 So before we go to questions, and thanks very much, Lillian. I just introduced Martin McKee, who is the founder of Eco Hosts and a professor of public health here at the London School. And he will host the Q&A for this session. OK, thank you very much. Could I just ask all of the speakers maybe to come over here so that we can and the people who are watching us online can see you. And we've only got about 15 minutes for questions. So we're going to have to be relatively brief. So if anybody thinks that they want to give a presentation, sign up for the next one of these. Don't do it now. We want short questions of no more than 140 characters. But meanwhile, let's start and see if we get any questions online. If not, we'll take a couple of questions at once and then we'll put them to the panel. Who would like to start? And just wave at me. So gentlemen here, gentlemen here, and three men over here. There must be a few women in the audience as well. But we'll start here. Please sit first. Thank you. And if everyone could just say who they are as well. My name is Ali. I'm from Onrwa. One important challenge facing us, all the humanitarian justice in the ground is the coordination between them and the coordination with host countries and the coordination with other agencies. Because in many instances, the NCD patient is going to MSF, coming to Onrwa, taking medication and going to the Jordanian Ministry of Health clinics to take medication. He ended up with different protocols of management. He ended up with different regime of treatment. Another issue is the priority agenda. Each humanitarian organization has different agenda of work. And just to give an example, in such a humanitarian situation, many, many of the humanitarian agencies they focus on, they come to work on gender-based violence while the priority of the community, the priority of the refugees are to get food and to get shelter. OK, great. Gentleman there. And then if you pass the microphone back there. Yeah, my name is Kwaku and I work with International Medical Corps UK. A couple of questions. One to Helen and one to, is it Kiran? Yeah. So for Helen, did you see any, or did you look at the comparison between the funding for HIV and for NCDs? Bear in mind that, of course, HIV over the years have to define a very, very well-defined package. And whether, for example, if the NCD group come up with a similar package based on some of the practice we are talking about. OK, so NCD is quite broad. But especially within the humanitarian settings, if they can define, or if there's a definition of what NCDs to target or prioritize in certain contexts, would that help with the funding situation versus, let's say, HIV, which already has got a very clear, defined package? For Kiran. Keep the questions quite short. Yeah. For Kiran, South Sudan, I will. You mentioned you see children with diabetes ketosis, which prompted you to take into account. Can you give us the, let's say, the proportion of those? And what other NCDs you are seeing, but you are ignoring still, if that is still the case? OK, so it's a question about the burden of disease in South Sudan for Kiran. Yeah, versus other NCDs, because he touched on, I think, type of diabetes in children. And then you are acting your last point. You mentioned about guidelines that MSF is developing, guidelines for NCDs. Is this in collaboration with other groups, like the WHO or UNSIA? There's a group already trying to look at this. Is it in collaboration with those groups, or is something very specific to MSF? Oh, lovely. Thank you very much, gentlemen, over here. And then if other people can waive at me for the second round of questions, please. All right, thanks. I'm Dr. Jomar Khodonazarov, and I'm representing HelpHage International. My question to Ellen. It was a wonderful presentation. Thanks for that. And I think a lot to learn from that presentation. I think you well connected there in terms of sustainability, peer involvement, in terms of fixed dose combination, use gene expert, all of this make perfectly sense. Did you ever thought about addressing nutrition issue for those people? Or is that was big problem? That's my question. Thank you. OK, thank you very much. So a couple of questions, and maybe rather than there are some individual ones, but let's broaden it out a little bit. This issue of coordination, first of all, coordination, and also the issue of prioritization. Whose priorities? The development assistance organization, the community, reflections on that. Who would like to start off on that? Here and maybe. Or Pablo. Pablo. Ah, yeah. Hello? Yeah, I think that's why we are here. I mean, I think that that's one of the key things. I mean, we've been talking to each other, and we feel that there is a need of better coordination, in particular, I mean, guidelines, and I mean, there are different groups working. I think that is happening, but it's happening maybe too late. And that's part of the objective of this event. And hopefully, and that's what our aim is, is not just to do as impossible and forget about this, but from today, I mean, find ways to work in a better way and keep this communication. I don't know if, Slim, you have anything to say about the global coordination of different agencies in the region, because I think WHO, of course, has a key role on this. And I know you are working on that. So I don't know if, well, let me push you on that, Pablo, because you have another half that you wear as well. And one of the other ones, the World Heart Federation, and then somebody also mentioned the diabetes community, the International Diabetes Federation, for example. To what extent are they getting engaged in this agenda? Well, maybe, Helen, you would like to comment on that. I think, I think, well, WHO isn't the one. Well, yeah, I mean, I'm also, I work at the World Heart Federation, and that's basically a federation for cardiovascular societies, and well, we have some cardiologists there, but I think that cardiologists are really, I mean, far away from this discussion. And we just came from the European Congress of Cardiology, 35,000 people. I don't think there was any presentation on these kind of topics, and they're discussing the latest, I don't know, stent and things for, and they're neglecting this issue. I mean, that's what I think we eventually need to work with them, but I think they're far away. I don't know, that's my feeling. Helen? Yeah, I mean, the issue of coordination comes up time and time again in the HIV world as well. I think it has to come from that international level to the Ministry of Health level. I mean, what we're still constantly seeing is different NGOs still reinventing the wheel and lack of leadership by ministries of health to bring those agencies together. And that's not to stifle innovation, but to make sure the base is clear agreement on what the basics should be and how those basics should be implemented. And I think that's where really in many of these countries in very, very difficult settings is how can we work with those ministries of health to bring some of these agencies together? Maybe I could ask Karen to pick up on that one because I was struck listening to your presentation that it was actually remarkably similar to ones that Pablo and I gave in Rome at the weekend at the European Study of Cardiology, except we used the words cardiovascular disease and you used the words HIV. And in fact, we were saying exactly the same thing. So can MSF do something? I mean, you've got this tremendous convening power and the ability, everybody likes you and listens to you. Well, I'm a bit nervous to answer that because there's actually, I could see there's a current and former president of MSF in the room and I don't want to say anything wrong. In terms of collaboration coordination, it's true that we see our primary partnership generally as being with the community and the ministries of health in the countries we work. And in the past, we have sometimes been reticent about seeing opportunities in partnerships with other actors, international actors, UN actors and so forth. I think that working in NCDs, it forces us to look more broadly. It forces us to some extent think about health system issues where we've been a little bit cautious in the past because of our emergency mindset. I know that Philippa, for example, sits on groups with UNHCR or at least participates in discussions with Slim's group as well. So I think that we are starting to coordinate on that issue. Civil society, well, I think NCD Alliance didn't make it in the end so we do need to try and activate the activists a bit more. But at the same time in this room, as Pablo said, we have humanitarian actors, we have academics, UN agencies, and I think this is also a move in that direction. Maybe just to say about the guidelines in response to Quaker's question, the actual remit here was quite modest. It was to provide guidance to MSF field teams who actually had asked for this. And I think it was Tamam who actually did a survey across all MSF projects and found that this was something that was universally requested. Given that national guidelines were available seemed not to be implementable in these situations or where there were WHO-PEN guidelines that were too long to be read. So simplified guidance for NCD management in emergency settings was a very much a grassroots need within MSF. Now we are actually sharing those guidelines and starting to discuss with other actors about improving these guidelines and making them a little bit more generalizable. But even in relatively resource deprived situations, people do have access to mobile phones and things like that. So presumably these guidelines are now all in the form of apps, yes? Well, very soon. I'm not actually great with technology. I think I know there's someone in the audience who's been sending me WhatsApp messages to tell me to stop speaking. But yeah, MSF guidelines are starting to be available as apps. This NCD guideline is a draft and so that would be a precedent. Well, we have Google just up the road from us here. Martin. It also says that it leads to any philanthropic organizations. Can I just follow up with your question, W.H.F., because actually what I think is the role of cardiologists is to stay away, basically. I mean, stay away and not interfere. I mean, I don't think the solution for NCDs is not specialists. And that's part of the challenge because we need, unlike HIV work, and most of the specialists, I mean, eventually were in those settings. We are coming with specialists that come from Hancom countries and we cannot make those models applicable in these settings. And I think that's part of the challenge. We need to rethink that. And what we need is, as you've seen, for example, in Lebanon, if patients come with the latest, I don't know, anti-hypertensive, but actually we know that the important thing is to just lower black pressure. At least we want the cardiologists saying that's fine and not saying, no, you need the latest version and the most expensive. So I don't think we need the specialists to solve this, but at least not to interfere in the solution. Yeah, and maybe at a later stage today, because I know others like David Barron and others are speaking, we might talk about what we're trying to achieve, what level of blood pressure, what level of HBA1C, what level of whatever, which is another issue. So, Lillian, you haven't spoken yet. So any thoughts on this issue of coordination from your perspective and prioritization? Yeah, I think the NCDs in crisis group that UNHCR convinced, I think we started last year and we've been having a series of meetings trying to be on the same page in terms of treatment guidelines, in terms of how we manage NCDs in humanitarian crisis. And it includes a lot of the agencies that work in these settings. And one of the things we've come up with is trying to come up with a misplike document, like a minimum initial service package similar to the reproductive health one, that will be used as a guidance for programs that we all work in. So I think that's a good first step. Okay, great, thanks, Helen. There was a question for you about nutrition. Oh, yes. So in answer to your question, yes. We do think about nutrition. I mean, I think that now in the age of antiretroviral therapy, if these patients are assessed, if they fit into the standard nutrition recommendations for a nutrition intervention, they're very much treated according to the country's national guidelines. There's not a specific protocol because they're HIV positive. So, and definitely within the health education, and that's where, again, where I see this overlap with the on-communal disease, in terms of healthy lifestyle, healthy diet, all that stuff, again, should be integrated into the packet of patient education. Anybody here from the pharmaceutical industry? Okay, well, in their absence, because one of the things that was coming through a number of the presentations was, they may be watching anybody online from the pharmaceutical industry. Anybody want to admit it? This issue of medicines, you were talking about fixed-dose combination therapy for HIV, that's certainly been talked about for cardiovascular disease, the simplification of the procurement. Many of us know that classic slide of the pharmaceutical procurement in Kenya, which looks like an integrated circuit board, and the problems with stock outs that were mentioned in a number of the presentations. So, are we all coming together in a coordinated way to address this? Because it seems to me that these are practical solutions that would actually address some of the issues you're talking about. Who's doing that? Who's in charge? Who's leading the battle? MSF? We're talking about it. We're looking at WHO, I think. Yeah, so, WHO, shall we... I mean, how about getting the fixed-dose combination therapy for hypertension and essential drugs? I mean, that's something that actually, I should have mentioned, the World Health Organization is leading. We put together a group on the polypil that actually, Philippa, participated in representing MSF, and we are looking at that kind of thing. No, and we are working with WHO, with the people in Geneva, to put the polypil for secondary prevention in the lease of essential medicine. So, there is a group, and WHO is part of that group with regulators and also pharma companies. Great. Anything you'd like to add? Yeah, just to compliment to that, there has been already a proposal for the adjunction of fixed-dose combination therapy for secondary prevention that had been rejected last year to be added, actually, to the essential model list of WHO. And we are reconsidering now, again, there was a new proposal, probably, in preparation for the next round. So, this is something that is already, I mean, had been discussed. The committee, when they reviewed, I mean, the proposal thought that there had not enough backing of evidence, actually, to support this. This has been, I mean, a controversial discussion that we had, I mean, this year, again. But clearly, in the coming years, the fixed-dose combination will come again. If I may, just a one point about the coordination aspect. I think it's an important element, and sometimes we tend also to mix up everything. In emergency response situation, and I have colleagues also from WHO, emergency department, that might mean, people have a poor understanding of how also the response is mounted in support to member states. The member states are there when they can't actually cope. I mean, there is an international community that support them. There was a global health cluster. We work in clusters, and the health cluster lead is often WHO, when you have refugee situation, like in neighboring countries, the UNHCR are leading, and this is how actually things are organized. Most of the time, whether through Ministry of Health, mainstreaming, I mean, the services to them and the response, but also through implementing partners. Having that understanding, I think it's crucial to understand who is doing what where, which is one of the aspect that we are doing in the early response of an emergency is to map out who are the actors and stakeholders who should be involved. So I think the coordination, of course, I mean, the UN agencies most of the time do it, but of course, you have additional actors, like MSF, that work independently and provide actually a lot of support to member states at work, that we need to put in the equation. So I think having the understanding of the mode of operation of emergency response is key or so, because sometimes we tend to give a lot of criticism of what is happening in coordination, but I think to get things right, we need to understand who is operating and sometimes how or so the member state themselves decide, in Turkey, they have decided they need to themselves provide the support and not calling for international agency, I mean, as much as other countries. So I think this is a crucial difference to take into account. And of course, these things always get caught up in geopolitics. So the key message from that is that everybody should be talking to one another, which is rather good because we're almost time for lunch, which will be a great opportunity and if you haven't met other people sitting around you, you will of course find the opportunity to see how you can collaborate with them, not only over lunch, but later in the day. But before you break, we do close this session with thanking all of our speakers, of course, but then a final short video, which we're about to have. But anyway, thank you to all the speakers all the way. Thank you.