transport facilities, unemployment, low socioeconomic status due to which the health security was not there. People were actually not willing to go to the higher centers for undergoing some surgeries or some other higher tests if they needed. Then due to the lack of jobs the young population from the villages they went out to the bigger cities for good lifestyle, good jobs. Whereas their parents and other old persons were left behind in the villages. So there was increasing geriatric population in the villages but no one was there to take care of them and they had a lot of mobility also. So these were the challenges which we faced and we started formulating solutions for them. So first thing was that if the patient cannot come to the hospital then the healthcare services should be provided to them at the village level near to their homes. So we know about the WHO and the government they do a lot of health programs in the villages but apart from that we also started doing something that we started a project of training the rural workers. They may not have a health background as such a medical background but we started educating some informal workers who were enthusiastic in working for the community. So we started a project in which we started screening for hypertension in the villages and we trained the local representative from each village how to measure the blood pressure. Then we collected a lot of data and we were quite successful in decreasing the, I mean in counseling the patients regarding how to do lifestyle modifications and went to report to the health center. So that was a very important time. Although we had to stop the project in between due to funding issues but it was, we are planning to again introduce these projects also focusing on child health, maternal health and the elderly health. Then second interventions which we did and which can also, which can be done in any area I suppose is that camp-based public health intervention. Many times we have seen that people conduct camps, medical camps in villages or remote areas but what happens is that once a camp is conducted there is no follow up. That is doing a single camp a sporadic camp does not help. We have to do periodic camps. So what we are doing, we are whenever we do a camp in a remote area where there are no roads available. So we go there and collect the data. Regarding how many patients we saw, what were the diseases prevalent in that area? What is the local practices? Do they have some local practitioners or they follow some local witchcraft advice? Then whatever the health issues are there, we formulate a data. And according to the data, the next follow up camp is also organized within one or two months. So that and consistently we do that for around the five to six months and then clearly we see that there is a difference in what the condition was there six months ago and what is now. So this is, if we do periodic camps and that is quite helpful. But the main thing is that consistency should be there. If we do some camps and leave it midway then it's of no use. Then lastly, the role of technology. Technology has been a bone to our age. So I'll come to the role of technology later on. This was a screening camp organized for hypertension and diabetes in the, this was a rural area, which was approximately five to six kilometers. We had to walk to reach that area. This was an ANC checkup camp organized in a village to be coordinated with the local school to get some rooms and which were properly sanitized and then used. Rapid kid based tests, the point of care tests were also done in the, some of the camps which we organized. These were some images of, this is an image of a pediatric camp. The, we did the screening for diseases like malnutrition and we counsel the parents also regarding how to provide good nutrition to the children. Now we are in a, we live in an era of globalization. So we, like today we are having this webinar. We are all over the world. We are connected to each other. So we can take anyone's help whenever we need. So similarly in organizing, in providing healthcare for the rural population as well. We can, we should take help from the other agencies, the other trusts or trust organizations who are working in that region. So by coordinating with other agencies, it becomes quite easy to do the task. And this is an image where we did a health camp in a very close to the Indian-Indo-China border. And we took the help of the army medical forces to, this can be done in any part of the world I suppose. This is an image to depict whatever it is available minimum we should utilize it. So this village, this was, this was a very far off village from our center. There was, there were no roads available there. So people used to use mules for transporting the goods and other stuff. So we, when we did a camp, we took our screening equipments as well as our few of the basic essential drugs there. So we used it for the transportation facility. So lastly, I come, what is most important, the role of technology in today's world. For the remote places, we can do, which has already been done, we can do telemedicine video consultations. It can be of two types. It can be patient to doctor or doctor to doctor. In our center, we had the facility of teleconsultation where in the cases where we were not able to reach to a certain diagnosis, we could consult a senior consultant or any other doctor for the expert advice. And field devices were also made available to us like the random blood sugar kits, which were somewhat, they could be connected to the smartphones and some smart ECG devices were also made available, which we could connect to the smartphones and expert opinion could be taken if needed. We can, this, we have not started, but we have an idea to start automated Google dashboards in which first we will train the health workers, the village level health workers, who will screen the population and they will feed the data in the Google sheets. So we can access the data real time and also provide the necessary advice and intervention if needed. This was, this is just an image. We as a group had started telemedicine during the COVID era for the difficult areas in the state. Now the role of the information, education and communication activities, which is very important. We, some of the, in the sum of the schools nearby, we organized this communication activities, awareness camps for COVID cessation to make the children aware about drug abuse and alcohol abuse. Then we also organized a few camps in and for the female population, their adolescents, females in the schools about menstrual hygiene. These camps were organized and these should be, these are the public health camps are needed at the primary level. They should always be done. This was a camp which was organized for to educate the females and the young adolescent females for menstrual hygiene. Then this is our, this was my primary health center in which we were giving some, the information related to vaccination to the local village workers. So the education is very important in providing the primary health care. This is our initiative by the name of Swasthi Himalaya Abhyan. In English, it means that the healthy Himalayas in the state of Uttarakhand. So this is an organization which we are a member. Lastly, I would like to end my presentation with my favorite quote, that strive not to be a success, but rather to be of value. So I thank Wonka for giving me this opportunity to share my experiences regarding the challenges which as a family doctors we face in the rural areas. Thank you. Wow, thank you so much, Dr. Guha. I think that was really amazing. I was just struggling to keep up with all the innovative things that you have done to really deliver health care to those hard to reach areas and to the rural population. There's so much you're doing and I especially loved the inter-agency cooperation. I think that is something sometimes we lack, especially in the medical field. How do we bring in other sectors and other agencies to help us strengthen health care service delivery? So thank you so much for that. We will have, once all the presenters are done, we will have a Q&A session. So if you have any question for Dr. Guha, please write it down somewhere and it will give you an opportunity to ask it after the panelists are done speaking. Now I'm going to move on to Dr. Etang. And to you Dr. Etang, I'd like to ask you what are some of the innovative approaches that you have taken to provide health care in your rural health practice seeing as Africa has a lot of challenges, even just with mobile phone coverage and such. So what are some of the innovative approaches you've used and which ones have worked for you? Please go ahead, Dr. Etang. Thank you so much for that. So as a background, I have the privilege of working both in the public and the private sector. I start my day in the public sector and I just a chance to try by the flex private sector, but I have, I've worked mostly in rural areas. And the biggest challenge that we've been struggling is having health care workers in the rural areas, having enough health care workers in the rural area. I'm going to use the public center where I do work, which I'll not mention just for privacy purposes, but I am the only doctor in that facility. Now being the only doctor in the facility, there's limitations in how much you can divide yourself in terms of giving health services to people. So we are using a lot of telehealth services very much. And even though there might be issues with privacy, but at the moment we're using what is available in the rural population where I do serve. Most of the people here have access to WhatsApp, which is a ubiquitous app that we all use for day-to-day communication. And we use it for a lot of things. One, use it with a lot of automation to remind patients of your appointments in the rural areas. We use it to, there's this thing on WhatsApp that is very important to let people take for granted. We only probably only use it for entertainment purposes, which is your WhatsApp status. So most times you just share things about our families and our friends. So what we did is that we have a different WhatsApp separate from your personal, because you want to separate the personal life and to an extent if not patients reaching out to you at two AM in the morning, which I personally do not have a problem with. So you use your WhatsApp status to give the current health education on issues where they can follow. Yes, there's Facebook, where people seem to be much more endeared to WhatsApp. Next, we use WhatsApp also for some updates about medication, updates about their conditions. And then finally, we also use WhatsApp for consultation. There are quite a few platforms available here for consulting with patients. There are ones that are used for inter-hospital communication because having worked working in the rural area, it is very difficult to get access to specialists in these areas. So we have two liars with your regional, your district, regional and tertiary hospitals to get health and assistance for your patients from that. There are some innovative platforms here. I'll just use one of the names, we call it the VULA app, it is open, where we're able to have consultations in the rural hospitals, in a rural hospitals with the big hospitals. Just as a caveat here, one of the major challenges which we have is about retaining young doctors in rural areas. It is very difficult to retain young doctors in rural areas because of a lot of issues, I'll mention some of them. One, rural areas often faces scarcity of healthcare professionals, including doctors, nurses and mostly specialists. So this shortage puts additional pressure on young family doctors to provide comprehensive care and to the patients in those areas. The next one which you've already talked about is about geographical barriers. So rural areas are often very remote and we have limited transportation options. The area where I work, there are three or four ambulances. Now, our referral hospital is over 30 kilometers away. And if those ambulances for some reason have to take a patient because where I work, we do not have the ability to provide even caesarean sections for emergency options where all have to be transferred to a district or rural hospital. Those challenges make it difficult for patients who need to be transferred when you have limited access to ambulances. The next challenge you also have is about the socioeconomic disparities of our communities. Poverty, limited access to education and lack of resources, it contributes to reduced healthcare access and poorer health outcomes among rural populations. And I'm not sure how people are struggling, but mental health is everywhere. And rural populations, we also face mental health challenges, including limited access to mental health services, high levels of stress and lack of awareness about mental health. So for a young family doctor that wishes to work in rural area, he needs to equip himself with at least the basics of how to manage acute psychosis, being the common mental health conditions that are seen in the area. Some of the doctors that work in the area, the biggest challenge they also talk about is access to care for those who have families, like schools for their children, growth opportunities for them and so form of isolation at the experience there, which makes rural healthcare a little bit challenging and not that attractive for them. So this is one of the challenges that we face, but in the context of these challenges, the use of technology, the use of AI, the use of telehealth platforms has been very instrumental in helping patients, given advice to patients for non-emergency care. Obviously emergency care, they have to come in to see the doctors. And I'll pause here for now. Thank you. Thank you so much, Dr. Edsang, for sharing your experience. I think one thing that has just stuck with me is the use of WhatsApp because WhatsApp has quite a higher coverage as a social media and chatting platform. And the fact that you have been able to use that to reach your patients is quite amazing. So thank you so much, Edsang. We are going to have a question and answer session after this. And if you have any questions for Dr. Edsang, please make sure you write them down or put them up in the chat and you'll be able to ask after this. Now going to move on to Dr. Yong. Dr. Yong, you've mentioned you have quite an experience in rural healthcare and rural health practice in Malaysia. So I just want to welcome you to fast, just share some of the challenges that you have had or you have met and also how you have managed to address them in Malaysia. So welcome, Dr. Yong. Hello. Good afternoon, everyone. My name is Albert. I'm a family physician from Malaysia. So today I'll be sharing a little bit about rural health. I have worked in East of Malaysia and as well as West Malaysia. So in both rural areas at the moment and I would like to share some of the challenges and how I overcome those challenges and provide the optimal care for my patients. First of all, I'd like to thank everyone for inviting me to share my experience with all of you. I'd like to check whether you can see my slides. Yes. We can see them. Thank you. So I'd like to introduce Malaysia to you. It's a very beautiful country. The capital is called Kuala Lumpur and we have about 32 million people. So as you can see here, the majority of our people are the Bumi Putras, making up almost 70% of our people followed by Chinese and Indian. And Malaysia is indeed a multi-ethnic country. So do you know that Malaysia has the tallest twin towers in the world and not only that, we also have the second largest building in the world after Burj Khalifa, right? Now talking about universal health coverage, WHO has actually declared that Malaysia has achieved universal health coverage. So what does it mean? Universal health coverage means that the people can use promotive, preventive, curative, rehabilitative, and as well as palliative health services that they need of sufficient quality and it does not expose the user to financial hardship. Well, in Malaysia, overall health outcomes, we have experienced laudable improvements over the last decade. Malaysians are now living much longer compared in the 1970s and the life expectancy for meal now is at about 72 years old and for women is about 77 years old. Well, in the 1950s, the infant deaths per 1,000 live birth were as high as 76 and with the improved healthcare system, Malaysia has managed to bring the number down to 6.7 deaths per 1,000 live birth in 2022. Well, compared to 1950, Malaysia also managed to reduce the maternal mortality ratio from a staggering of 540 maternal deaths to less than 30 deaths per 100,000 live births. Well, despite the positive achievements, the gains in health are uneven across the population in Malaysia, unfortunately. Malaysia's healthcare system promises universal access to healthcare for its people, but health inequalities suggest that universal access alone does not ensure good health for all. Rather, health outcomes are due to mix of factors including income, working environments, and individual behaviors. When these determinants are unevenly distributed in the society, this contributes to health inequalities within the population. Does public policies play an important role to reduce these health inequalities? Just to highlight a few problems, one is the access to healthcare in rural areas is really a real issue. Up to 30% of rural population needs to travel at least 3 to 5 kilometers to reach basic health facilities. Well, according to the Malaysia multi-dimensional poverty index, health indicators reflect Malaysia's focus on ensuring universal access to healthcare with virtually all Malaysians having access to public health facilities at substantially subsidized price. According to the World Bank, only 1.4% of households in Malaysia experience catastrophic healthcare spending. However, there's mounting evidence demonstrating that health is not just determined by healthcare and having access to it. Rather, health outcomes are due to a mix of factors apart from healthcare, including living conditions, work and environment, as well as behaviour. Well, inequalities are a matter of life and death of health and sickness or well-being and misery. Creating a fairer society is fundamental to improving the health of the whole population and assuring a fairer distribution of good health. What the second challenges that I would like to highlight is lack of proper equipment. Rural clinics and health services are only equipped with basic healthcare. Smaller district hospitals do not have high-tech facilities for investigation or treatment. For example, in a state where I have worked before, in Sarawak, up to 40% of the state public health clinics do not have pharmacists. 70% of these clinics do not have lab service and up to 90% do not have x-ray services. Well, in 2020, Malaysia's doctor population ratio is one doctor for every 454 people and that has surpassed the one doctor to 500 people ratio recommended by the WHO. However, the distribution of doctors, especially in rural areas, is unequal compared to urban areas, just what Dr Itang has pointed out. So this is a map to show you the distribution, the ratio of doctor to patient in Malaysia, in Sarawak where I have worked before. It is one doctor to 900 class patient compared to the Malaysian ratio of 1 to 454. And according to the Sarawak state government, 98 out of the 215 rural clinics in Sarawak do not have a medical doctor. Well, the fourth problem in rural communities is that every three out of 10 rural patients actually had an undiagnosed medical problem. What the goal of health for all draws attention to the all at present health resources are not shared equally by all the people. There is still significant gaps in many countries and health is the privilege of the few. Indicators should reflect progress towards correcting this imbalance and closing the gap between those who have health and those who do not. Well, what we can do as family doctors in facing health inequality, especially in rural areas. Well, Malaysia has achieved great success in improving its people's health. However, several challenges remain, including the unequal distribution of health outcomes or health inequalities. So this framework summarizes the mechanisms generating health inequalities. Well, you can read from left to right, we see that the socioeconomic and political context generates a social structure in which population are stratified by income, occupation and more. The context and resulting social structure are known as the structural determinants. Well, these structural determinants do not affect health directly, but through direct determinants. Health inequalities are generated when these direct determinants are unevenly distributed, reflecting and perpetrating other social inequalities. In other words, individual experienced differences in exposure and vulnerability to health promoting and compromising conditions based on their respective social status. Well, I would like to start off with West Malaysia, where I have worked before. I had the opportunity to work in both East and West Malaysia, and today I would like to share my experience working as a family medicine specialist and what I can do and what we can do in the capacity of a family medicine specialist in addressing the rural health challenges. Well, when I got my posting after passing the exam, I prayed that I did not get the rural area as I did not wish to be separated from my family. Unfortunately, my wish did not come true. I was posted to one of the most rural, most remote regions of Malaysia, which is Borneo. So I was posted to Som Kapit, which is located about two hours boat right away from the city of Sibu. And a few months down my posting, the COVID-19 pandemic struck, and the boat service was ceased. And as a result, many of my patients would not travel to Sibu or coaching to receive their treatment, especially talking about cancer patients. As a result, their disease progressed, and I started to see cancer patients came into my clinic with pain and other symptoms. So in response to the new needs, I started the cancer registry as well as the palliative care service. Well, due to the lockdown as what you can see here, health system, social factor, physical environment, psychosocial circumstances where most of my patients could not travel to the nearest tertiary hospital. And there was no palliative care service available in my clinic at that point of time. So the changes that I made that time was to create a new service, which is the community palliative care service. So I had this young man came in with colorectal cancer in a lot of pain and he actually had a prolapse storm. And due to the pandemic, he could not get the storm out back for himself. So at presentation, he was in a lot of pain. So I started him with traumatol, which was the strongest medicine that I had at that point. And we had to source morphine for him the following day. And we also helped him to source the storm out back. And with the intervention given, his pain was controlled and he managed to get his storm out back in place. And overall, we have helped him to have a sense of control over his illness and improve his quality of life. And towards the end, he needed a wheelchair and for that we sourced it for him. So to prepare my team for the new service, I had to train them. So I organized teaching sessions for them on basic collective care and also develop a clocking sheet to facilitate comprehensive assessment and management of collective patients. At that time, we did not have access to essential medication such as control release morphine, dexamethasone, and some other medication in collective care or your information just three years ago, in the state as big as Sarawak, we had not a single palliative care physician. And I had to put up a request to get the medication from the consultant palliative physician from West Malaysia to get the essential medication into Sarawak. So once the community palliative care service had been developed, I engaged the district hospital and established the NEC working. Since then, we received numerous graph rows and we were able to ensure seamless care achieved for patients with palliative care needs. So this is the patient. I had the opportunity to care for this lovely lady who had breast cancer with meds-to-lung. She was in a lot of pain when she first came to me and was breathless due to the massive lung effusion. Well, with intervention given, her pain was controlled and we managed to discuss about end-of-life care. And despite the limited resources that we had, we managed to achieve a good death. So not only adults needed palliative care, we also had many children who needed it as well. So as a young family physician, I had very limited knowledge and skill in caring for children with palliative care needs. So I decided to reach out. And at that point, it was locked down and the only way we communicate with other health care providers was via Zoom. And we had our first and subsequently monthly case discussion to better manage children with palliative care needs. So in my clinic, I had care for many children with special needs. However, we did not have speech and also occupational therapies in the whole division. And in the whole of Sarawak state, we only had a handful of these therapies. So with the COVID pandemic, there was a blessing in disguise. You know, telemedicine became popular and we had the opportunity to collaborate with an NGO from Epo Parra in West Malaysia to deliver speech and occupational therapies via Zoom to my young patients. So with the intervention given, we have seen tremendous improvement in children. So what I would like to highlight is that speech and occupational therapies can be delivered in a 1,347 kilometers away, apart across the South China Sea. The other issues that my community are facing is the rising threat of malaria nolicyte. And we had seen a significant rise in malaria nolicyte cases in nearly 376 cases in 2008 to 4,000 cases in 2018 with 12 mortality from this treatable disease. So if you look into this framework again, what I did was I piloted a pre-exposure prophylaxis with chloroquine and strengthening the malaria nolicyte presumptive treatment for my rural community. And with the result that I had, I went back to the policy makers, to the state health department to implement this statewide in Sarawak. So this is the pre-exposure prophylaxis package. It looks like we have a simple brief about the disease and then the consent form, the prescription, and as well as a three month supply of chloroquine. So beside creating a PEP, I have also engaged the community with series of malaria outreach by giving lectures and malaria screening. So all these efforts had helped to increase awareness about the disease and the people were more receptive to PEP with chloroquine. Well, as I mentioned earlier, many clinics in Sarawak are without a medical doctor. Thus empowering the medical assistant and nurses are crucial in managing severe malaria. I created this management flow chart with my pharmacist and we wrote it out for the carpet division and later adopted by the Sarawak state health department. Moving forward, another issue that faced by my local community are smoking. This paper from our local researchers showed that the prevalence of smoking among secondary school students in Sarawak is extremely high. So the prevalence stood at 32.8% with mean age of smoking initiation at age 12 years old. So based on this framework, what we can do is we can intervene via education and health impacting behaviors. So I started engaging school management in Som and delivered lectures on the danger of smoking followed by screening and smoking cessation intervention. So I'd like to share a couple of photos of what we have done. We had group interventional program carried out and thankfully all the children under our program managed to quit smoking towards the end of the program. So as you can see here, beside the smoking issue, the young people in this region had another social problem, which is teenage pregnancy. The youngest patient that I had under my care was only 11 years old. And based on one of the local papers, Kapit had the highest teen pregnancy in the whole of Sarawak state and in response to the problem, I also initiated numerous engagement with young people in Kapit to empower them on sexual health and as well as healthy living. But now I shift the focus from Sarawak back to where I am practicing now in Peninsula Malaysia. So my interest in palliative care actually grew stronger and I aim to make community palliative care available in every district in Malaysia after having seen how my patients actually struggle in rural areas. Well, in Malaysia, we are still lacking in universal health coverage, particularly in palliative care. And the community palliative care providers in Malaysia are mainly from the NGO and most of them mainly in urban area and leaving the rural patients behind. And there is also limited services from the government health facilities. So last year I had the idea to pilot a project on community palliative care and I presented it at district level and move on to get the approval from at the national level. So after a few months of hard work, we managed to officially start our service. So this team is a full-time team caring for patients with palliative care needs in the Kintah district with a population of 1 million people. So this pilot project is crucial to the development of community palliative care in Malaysia. As I mentioned earlier, we plan to roll this project out to other states in Malaysia. We are also the first in Para state to prepare morphine at primary care level. Before this, we had to send our request to the nearest hospital and it took about two to three days to get the morphine. So now we had the liberty to prescribe it at primary care level. So this is the opening ceremony officiated by our state health director and this opening ceremony also attracted many press coverage and we have also helped to increase awareness about palliative care. So besides, we started a new service in my district. I also took up a new responsibility by going around Malaysia to deliver and to train other states to develop their own domiciliary palliative care services. So this is one of the pictures. This is in Malacca state. This is in Pahang. This is in the Negrisambiland and this is in Para state and lastly, I just came back from Sabah where I shared and trained the team over there. So I have made my proposal to the Ministry of Health which is to establish dedicated domiciliary palliative care service in every district to ensure the universal access to palliative care throughout Malaysia where we can have a focused care by training the people to shorten and enhance the training. We can develop specialty in palliative care, minimizing duplication of work and maximizing the manpower. Well, back in where I'm practicing now, we also have our indigenous people who are called the Orang Asli and they are basically the descendants of the Pleosint era, the earliest inhabitants of Malayan Peninsula. And as of 2004, the population of Orang Asli was estimated at 150,000 which is about less than 1% of the national population. And just for your information, there are many subgroups of Orang Asli and some of them are Negrito. As the name suggests, they are generally physically smaller in stature, dark skin with typically woolly or frizzy hair and with broad nose. Senoi are slightly taller, their skin is much lighter color and they have wavy rather than frizzy hair. Well, I have never seen a malnourished child as a young doctor before I became a family medicine specialist and I always thought that malnourished children could only be found in Africa. But I was proven wrong when it was during my training. I actually met a few severely malnourished children and one of them is this child who was 5 and she weighed only 8 kg. So the two forms of malnutrition that we see in para among our indigenous people are merismus which is the visible, severe wasting where they do not have fat tissue or very minimum fat tissue where the wasting can be clearly seen over the shoulder, arm, buttock and thigh region. Besides merismus we also have quashokok where the wasting is not apparent but they do have edema. Just to give you a little bit of background about the indigenous people of Malaysia the poverty rate for our orang asli remain as high as 77% and 35% of them are classified as hardcore poor. The infant mortality rate for orang asli are more than 3 times national average of the population versus 6.2% per thousand life birth orang asli children under 5 years old are 15 times more likely to die than Malay, Chinese or Indian children and malnutrition rates appear to be increasing in orang asli children with more fatalities on presentation to government hospitals. So one of the challenges that face by the local people are the lack of a natural lens and many of their lens were taken away and made way for mega project logging activities mining and agriculture. And this is some of the pictures taken by myself and my team as you can see deforestation is going on rapidly and as a result the waters are polluted. With the climate change we see more and more extreme flooding as well as drought and these have led to deteriorating of health status among the indigenous people. And school drop-up rate is also very high and many of our indigenous people do not have access to clean water, electricity, let alone healthcare. So in response to the need with the help of local church we started our outreach since 2014 till present time to improve the lives of indigenous people. So we carry out monthly medical outreach to various villages some we need to travel like up to 3-4 hours and then we need to cross rivers and some we need to take boat to reach the villages. So we run our clinic open air as you can see here we just put up tables and see our patients. So we carry out a lot of activities like deworming, screening for male nutrition, TV screening malaria screening and so on. So we also mobilise our dental mobile clinic into the difficult to reach areas and we actively teaching the children on oral health by supplying them with toothbrush toothpaste and we get our dental nurse to engage the parents and children on proper way of brushing teeth. So we run our clinic everywhere even under the open air. So due to the climate change emergency relief is part of our work. Food aid is integral to our SOA community development programme. Hunger and malnutrition greatly affect our orang asli communities especially babies and young children. So we provide short and long-term food aid you know food is given for emergency relief caused by floods and droughts. So we collaborate with many local companies where they sponsor us this food pack which we source from rice against hunger organisation. We also supply our children with rice, anchovies, iodized salt, sugar fortified beverages and biscuits. So this is some of the monthly activity that we do you know we pack the food and then deliver to children whom we have detected the malnutrition. So we also help to source for this F-75 and Rosso Mal which are important to treat severe malnutrition and you know we personally source these products from France and we shared it with all the hospitals in Para and as well as clinics. So we also share our fortified rice and food basket with the hospital you know and they help us to deliver to the malnourished children in areas where malnutrition prevalence is high we actually set up a milk house so we appoint you know local volunteers to prepare two basic meals for the children basically we're providing milk and biscuits so this is some of the pictures So as we journey with the local communities we know that medicine alone is not sufficient and thus we venture into construction of water and sanitation and hygiene facilities So as I mentioned with the climate change the water source is affected hence we decided to build mini water catchment area and installing parts to channel water to the village So in certain area where we don't have water catchment area we had to dub well to ensure water supply is sufficient. As I mentioned many of these indigenous young children they do not have access to education and for that reason we have set up two schools we run two schools operated by the local communities we bring the indigenous people to our cities to train for about six months and then we send them back to their village and yeah so these are some of the pictures So with this school around we actually address the male nutrition as well so for those children coming to our school they receive two meals per day from Monday to Friday So climate change has also impacted the lives of the indigenous people with inconsistent harvest from the jungle and to ensure stable food source we have introduced agriculture to the people So this is the fish farm that we are running and at the moment most of the village that we have been reaching out they are self sufficient So in the initial stage we provided them with the seeds for them to start off their farming projects So we also carry out awareness and training programs for our parents to recognize warning signs how to provide basic CPR and so on Well I think that's all from me Thank you so much for listening Wow Albert I don't know what to say I was just amazed as you are going through everything because you have covered so many things from how rural practice for those who are wondering how to find themselves in rural practice and then what do you do when you get there and you've done quite a lot you've covered things even to do with community oriented primary care you've covered addressing social economic determinants of health for rural and indigenous people you've covered the issue of the environmental effects I think we might just have to have a separate webinar for people to digest everything for those who have joined us later please if you have any questions for Albert or any of the other panelists we will have a Q&A session after this for you to ask your questions Thank you so much Albert now we are going to move on to our next panelist Dr. Natalia Galarza who has experience both working in low income country and also high income country and experience also with medical education amongst other things Dr. Natalia, welcome please introduce yourself and then I'm going to ask you if you could talk about what are some of the skills or training that young doctors would need to equip themselves with to be able to thrive in rural health practice not only professionally but also personally because you find that a lot of young doctors find themselves far flung away from their families and their friends so how do they deal with that and ensure they have a well balanced life both professionally and personally and what are the skills that they need to equip themselves with in order to thrive in rural health practice over to you Dr. Natalia welcome Good morning everyone Buenos dias a todos I'm Dr. Natalia Galarza I practice in Southwest United States I I'm what they call an international medical graduate here in the States I graduated from a school in Mexico and then emigrated and did my residency in family medicine here in the States in a semi rural suburban area I was part of that I stay in that program after I graduated as faculty and here I moved to south of the county where it's actually a rural area to start our own residency program there and act as the program director for that program so right now we're starting our program from scratch and the reason why we do this is because of all the necessities that everybody has stuck in the rural areas here in the States there's only two populations that have universal health care and that's the Native America's indigenous population with Indian health services and the other ones are inmates from federal and state prisons everybody else in the population has to have coverage by themselves what we call Medicaid that is federally state funded but that's through application that everybody qualifies or through private insurance you know, thanks to the Affordable Care Act from President Obama if they can afford the payments for private insurance on their own out of pocket so the health care unfortunately here it's a mixed bag depending on where you are there's even areas in urban areas like downtown LA that is considered underserved area for health care because the lack of doctors are readily available and obviously rural areas are very underserved when it comes to access to care and the people that are able to afford it one of the things that we need the most and have made real advancements over the past 10 to 15 years is increase the number of medical students now the problem is that there's not enough residencies and that's what we have been trying to change through legislations and grants that's actually how the current residency program that I'm constructing in the organization where I am is thanks to some legislation changes that made it possible to fund the program so there's definitely positive changes and when you think about family medicine here in the states more than 50% of the emergency departments and rural health access or critical access hospital in the states are actually run by family doctors after the pandemic we have shown that we are the specialty that is very dynamic and can cover many of the areas and necessities because of our training and pediatrics and all the way to geriatric patients as a specialty I think the pandemic was good in a sense because we were able to show our worth but now we just have to continue to be able to fund more family medicine programs and one of the things is not just fun programs in urban areas but also in rural areas one of the things that I would say has been more important after seven years of medical education and educating residents is teaching the residents about emotional intelligence we have all heard about this term but I don't think we have ever really been teach about it especially not in medical school and it's really important in the sense that we don't we all know that we're smart and able to process different problems and solve problems but what about how we manage our emotions and that sometimes studies show that that actually determines a lot of success in life and personal and professional and being able to manage professional and personal life is important to be successful all over and emotional intelligence plays a key role in this having what we call now adult learners who are both motivated and able to control their emotions and their response not ignore their emotions but just control them and work with them to fulfill the goal that they have this is important because that usually is a person that does need external motivation and they're able to so that is really important in rural medicine not because we want people to be isolated but we want people to find fulfillment within the work that they have and be self-motivated to continue working in there yes the system has to change there's actually multiple studies now that show that having multidisciplinary teams and being part of that team reduces burnout because we were even discussing some of my colleagues and me last week that as much yoga and exercise that you can do if you keep going back to the toxic environment it doesn't matter how fulfilled and recharged you are as a person you have to also go back to an environment where you want to go and it's possible to work another thing that I would say that is very important for young doctors to realize advocacy we have to advocate for ourselves within our institutions and within our organizations within our friends in our states not only for better outcomes for our patients but better outcomes for ourselves we're the most about other professions they're really good at closing ranks and somebody mentioned earlier that as doctors we don't really collaborate among ourselves and also that comes to when we have to vent for ourselves and defend ourselves we're even from medical school we're thought that oh you'd be a good doctor and stay in the office that doesn't matter anymore we have to go out and advocate we have to talk to the share of the service we have to talk to the CEO we have to talk to our local representatives in states and the federal government because this is how we're really going to change policy and benefit our patients so you know studies have shown that also advocating gives you a better or a lower rate and burnout and improves outcomes not only for your practice but also for your patients because if you're able to change policies you will benefit the community that you are and like Dr. Young was saying change those social determinants of health because sometimes as most of the time studies have shown that as much time as we spend with the patient if the patient goes back and sees the social determinants of health and social political determinants of health have not changed their health unfortunately will be minimal impacted by the changes that we do in the clinic with them so I would say that those are the two most important things that we can do for young doctors when we educate them teach them about emotional intelligence and how to achieve them and advocacy advocacy in all levels from their organization all the way to legislative levels in their state and federal and once we do that actually as a group and understand how powerful we are it will be even better for us and for our patients I always tell my residents and my students that as doctors there's no other profession besides politics where you touch so many people's lives in your lifetime you know here in the states it's calculated that as a doctor you will probably see more than 50,000 people from the start of your medical education till you finish so no other profession gives you that power other than politics and as politics we should have the influence to really have better outcomes for ourselves and our patients so thank you everyone I think that's one of the message that I have learned especially for rural practice is so hard to go out and you don't want to leave your patients because you know sometimes they're very dependent on you and every day it counts but what we can do also outside of the office for them is very very important thank you so much Dr. Natalia I think that was wonderful because you've covered quite a range of things all from the kind of skills that family doctors already have you know to see everyone across the life course in pediatrics, in geriatrics and adding on to that I think I love the component about emotional intelligence and how you manage emotions and not ignore them because rural practice can be overwhelming it can be lonely and I think it's important to really help you maintain your own and also you know maintain a good communication and relationship with patients and I also love the advocate because you know but there are statistics that show that if you advocate it also helps you thank you so much for sharing with us today and now I'd like to move on to our audience today if you have any questions for our panelists we had Dr. Guha we had Dr. Yong we have Dr. Natalia and also Dr. Etang so if you have any questions you can direct it specifically to one of the panelists or you can just generally ask the question and either one question and answer so please raise your hand and I'll be able to unmute you that any questions that so if you have any questions please raise your hand okay I'm seeing 100 let me just unmute you then you can take your question okay go ahead thank you and thank you so much for your wonderful presentations my question is for you Natalia I really appreciated what you said most recently the advice that you would give to young doctors coming up in family medicine I actually have a very similar challenge here at home in the Bahamas and my question to you is knowing that advocating is going to be such a multilevel task what is a small way perhaps that young doctors could go about when it comes to advocating for ourselves to reduce burnout as well as to increase joy in the workplace is there something that you have advised your residents or is there something in particular that seems to be working in your region I'm just very curious and anxious to get any ideas from anyone about how do you start to change this medical culture that we are currently facing thank you hi Renee thank you for your question I would say that one of the best things that we are able to do is improve communication and that might seem ironic when we try to reduce burnout but it goes hand in hand with advocating for yourself even at the most simple level that is your place of work your office and your organization if you are able to advocate for yourself to have proper team training from your front desk your medical assistant another ancillary staff in your practice whoever is available I know that resources are different through our countries but if you have well trained motivated staff it can really make your life easier and reduce burnout while improving communication so your patients feel that they have access to you on a proper on a timely manner in adequate way but also improving their care because now there is documentation in their shard but if you work as a team and have proper training for your team they will be able to triage or discern who really needs your attention or what can be taken care of them the patient just calls you for a refund or a prescription or meeting their yearly supplies before their chronic condition if you have protocols in place for your medical assistant or staff to be able to refill that automatically instead of adding that to your to-do list for the day of the week that can definitely reduce your burnout if you're going home earlier you're going home more rested and with less things to do because sometimes it's just the little things that keep bothering you so I would say that definitely advocating just for better communication training at your office will reduce the burnout especially now with a globalized year out where there's just no to-do list having a well motivated team can help you and sometimes a team actually does want more work but it's really not more work they want to feel motivated so if you give them that different things to do in different tasks they will feel motivated and always check in on them check with the front desk see gaps in their training sometimes when it comes to serving conditions you can even do and service for them but that's a way where you can actually start advocating right from the get-go and also help you reduce the burnout and that's actually how I tell my patients my best to start advocating to just start small just start with your practice and once you realize that you're able to move through that you can start going maybe even to your council members in your town or city Thank you Natalia Thank you so much Brunei for your question and I think Natalia has addressed it quite adequately and I love the emphasis on teamwork because I think that sometimes there's a lot of burnout in young doctors just starting out in rural practice or starting out their practices so thank you so much for that I've looked through I'm not seeing any other accounts there's a question on the chat about the respective universal health coverage percentages in your countries so I think you can answer that as we wrap up and I'd like to get us from each of the panelists if you could just give maybe just one word of advice to a young doctor a young familiar doctor somewhere either just starting out in rural practice or intending to start out in rural practice and who has seen all the amazing things that you have done what would it be? I'm going to start with you Dr. Guha Sorry Dr. Guha please go ahead and unmute Yeah For any young physician who is willing to start his practice in a rural area first I mean he or she must keep this in mind that there will be challenges and there will be there will be lack of facilities in the rural areas the first thing he or she should keep in mind because if we constantly are having problems in our own lives then we cannot we keep on thinking about that then we cannot do better for the community so after that acceptance then we can I mean there are two ways either he can serve in a public facility a government facility or he can start his own practice so in those ways he or she can start and then I'll just say that rural practice is very rewarding and gradually anyone when by starting it then you will like it you can make a lot of changes significant difference to the community and reducing their mobility so you should have a goal in mind and then if you start taking small steps then eventually you will succeed in that Thank you so much Dr. Guha around a lot of applause for Dr. Guha I think we will be able to share presentations later and you can see all the amazing work you have done Dr. Aetan I think the excuse me if I'm going to say anything because Advocacy would be for a mentorship program for rural health doctors the thing is that rural health is not very attractive because of all the different challenges we've seen here some people are in rural health because they didn't have a job in an urban center but then they got to love the job in rural areas like when I said to Dr. Yang he said where he ended up wasn't his intention but he made use of what happened there now to make it sustainable we have to look for either informal or formal mentorship programs for people who are in rural areas to encourage new doctors coming into rural areas to show them the path and going up other thing I'm going to emphasize is the need for collaboration collaboration with your peers collaboration with people see what other people are doing don't go through this alone people have gone through it it had challenges it had ways that they've gone around these challenges and they're happy to share from these experiences and that's why meeting like this is very helpful to see that you're not alone in your struggle the other people was talking with different research challenges and we're going to make it proud thank you so much Dr. Aitank for being with us sharing your experience and most of all bringing up the aspect of mentorship I think that is the key thing that a lot of young family doctors in rural practice are in need to Dr. Natalia then I'll have Dr. Yong close close for us Dr. Natalia Hi I would second Dr. Guha and some have said rural practice is essentially very fulfilling I think when we well when I imagine what in the old times being an old family doctor that's exactly what rural family medicine was like you're able to do full spectrum family medicine you know the moms when they're you see when the babies are born and then you're able to follow the auntie, the mom you know the grandmother from that family so it's very fulfilling you really are part of the community in a rural practice but yeah you have to also wear a lot of hats you have to be mad at them you have to personally advocate behavioral health specialists sometimes because of the lack of resources be creative on how you're going to use them I always say that I would choose the specialty again and I would choose this career again but you have to take into account that like any specialty in medicine is hard it's a different lifestyle so you and you have to be creative and adapted and have that flexibility to roll with the conscious but also find a joint that not every specialty gives you. We truly have continuity of care we will see that patient back we you know different from ophthalmologist I will only see that patient once a year and maybe that and they will they will not know you know that the quinceañera or the 316 for their daughter happened that summer but you will or at least you can have that when you're a family doctor so it's a very fulfilling and a very simple like and but yeah very very rewarding I think you truly find happiness it's like the same thing is the simple thing is the little things that give you happiness and that's what you find in family practice and in the background is my baby I don't know if you're hearing her yeah sorry I apologize Natalia I think this is part of the issue of balancing professional and also you know personal life so this is part of it so say hi to the young one she's so pretty and thank her for joining us and letting her mom join us as well thank you so much Natalia and I think I wish you all the best with the residency program because that is also part of mentorship and that's a very great initiative over to you Dr Yong thank you very much for the opportunity to networking with all of you it's really a blessing and you know I can't agree much with Dr Guha Dr Itang and Dr Natalia that you know is being a family medicine specialist being a family doctor is extremely rewarding and you know I am extremely thankful you know to be given the opportunities to pursue the master program and to be a family medicine specialist and I really enjoy what I'm doing right now family medicine specialist we need to be very versatile we need to be teachers, friends clinicians policy makers and during the pandemic we do a lot of public health work running the vaccination centers and our role as family medicine specialist has become more prominent during the pandemic and after the pandemic so coming back to rural health rural health medicine has never been my cup of tea and life you know throw you a lemon you just need to turn it into a cup of nice iced lemon tea it was very tough for me I was separated with my families for months during the pandemic extremely difficult extremely difficult and I'm glad that Dr Natalia talk about mental health talk about self-care I think it's extremely important because we are much isolated you know not only from our own people our culture but as well as our family members and one thing that I learned is that the need is extremely a lot in rural areas and sustainability is very important because you know people just come and go to turn around rate is extremely high for healthcare providers in rural areas so for whatever services that I've established in Song Kapit in Sarawak I always tell my staff that I am not important the important is the system I will come and I will leave but the system has to stay so whatever that my team has learned I tell them that they have to pass on the skill and knowledge to the new team to ensure sustainability and you know Malaysia is an upper middle income country we do not have a lot of resources and it is very important that you look into the local resources that you have and get the involvement of the community to provide the care care is not just about medication it's about clean water it's about prevention a lot of community based activities that you can carry out to sustain or to promote health last but not least you know I think being a family doctor we are blessed with lots of skills from basically we can't care for anyone that walked into our clinic from womb to tomb and we should take pride of what we are doing thank you very much thank you so much Dr. Yong and I like that we take care of people from womb to tomb and health care is not just about medicine it's about everything else that supports life thank you so much I want to recognize the presence of we have our wonka Africa chair thank you for your time to join us today and also the secretary Dr. Kwame thank you so much for making time to join us today I think we'll have you say something before Dr. Etang closes the meeting just to highlight some resources that are available from the wonka working party on rural practice we have a mentorship program we call it the mentor mentee program that we started a few years ago we've done ground one now we are doing ground two point O where we have older family not older in terms of the age but also experience mentoring young doctors and also students who would like to go into rural health practice so when you go to the website you'll see more about that program we also have the wonka rural health guidebook so there's a guidebook that is also on the website so if you need that resource it's also there amongst other resources including journals where you can find research on rural health practice as well so put the link to the website on the chat and you can look into that as well and also for your local ydm there's so many other programs that can offer you a community of practice as well as supports and mentorship because there is also peer to peer mentorship so you can also go to the wonka website and join your regional ydm because every region in the world has a young doctors movement like everyone that's hosting the webinar today so please join that for a community of practice for peer to peer mentorship as well and with that I'd be your moderator Dr. Mathew Andjala I'm a family physician from Kenya also in rural practice and before I forget we also have the wonka rural seeds program for young healthcare professionals who want to be groomed into leadership in rural practice, advocacy in rural practice as well back to you Dr. Etang thank you very much Thank you so much ladies and gentlemen as we bring this webinar to a close I want to express my sincere gratitude to all of you for joining us today to discuss the role of young family doctors in addressing rural health challenges and this has been an insightful and a thought provoking session filled with meaningful discussions valuable insights and inspiration. We've dealt into the key challenges faced by rural areas and explored the critical roles we discussed for the barriers to healthcare, the strategies for community engagement and the importance of collaborative approaches to overcome limited resources and infrastructure our esteemed panamists have shared their expertise and experiences shedding light on the innovative interventions and successful case studies I love Dr. Young's story and the transformative power of young family doctors in making a difference in rural healthcare your remarkable insights and dedication have truly inspired us all to continue working towards achieving equitable and accessible healthcare for all particularly in rural areas. I also want to extend a special thanks to all of your attendees especially young doctors who are at the forefront of this healthcare revolution your eagerness to learn to adapt and innovate will drive positive changes and pave the way for my opinion better healthcare outcomes not only in your rural place but across the globe. So I just want to encourage you all to just continue to stay informed, continue learning actively engage with initiatives and organizations that are dedicated to improving rural healthcare as Natalya said be a voice of change advocate for policies that promote equitable access to healthcare and never underestimate the impact that you make as young family doctors. So on behalf of my team I want to express our gratitude again to our esteemed panellists attendees and everyone involved in making this webinar a success. Thank you for your time and your contributions and commitments to what's making a difference whether the journey to improving rural healthcare does not end here it begins with each one of us. Thank you farewell. Thank you everybody goodbye and have a great week ahead. Thank you everyone. Thank you everyone.