 So, I would like to welcome all of you. Good morning, good afternoon, good evening to everybody around the world. It is wonderful that you have taken the time from your busy lives to come and be here. And I think that that also marks the importance of this topic. All of us have had our lives changed irreparably from COVID. If everybody could just mute, that would be great. Thank you. But everybody has had our lives changed from COVID for the worse and ideally also for the better. I'm sure that we can all identify some silver lining. On the world, we have family doctors who are really at the coalface of talking to people about how and about treating COVID. From this, we have a movement of WONCA, which is the World Family Doctor Organization. And within WONCA, there's the Young Doctors Movement, which is aspiring physicians, medical students, residents and new attendings who from all over the world come together to build community, to share stories, to support each other in different research, to support the people coming through as medical students and residents and more than anything to work out together how best we can care for our patients. This amazing panel who you see before you are all from the Young Doctors Movement of WONCA. And they really have taken time out of their lives as well to talk about COVID, to talk about the ethics of what has gone on at this stage and to talk about integration, how we can move to the next chapter of our lives during and hopefully after the COVID pandemic has settled down. They are the thought leaders of the future and I am very excited to be able to introduce them to you. They will each have about six, seven minutes to present. You'll hear me say it's six minutes and then at seven minutes we'll move on to the next one. And at the end, I would encourage you to post any questions that you have in the Q&A section that you see at the bottom. And we will address those questions after the first hour. So I really, without further ado, I want to thank WONCA. I want to thank the Young Doctors Movement. I want to thank all of the panelists. And most importantly, thank you all to our participants who are joining us from literally all over the world. First, I would like to invite Ozzden, Dr. Mia, who is an MD, PhD, coming to us from Turkey. She is going to talk on safety, burnout and suicide risk. She is going to now share her screen. Now she is actually an expert in this area. So it's wonderful to see her and interested to hear what she has to say. Take it away, Ozzden. Thank you very much. I am from Izmir, as Margaret has just said. And just working with Vasco de Gama from the Mental Health League, thank you very much. And these are my titles just to talk about. And I just want to thank you, Margaret, Sonya, Harris, and also our selected chief for just making us together. What is burnout? As you might say, there are lots of ways of being burnout. And we were just burning out before COVID. And so let's think about the stages, the honeymoon phase, that we just don't understand what was going on. And afterwards, it's just go to the habitual burnout. That just seems that everybody is. So this is important. This was the last VDGM face-to-face congress, was not hybrid. And our members from equally different group has just made a workshop about burnout. And the unpublished work just said that we were already has that problem of burnout before COVID. And this was again before COVID's Congress, because at that time there was in a week time a mental medical student, a practitioner, and also a surgeon has just committed suicide, has died in Turkey at that time. And these were just before the COVID times. And we were just trying to talk about this on the workshop. So depression was our main problem in our healthcare workers area. And also bullying for the ones who have got job is just still as a problem too. So with COVID, what happens? First comes the ignorance. We just didn't want to see the problem. Afterwards, we just understand that it is not just come on with just ignorance. We have to fight with and also not the ones on the front lines, but all of us has to fight with it. Because if not, we just can't get deal with that problem. By this way, we just try to get a review of the reviews, just see what's going on under telemedicine, just not to see each other face-to-face. How can we help to us? At that time, we just figure out that not only for this time, but also after the COVID, if we can reach at that stage, we will have problems, emotional problems, not only for the healthcare workers, but also the communities because these are just under the water will just come to us on our faces. The other part is about the safety. We just have to be healthy to just protect the health. So not only protective equipment, but also the other things have to be needed. So the eagle eye observers are observing us if it's everything that's going on for the contagious diseases and so on. Maybe we should get an eagle eye for our mental health to just to check each other. So at that time, we just can see that there are lots of things happening, not only on individual side, but also in the planetary health side. The climate change has also affected us for the contagious diseases, not only with the contagious diseases, but also the other factors, so our mental health is affecting. Have you got some tools to prevent this? Is community-oriented primary care could help us? Well, there are some tools about it. First of all, we just have to see the root reason. So the root reason for we had to define the reason. We may say that there are lots of people in the healthcare just the target of the seasides. And also not only the healthcare workers, but also the medical students are just need of help. So as we have got lots of hypotheses about seasides and how we can get prevent from that, we should see the risks about it. Most of the physicians are just committing seasides, not with bullets, but they are using drugs because they can reach it. The other part is just working together. If we could have some job, that means we should be happy with that. True, but bullying, mobbing, and the other factors are just coming with this too. So is it only a pandemic that we are living in or a tsunami? Because economic burden has just comes to with these targets that we can't reach. And here we just became another window on the Zoom, not just like a mob show, just we can't touch each other and we can't reach the home in touch. So at that time, what could we do? Education could be one sign to get the tools. The continent curriculum could be just told. And the work and life balance could be a choice for us to do what we can do about our mental health. Let's think about core values, what is much more important for us and what could just say for us. So at that time, we should be just look our faces in the mirror too. So the options to be honest to us and also to just say that it is okay not to be okay because we don't need to be well all the time while everything was just juggling down in this. We are just survivors. So the improvements not only for the curriculum but also for our health is needed. I just want to thank you. This was just from a poem. I hope we will just meet each other in the center after the COVID. Thank you very much. Wonderful. Thank you, Arstin. And I think that that is really that hits straight to the heart of how so many of us and our patients have been impacted. And thank you for just being so authentic in talking about it as well. We need to talk about it more as physicians and as human beings as well. So I think that that is fantastic. And again, if people have questions, please do not hesitate to put any questions in the Q&A box. I'm already seeing some come through. So that is fantastic. And I would like to now invite Dr Oteju Aramede who is an MD from Sierra Leone, originally from Nigeria, now working in Sierra Leone, who is going to speak about access to care. Now, Dr Oteju is going to try and share his screen as well. If we have any troubles, I have it here on my screen as well. I think it is phenomenal because we have seen how devastating Ebola has been in Sub-Saharan Africa. And now on top of that, we have really two pandemics, one of communicable disease and the other of non communicable disease. So Dr Oteju is on the forefront of that, working in Sierra Leone. And I want to welcome her and hand it over to her. Fantastic. So Dr Oteju, yes, you've got it. Dr Oteju, we can see your screen beautifully, but we cannot hear you. Is there a way that we, if you can unmute, just at the bottom of your screen, see if you can unmute. Is that better? Okay, can you hear me now? Yes, we can all hear you now. All right. So I'll start again. So I'm talking about access to care and how it has been affected by COVID. I'll be talking on the Sierra Leone view, what we have, what we expected. So WTO Constitution talks about access to care and it's, you know, healthcare is supposed to be what a fundamental human right. So the highest attainable standard of health is the fundamental right of every human being. And that right to health means that everybody should be able to access the health services that we need, when we need them and where we need them without suffering any hardship. All right. Quoting Dr Tedros on that. So looking at the concept of framework of access to healthcare by Levesque, you can see here what the factors that impact on healthcare and accessing it. So we have healthcare. So how do we reach the people? Okay. So access to healthcare basically is getting the health that people need to them when they need it and where they need it. And there are many factors in this. So we have the healthcare itself. Is it reaching the people? Is it available? So talk about even being available. And then are people able to get to it? Whether physically, talking about where are we? How far away from the healthcare that you need? Are you? Is it from the health facility itself? Where do you live? Talking about the accessibility. Is it the kind of healthcare that you are willing to accept? So talk about it being physically accessible, financially accessible and appropriate towards you as well. Is it something you can accept? Is it the kind of healthcare that you're willing to believe in or accept as well? So we can see all of this is shown in this slide here. Healthcare, the perception of the needs for care. Do you think you need it? What's your healthcare seeking behaviour? And how the healthcare, how do you use it? Okay. So that's the basic framework there. So let's look at the Sierra Leone story. So Sierra Leone is a small coastal West African country. A population is just about 8 million. Okay. And have a population growth rate of about 2.1% annually. But the rate is still quite high. 4.2 as it is in most low-income countries. Average life expectancy is 57 years. Maternal mortality, it was the highest. They had the worst highest maternal mortality in the year 2000. Okay. And it's still high right now when the top 10 at about 800, 800 by 100,000 live births. If a mortality is 70 by 1000 live births and a 5 mortality also quite high. It's majorly more of a rural population, about 57% rural. And the median age is 19. Okay. So that's a flag of Sierra Leone right there. I am based in Kono, which is a major district in Sierra Leone. So a couple of Sierra Leone is free town. Kono is the third largest, third most populated district in Sierra Leone. Okay. So it's the center of diamond mining. And we all know that Sierra Leone is known for diamonds. That's one of the some of the best diamonds in the world. And the diamonds have been both a blessing and a curse. It was one of the major reasons they had a war about 20 years ago. And right there, Kono is the center of mining, the population of about 500,000. So right there, the center of mining, yet the health statistics are, you know, nothing to write home about. In the midst of so much wealth, we have just one hospital in the district, which is the quality government hospital where I am based. And then several primary health units, okay, peripheral health units that stand out about the 14 chiefdoms. So how did the first COVID wave came in about March 2020 and lasted about three months till June? The second wave was about December, January, okay. And then the third wave was about from June till now. Let's look at some numbers to see how these affected, you know, the care given behavior and the care that was received by the community at that time. So let's look at the numbers. So these are the general outpatient department numbers of quality government hospital. Let's look at the number of patients in 2020, just before the first wave of COVID became in March, you can see the numbers, averages were 1026, 1024, which is about what we saw, you know, usually, okay, then it dropped, started dropping in March 940, April 508. In May, we had just 130 people in the outpatient at the peak of the pandemic. Then in June, it started coming back up 377. And by July, by which time we were hardly seeing any more COVID cases, we said they're going back towards the normal outpatients we're seeing. So if you look at that right there, you can see how it affected it. So initially, we're having patients coming in, then the numbers of patients that were coming to the hospital dropped. Why? When there's a pandemic, we're expecting to see more patients, aren't we? But that's not what we saw. And after the pandemic, the number of outpatients rose again. Then there's one of the peripheral health units or the health clinics that we have also had a similar pattern, all right? So the peripheral health units are like primary healthcare centers that's, you know, in those chief domes or local governments. So looking at the quarter, January to March, that was just before the pandemic last year, 2020, about 3867 patients coming in. April to June, we have one minute we're looking for. 2176. And again, it rose back again. So we see that. And look at the COVID control measures on the first wave were very strict and effective. I know. And because of the Ebola experience, a lot of people were compliant to that. Well, the fear, oh dear, the fear of COVID, like to go back there, the fear of COVID made a lot of people not come in for care. Okay, the fear of being quarantined made people not to come in for the care. And we see that happening. So we're having more COVID cases coming in. Well, fewer people come in accessing the care for other cases. And the numbers coming in, okay, for the third wave, it wasn't as much as this. We had better care. Because by this time, people were wondering, why was this? Was there increased confidence in the health system that they wouldn't come in and get COVID from the hospital? Or was it there was a reduced fear of virus or what could it be the vaccination? Those are some of the things that we are looking at. Okay, so there was a lockdown. I think about some of the factors. But this is just a picture of that we're not even having enough healthcare. So this is a picture of the road right here, the kind of access already really had bad access to healthcare because of roads like this, some of the peripheral health centers. Okay, and I'm looking at that. So I just get a picture of what we look at. So just one of the health centers where our sister organization, as a partner in health, helped us to get access to health. Okay, so because of time, just how the road to where we're going there, right there, is it? So this is what the health center looks like before, until the sister organization came and helped us with that. That's me, you some of our patients. And on behalf of everyone, young of Wonka Africa, I've talked about access to healthcare during the COVID and how it was affected. We had less people coming in for access for other conditions, aside from COVID related conditions, and then the numbers improved again. But we're not having as much as a decrease in this third wave. So when we're trying to find out what are the factors that affected that. Thank you. Wonderful. Thank you. I think that you speak to all of our experience and yet it is so unique, your experience in Sierra Leone as well, that road brought back many memories of after the rainy season in Sub-Saharan Africa. So I can only imagine the barriers that you are overcoming. And it'll be interesting to hear not only from our panelists, but also from the floor what barriers are new for you that you have overcome in COVID. So please go ahead in the Q&A and if there's anything you want to talk about there and identify what barriers. So that was great. And any questions directly for Dr. Otagil, you can also post in the Q&A section. Now I would like to invite Dr. Kinley Bhutty, who is a general practitioner from Bhutan. Would you like to go ahead and share your screen, Dr. Kinley? She's also wearing the beautiful traditional Bhutanese top, which I thought was really lovely. And she is going to speak on underserved populations. All right, I'll hand it over to you. Thank you. Thank you. I'm Kinley Bhutty from Bhutan. I'll be speaking on the topic underdeserved populations. So as per the definition by the health and human services, it characterizes underserved, vulnerable, and special needs populations as communities that include minority population. And it says Latino population, African American population. It doesn't really say Bhutan or Southeast Asian, but then we have the individuals with limited English proficiencies, young adults with the unfinished education who do not have a coverage for health care and also the women and women with children and individuals with disabilities. So this is the definition as per health and human services. So if I just talk a little bit about my country, Bhutan is a democratic monarchy, a tiny kingdom in between India and China. So why underserved? Because this, our country doesn't produce any pharmaceutical drugs or vaccines. So if I update a little bit about the COVID situation in our country, we have about 2,500 cases as first, for 6 p.m. today. And we have two new cases detected in last 24 hours and two confirmed deaths since the pandemic started. So how the underserved population could cope up with COVID-19. So I would like to bring up how we had coped up with the COVID pandemic. We further characterize the underserved populations. It means it's receiving fewer health services, encounters barriers to accessing the primary health care, basically on the geographical or economical and cultural barriers. And we also, the population also have a lack of familiarity with the healthcare delivery system and also face the shortage of the readily available providers, mostly seen in our neighboring countries in India and all. So there are various factors for the healthcare disparities. One is racism, and the one is bias and discrimination, economic and educational disadvantages. So if I talk about the three main categories where it increases the risk factor during the pandemic, it's number one is economic and social circumstances, assist with the testing and treatment and those populations who have underlying health conditions. So since the pandemic began, it had impacted much on the economic and social circumstances. It has lowered the median income people where they have reduced the livelihood due to the healthcare coverage. And because of the deemed essential front-line services and other many frontline healthcare providers, we are put at the much greater exposure, risk exposure to coronavirus. And also because people do not have much paid sick leave, they do not come forward to get tested and all. So also living in densely populated areas have hampered a lot in controlling the spread of the COVID-19. So the number two, the risk factor is assist to testing and treatment. The number one most common barrier is the language and culture barriers. Our people still believe that there is some evil spirit or something hampering their health, so they don't come forward to seek healthcare until it becomes severe and then we cannot do much to them. So this is one long-standing mistress of the healthcare system. And since healthcare is free in my country, we don't have much problem with healthcare insurance, but it's seen in the neighboring countries in the region. So the other important thing is underlying health conditions. We have many populations who live with noncommunicable diseases like diabetes, hypertension, heart disease, and also like HIV-AIDS and all. So there are various ways that we have put forward to protect ourselves. We strictly follow the CDC guidelines and we got vaccinated. People practice social distancing, they stay home as much as possible, hand hygiene practice, and then using face masks is must for everything. So hello, am I audible? I thought I lost my lines. So Bhutan got its first vaccination from the government of India. So our country underwent mass rollout vaccination after considering a special zodiac sign to fit the special auspicious day. It began on 27th of March this year. And we're supposed to get second dose by end of May or first week of June, but because of the various circumstances and situation our neighboring countries were facing, we were not able to get the second dose on time. But then we're very lucky that various the nations of the country, they donated. And then we received our second dose of vaccination on 17th of this month. And our nation right now is undergoing the second mass vaccination campaign. So the various things that we that we practice to cut the chain of the COVID-19 was a national lockdown where people we see the town of the capital city Bhutan, where we don't see any anyone roaming in the town. And then the social distancing testing were all provided, of course. And then to move forward, we have the health care is located in a community where people don't have to come in a crowd. And then we also have the teleconsultation put in line where people can freely call in. So we have various flu clinics set up away from the hospital to prevent the hospital from shutting down from like so that we can isolate the people at the right time at the right place and then isolate them before they actually get into in in relation to other people. So this was the various and then people were reminded continuously on the radios and the national television how to notify the symptoms of COVID-19 and the various protective measures they should practice. So that's all. Thank you. That is really fascinating. Thank you so much, Kinley. And the photos are just beautiful as well, inspiring us to want to come. Also really interesting, you know, the vaccine story and just how dependent we are on supply chain and on access in different ways as well. So I'm thrilled that you've been able to get the second dose for so many people there. Thank you for your ongoing work there. I think that that is, I'm sure I can see the questions rolling in as we go as well. And now it is my pleasure to invite Dr. Erwin Gustiawan Sawanto, who is a doctor and who is also a lawyer and who is also an ALM to who's done to speak about the rise of telehealth. And it's a perfect segue because as you saw Kinley spoke about in Bhutan and how they're going to do the flu clinics and do more telehealth. So I think that, you know, we have these amazing up and coming young minds and Erwin, I want you to take it away with these next ideas. Yeah, thank you, Margaret for your kind introduction. So we will discuss about telemedicine and its ethical response to COVID-19. I'm Erwin, I'm from Indonesia and Indonesia is one of the epicentrum of COVID-19 infection nowadays. And it's a pity actually, but we will just do our best. So you can see in this first slide, we will talk a little bit about industry 4.0. So we know that the first era is all about mechanical machine. And then the second era is all about electricity. And the third era is all about internet. And now we are entering 4.0 era. So it will be more complicated because we will combine technologies and also human resources with its complexity and especially in our society. And this is our online meetings and also online webinars. So in Raja Kumar movement, one kind of Pacific Young Doctors movement, we have discussed a lot of things. The first one is all about entrepreneurship. And the second one is about clinical case discussion. And the third one is basic medical research. And also we also did mental health and emotional well-being sessions for young doctors in our regions. And this is the pandemic impacts on non-COVID patients in Indonesia. So especially if we talk about diabetes and hypertension and cancer. So actually 3.6% of our government America centers have decreased visit rate because of this pandemic. And 43% of government America centers have closed their basic services in community, including for geriatric services. And 32% decreased home visit by staff of our government America centers. And survey that is made by CISC, an Indonesian Society of Respirology from 355 cancer survivors in Indonesia. Most of them are well involved about COVID-19 protocol. But 60% are not worried about their disease during this pandemic. But almost 40% are worried about their disease during this pandemic. And 38.8% are worried about the progress of their disease. And 29.2% are worried about the telepathical process, for example, long QE. And then 22.5% are worried about accessibility, for example, farmstock. And that's from national head incidence agency, the decreased visit of cancer patients to hospital. And 9.7% deaths in Indonesia is caused by cancer. This is the sample from China. And we will try to copy this also in Indonesia. So this is one of the successful point from China. They use community residents they combine health science, psychology, consulting, update information of COVID-19, and online clinic consulting. And you can see that the telemedicine is the center of it. And they have screening, latency, fear, pertinence, consulting and medical staff there, training, consulting, quality improvement, panel discussion, broadcasting, and also psychology course. So this kind of system can be copied in other countries actually. But in Indonesia, you know, we are democratic countries and we have a liberal economy system. So it's hard to make a same system like this. There's a problem. So we have a lot of sporadic online platforms, especially telemedicine platform. And I'm also starting my own startup companies in telemedicine. And this is one of the video that you can open by yourself. We have started our pilot project in India also, not only in Indonesia. So you can see this is the stages and layers in China. So they insist on primary care, treatment, and screening for COVID-19 patients. So they can take patients to be revered to the hospital. So it will decrease the burden of the hospital. That's the point. And telehealth has been discussed in World Medical Association, Congress. So they make a difference between telehealth and telemedicine. Telehealth is the use of information and communications technologies to deliver health and healthcare services and information over large and small distances. And what about telemedicine? Telemedicine is the practice of medicine over a distance in which intervention, diagnosis, therapeutic decisions, and subsequent treatment recommendations are based on patient data, documents, and other information transmitted to telecommunications systems. So telemedicine can take place between a physician and a patient or between two or more physicians, including other healthcare professionals. And the ethical recommendation from World Medical Association is telemedicine should be appropriately adapted to local regulatory frameworks, which may include licensing of telemedicine platforms in the best interest of patients. And where appropriately adhered to a national medical association should encourage the development of ethical norms, practical guidelines, national legislation, and international agreements on subjects related to the practice of telemedicine while protecting the patient-physician relationship, confidentiality and quality of medical care. And the telemedicine should not be viewed as equal to face-to-face healthcare and should not be introduced solely to cut costs or as a purpose incentive to over-service and increase earnings for physicians. And use of telemedicine requires the profession, sorry, to explicitly identify and manage adverse consequences on collegial relationships and river patterns. And new technologies and styles of practice integrations may require new guidelines and standards. And physicians should lobby for ethical telemedicine practices that are in the best interest of patients. The biggest problem is that it is often that we can address the emergency emergency situations. And also we avoid to make a feed call for the patients. In fact, we should facilitate that feed call because even though there is no emergency situation, but sometimes the patients could feel very anxious. That's the point. And you can see that if we talk about e-health ethical problem, then we should focus on this area. So there is application area about treatment, monitoring, communication and research, and also user groups that use elderly and dimension of individual, organizational and societal. And all of it, of course, we will, we should consider about the informational self-determination, confidence, privacy, data security, patient security and justice. And we need a good leadership in governance to make a good e-health system, especially telemedicine system. And the strategy investment also very important in services applications, standards, interoperability, infrastructure, legislation, policy and compliance and workforce are the main factors for the success of telemedicine system. For the conclusion, currently there are still no official general guidelines available that may be applied to address these questions in practice. Given the broad application areas and it involves stakeholders, it will be probably impossible to formulate general guidelines for all possible usage scenarios. And for its application and research study, researchers and healthcare providers need to carefully wait harm and benefit for the individual patient or groups of patients. And Indonesia has law number 11 of 2008 Electronic Information and Transaction Act, revised by law 9 of 2016, law 29 of 2004 Medical Practice Act and Medical Ethics Code. And also we have health minister regulation on telemedicine among health facilities and health minister regulation on teleconsultation during pandemic and medical consul regulation on telemedicine. And also we have food and drugs administration regulation on online drugs prescription during pandemic and some of specific regulation that are still ongoing revised Shades regulatory sandbox. Okay, that's all from me. Thank you. Wonderful. Thank you. That was very informational. I actually learned and I think also really a wonderful challenge that you have offered us as well, Irfan, because what you are really saying is that we have this opportunity and you are perfectly positioned with your law background and your IT background and your medical background. But all of us as family physicians, the ethics of the next phase as we move into era 4.0, the ethics we need to think through and we need to advocate for our patients because otherwise these decisions will be made without our input. And we have something very unique to say. Thank you. That is very important. Thank you for that. All right. So now it is my pleasure next to invite from Mexico Dr. Jose Alberto Loyal who will be speaking on the family doctor's role in creating integrated care. We've heard about access to care. We've heard about no telemedicine or telehealth. We've heard about the importance of mental health and all of this and now really talking about integrated care of which the family doctor is really the center. So welcome Dr. Jose Alberto Loyal. It's all up to you. Well, thank you. Good day everyone. So we have been talking about integrated care here and well we need to know exactly what it is before we continue on mostly because it's a care that reflects a concern to improve patient experience and achieve great efficiency and value from health delivery systems. Now integrated care aims for the patient to be able to get every kind of attention in order for it to be effective. Okay. In this case we are not aiming to cure but to prevent everything and in given the case that the patient needs something that he or she or they could afford it and get to it in the most efficient way. Now who defines it as an approach to strengthen people's center health systems through the promotion of comprehensive delivery of quality services. Now these are all infographies that the who gives us about quality health care. It must be effective. It must be people centered. It must be efficient, safe, timely, equitable. Okay. And all of this is basically we are just repeating what we know is the family doctors. Okay. The first contact doctors. We are those. Okay. Now the who acknowledges the importance of integrated care and global health services delivery and many governments around the world are aiming to transform health systems in something that focus on primary care on prevention in order to reduce costs. Okay. On the long term. Now what role does the family specialist play in delivering integrated care? Well, we are basically the foundations of all of this system. Okay. Why? Because coordination of clinical care is complicated. Mostly because of the multiplicity of players involved and the first lines of authority among them. Now many patients don't know who's in charge. Don't know who to go who to seek counsel with when they are sick or when they need something from the health institution. Okay. Now sometimes when they are in a consultation, patients think that they are in good, competent hands. But what if the doctors that give this attention to them, okay, also knows about their lives also cares about what's happening. We must remember we almost remember that we don't treat just illnesses. We treat patients with lives with families with problems and issues that they have to deal with every single day. And that's precisely the strength of the family doctors of the family specialist here when creating integrated care. We need to let the patient know, okay, that he she or them are being hurt are being treated. And we are paying attention to all of their issues because many, many health issues are not entirely health issues talking about medicine, but also about mental health. Now we have to work some points here that are basically communication between patients and clinicians, shared decision making, alleviating discomfort and emotional support and alleviation of thirst and anxiety. Now, all of these points, we already work in primary health units or in primary health services. We have to pay attention to them. Again, I may be repeating myself saying this, but the family doctors, the family specialist, the primary care is vital for the creation of integrated care. Because what we want is to give everything we can to those who need it, but also to prevent every single aspect of any disease or of any action that could lead to greater costs, to harder to find solutions to problems that could very easily be solved from the beginning, if only paying a little attention or perhaps trying to make the patient feel comfortable so that they understand and follow the orders or indications that we give to them. Now, we are providing with family physicians a system of frontline healthcare, like Dr. Otegi said before in Sierra Leone, in many countries in Africa, Europe, Asia. All around the world, we are there. We are in the first point of contact for patients to go. Those are us, the family physicians, the family doctors. Our role is to try to integrate this, to let the patient know what they need to do, what they need to ask, where they need to go, when they need to do it, to give all of these proper recommendations in order for their health to be at every point of their lives. And if they actually need something that must be heard, that it has this importance, this greater impact, we have to let them know. Now, emergency care, home and long-term care, all of these that we read here are the places where we, family doctors, family specialists, are. We are everywhere. We are around the world and sending to patients everywhere we can because we want to do it. That's the reason why we are dedicating our lives, our work to this. Now, during this pandemic, as we have heard before, we have been there in front of the patients. We have been exposed to these health risks because it's part of our job, but we are doing that gladly and proudly, mostly because we are trying to do that. We are trying to prevent everything bad from happening. That's the reason why our role is so vital to this that I have been talking to you about. So, we have to protect ourselves. The family specialists also have this particular thing that we have to be researching. We have to be studying. We have to be preparing ourselves even more for day-to-day challenges that we compound. Now, we not only deal, as I said before, with health issues. We also deal with emotional issues of the patient, and we have to try to integrate those into the scientific background that we have here in our offices. On a daily basis, we have to explain. We have to create all of these analogies, all of these explanations to the patients so that they understand that whatever they have, it's important. We have to be sure that our messages are getting to them, that we are not only speaking to other doctors or to other health specialists. No, no, no. We are talking to patients. We are trying to integrate all of this into the consultation. Now, according to the University of Washington, the clinical specialty of family practice is a patient-centered, evidence-based, family-focused, and problem-oriented. We are way too used to deal with problems and solve them. We try to focus, find a point where we can work with, and then we move on. That's the role of the family physician here. We are the ones that solve problems. We are not only going to be solving them, but we also are aiming to try and provide every single tool the patient needs and that we can give to them in order for integrated care to become a reality. Very well. That would be all for me. Thanks for listening. Well, that's it. Wonderful. Thank you very much. I really love actually the integration of your presentation as well, because as we go forward and develop people-centered healthcare, then having these concepts from the top down from the World Health Organization and combining that with what we know from our own community and our own experience and the grassroots of our patients, that is exactly as you say where we are. So thank you very much. That was another wake-up and challenge to us all. Now, I would like you to come and invite you again to share your screen. I'm inviting Dr. Hanen Taha, who is speaking from Jordan. Wonderful. She is so on top of it. So that is great. And she is going to speak on the integrated care up to COVID, specifically with the focus on women. She has real expertise and experience in this area. And she is one of the upcoming family medicine trainees, a resident at the moment at the Jordan Ministry of Health. So, passing it on to you, Dr. Hanen. Hello, everybody. Thank you, Margaret, for this kind introduction. On behalf of Razi Movement, I will talk about the impact of COVID-19 on women. We will assess the many aspects of impact on women across the key domains of life. We will talk about some of the ethical challenges that emerged during the pandemic and to talk about the policies and solutions that can be developed to meet the basic needs of vulnerable populations. Like the rest of the world, Jordan has been hit hard by the recent and ongoing crisis. And our government and Ministry of Health, they acted early in March 2020 by ordering a nationwide lockdown to cushion the impact of the COVID-19 on healthcare system and limit the spread of the infection. Actually, Jordan is surrounded by many countries of conflict. We are struggling to cope with the vast numbers of refugees and the tremendous pressure on the healthcare facilities. We experienced many difficulties, especially in terms of scarce health resources. And it appeared that the pandemic has created a situation that disproportionately having negative effect on women. And we will discuss some of these negative impacts that we faced during our work, either during the emergency or COVID facilities. First, it increased the demand for caregiving as the result of joblessness and school closure. Women had to balance between homeschooling and taking care of sick people at home, plus working, doing their works and jobs from home. So it creates stress and additional conflict. We have seen many cases of depression and anxiety due to this increased demand. We know there is good percentage of healthcare workers, they are women, about 67%, which exposed us to increase the risk of infection among frontline workers. When it comes to pregnant ladies, the pregnant ladies were found to be at heightened risk of more severe symptoms than people who are not pregnant. But pregnancy does not increase the susceptibility of the infection. We had many cases where pregnant ladies refused the treatment and exposed to radiation in order not to harm their babies. So it really raised our concerns on their safety and the course of their disease among them. Many studies were conducted to study the effect of a pregnancy on the severity of COVID-19 on pregnant ladies. Actually, another roadblock is the inability to access healthcare facilities and disruption the continuity of maternal and reproductive health services. In Jordan, 24% of ladies, they could not access healthcare facilities. Many, they were not able to gain the regular antenatal visits and we noticed increased in the prepartum complication. It also increased the incidence of an issue that already exists before the pandemic, which is the intimate partner violence. We noted increased in the calls to the hotlines. The percentage was 33%, reporting for abuse and intimate partner violence from women as opposed to men, which raised our concerns about their safety indoors. When it comes to the ethical challenges, COVID-19 has highlighted many. The government and healthcare system put difficult decisions and policies to allocate health resources, like deferral of elective surgeries, with resultant long-term ramifications and loss of organ function. Limited access to the family planning methods and contraceptives that due to lockdowns and shutdowns increased the cases of undesired pregnancy. We received many calls seeking for illegal abortion, which is banned in our country and as well many countries. So this is due to the lack, the accessibility to the contraceptive. In Jordan, actually we used to, during the pandemic, we delivered the medication for electronic diseases to home, but this was not done for the contraceptives. So we should pay attention to the basic reproductive health services. Polices regarding the prevention and the treatment of COVID-19 in the context of pregnancy demonstrate the ethical and legal legal tension that is deep rooted in the maternal fetal diet, especially when it comes to the vaccination. A lot of studies were conducted to study the effect of COVID, of vaccination for pregnant ladies and actually pregnant ladies were excluded from many and even all the clinical trials regarding the treatment and vaccination. All the results were connected on animal studies. What we should do, we should actually, we look forward to pay explicit attention to the role of women as a frontline health workers. We should provide them with appropriate size PPE. Actually, we noted that the PPE were of default man size and they were unfitting us, they were loose, so we were at increased risk of exposure to the viral load. We should provide them with essential hygiene sanitation items. We should ensure the psychosocial support, either for the frontline health care workers or for the pregnant ladies, for the infected lactating mothers, how to deal with their infection and to prevent, transmitted this infection to their babies, at the same time prevent their separation between the mother and the infant. We should ensure the continuity of maternal and reproductive health services by providing the contraceptives even in times of lockdowns and complete shutdowns. We should ensure the availability and accessibility of social agencies and family protection services all through the week 24-7 and hotlines to report for intimate partner violence. Thank you for listening and paying attention. Thank you. That was really valuable and unique lens into the impact of COVID on women's health and amazing. Sometimes, I wonder if it's just an oversight that somebody forgot about contraception. It's easy to do but how it really impacts so many women in Jordan. Thank you for all of that. Also, as a family physician that was pregnant and had a baby during the COVID epidemic, I really relate to everything that you were saying. So that was very important. And now last but certainly not least, I want to introduce Rohini, who is our family medicine medical student, joining us from Canada, who has really has given so much already to her community as well as studying unbelievable how she manages that as well as supporting young doctors all over the world. And she is very active in our North American branch of Wonka, which is Polaris, which includes Canada, United States and the Caribbean. Of course, we would love to have Mexico, but they are understandably associated with the Latin American and Spanish speaking area. But Rohini has done so much and now is going to speak about one of the important things because COVID, we know about its impact on our patients and the impact as Dr. Ozden looked to me, spoke about us and us as family physicians and as physicians. And so really looking at the impact on medical students is vital for us to look forward as well as to look back at what we can do. So handing it over to you. Amazing. Thanks so much, Marguerite, for that kind introduction. So my name is Rohini Pasrecha and I'm a fourth year Queens medical student located in Kingston, Ontario, Canada. And I've had the privilege to be part of the Polaris chapter of Wonka over the last year and a half. And it's really been an honor to see such amazing things that everyone's been doing. So today, what I wanted to share with you is a bit of the medical student perspective on how the COVID-19 pandemic has impacted us. So as you can imagine, each and every one of us across the world have been hit hard by the COVID-19 pandemic in so many ways. As medical students, I remember back in March 2020, I was leaving my classmates for our March break and a pandemic was announced and we thought we weren't really sure what to expect and we thought that we would be back in classes within a week or two. We're saying bye to our friends. Little did we know that a year would go by and we would be in a completely remote virtual curriculum. So three kinds of main areas that I wanted to talk about how COVID impacted us is first in the fact that curriculum was instantaneously restructured. We went from face-to-face sessions of lectures, clinical skill sessions, observerships, where you could have hands-on contact with professors and other colleagues to a completely remote curriculum. The second thing that happened was that there were clinical placement delays and with the personal protective equipment shortages and lack of resources as well as with the absolute chaos that was kind of coming in, students had to actually be removed from hospital rotations for a period of time and as a result there were some delays. And finally you can imagine that being in this stressful environment, medical students, healthcare providers, frontline workers were all at increased risk for stress, anxiety, and having poor mental health and all of these kinds of changes can have a toll on the mental health of medical students. So I just want to kind of dig a little bit deeper each of these concepts. So with regards to the curriculum restructuring, we went from a completely face-to-face model at Queens. We have a very small community. Our student population is only a hundred people and we have small group sessions a couple times a week. And all of a sudden we were go from the lectures to the hospitals to observerships in the hospital environment to sitting in front of our computers every single day for eight to nine hours a day that combined with meetings online and lacking some social interactions, they can put a whole toll on sort of your energy and your overall kind of desire to want to learn and engage in certain things. The idea of being able to do clinical placements and observerships was removed from this and this was because of all the stress and chaos that had been brought on by the pandemic and the amount of uncertainty. And as you can imagine in the early years, medical students are really really keen on sort of getting their hands into the clinical environment and learning what kinds of specialties or areas of interest that they really get an affinity to and not being able to get that kind of exposure can definitely be quite challenging for medical students when they come to making their decisions and learning about what kinds of things they would like. And last but not least, but perhaps one of the most important things is the lack of social interactions that were consequently impacted as a result of the COVID pandemic. Being in a medical school environment, especially in a very close knit community, you always have the opportunity to bond with your friends in class and outside of class in extracurricular programs. We have a lot of sport teams and clubs that we do after the typical day and that was all of a sudden all removed. And so our way of kind of making sure that we're having a good focusing on our physical, emotional, and mental health, that can all as a result be impacted because of the COVID-19 pandemic and the need to socially distance and isolate ourselves. The next thing that I want to talk about is the clinical placement delays and how that impacted us is that students were actually removed in Canada from the curriculum for a period of a few months and this had a domino effect not only on those students but also the students in the years to come. Placements went from six week rotations to four week rotations and this can be quite challenging in itself. The next thing that happened is the electives, the way to so that you can learn about different specialties and kind of explore different locations and environments where you may want to practice, that was quickly removed because of the need to kind of stay in one location and avoid the transmission of COVID. And so what that meant is for students who may be interested in specialties that may not be offered in their home school that can definitely increase and elevate the stress levels of those students. And lastly, and I'm not, I'm speaking from a Canadian perspective and I know that other countries had changes as well with regards to the residency match process but our matching interview process actually went from a complete in-person model to 100% remote. And while this has its benefits in terms of the cost, there's cost reductions with that and the reduction in carbon emissions, this can also be quite stressful on students as well because it may limit their face-to-face interaction, their ability to kind of build rapport and learn about certain programs. And lastly, the thing they want to talk about is in terms of the mental health, being on front-line worker, being medical students, studies have actually shown that each of these types of people are at increased risk for poor mental health, anxiety, depression, as well as at increased risk for suicidal ideations and attempted suicide. And you can imagine that being in a very sort of stimulating and stressful environment and then combating all of the changes that are coming in with COVID this only elevated some of the stress levels of many medical students. So speaking about the actual concerns that kind of medical students were faced in the COVID pandemic, what I want to talk about is that as medical students we have a very intense curriculum that we take part of for a certain number of years and the beginning part is lecture format and then you go into your hospital rotations. But medical students innately are wanting to give back, volunteer and are very altruistic in terms of what they want to do for society. And a study in the National University of Ireland in 2019 when they looked at medical students they asked the participants their willingness to volunteer if a pandemic should arise. 59% of them said that they were willing to volunteer, of which 81% of the participants said that they felt it was their moral obligation. And 98% attributed this to the most motivating factor being altruistic. What my reason for sharing this is that you can see that medical students really do want to volunteer. And so when the pandemic arose I remember seeing many of my classmates wanting to give back and see what they can do to help out. Things like building personal protective equipment, helping out disadvantaged populations and picking up their groceries, holding daycares for frontline workers who couldn't take care of their kids because they still need to be there and doing research to learn more about COVID-19. Everyone was trying to pitch in. But what's important to remember here is that there is that fine balance and it's important that while we're still, what I realized when reflecting on the pandemic and sort of how medical students responded to it is that we were still in a full curriculum in terms of our lectures and needed to build all that knowledge base. But at the same time many students wanted to still volunteer and the question is, what is that balance? And if we're not careful enough we can end up kind of overextending ourselves and over committing ourselves and that can actually be detrimental to medical students from a learning perspective but also to society if we're not able to actually build that skill set. And what I want to reflect on this for the future is that we can't guarantee that a pandemic won't happen again and I think it's really critical to actually put into our curriculum in our pre-clerkship or our clerkship curriculum how to kind of combat and prepare for a pandemic in terms of resource allocation. What can medical students do? How can you combat burnout and what can you do in terms of reaching out for help and what can you do with the knowledge base you have without kind of overextending yourself and while still learning the things that you need to do to become a medical doctor at the end of your four years. And the last thing I want to talk about is the importance of wellness days and that's because in order for us to provide the best possible care to society to our patients and support our colleagues that we need to still focus on our mental health and physical and emotional well-being and so having integrated into our curriculum appropriate wellness days and sessions where you can take the time to reflect back on the things that you've done and the goals that you want to have for yourself in the future are really important. And so with that I want to thank you all for your time and I look forward to answering any questions you may have at the end of the webinar. Thank you. Wonderful thank you Rohini that was the perfect wrap up of everything you really came back to the mental health the importance of lifestyle medicine the importance of how we manage our own minds. I want to thank all of the panelists for the very valuable lens which they brought and all of the content which they shared today and I also want to thank you panelists and thank you to all the attendees for all that you do for yourselves for your patients and for your community throughout this COVID pandemic and looking forward to as you're saying preventing but burnout and preparing for future pandemics and so looking after wellness wellness in our communities in our patient population and in ourselves. I would like to now address some of the questions the webinar is designed to go for another 20 minutes but ideally we would just go for another five to ten addressing these questions. I also again want to say my name is in Rosy Magarita is Zinua. I am the YDM lead for Holaris and for the Young Doctors movement of North America and I am I encourage you I am very open if anybody wants to reach out if you look around to all of these panelists and you look around to your colleagues around you you look to your patients we need to as Rohini said we need to do this together and the social interaction is really important so now we are your community so please do not hesitate to reach out and with that being said everybody give a hand for the panelists and now we can move to questions and again Rohini Parisha who as a medical student has been multitasking has brought some of the things from the chats and into questions I've jotted down a few as well and I also want to say that Rohini is the up-and-coming leader of Polaris as well so I want to welcome her and I want to thank some of the outgoing leaders in the area especially Erefin and Dr Oteju as well and there may be others among us so I want to thank you all for your service. Right questions so one was the first one actually was about the fear this is addressed to Dr Oteju whether you could just speak for one or two moments about the fear of COVID whether this was different to or similar to the fear of Ebola and also there was a later question about cost the cost to the patients of not addressing their non-communicable diseases in this time and whether they're in the impact of absence from the clinics I know that's a lot to answer so we'll go to Dr Oteju and then we'll open the floor to all the panelists so you have about a minute to speak with Dr Oteju. Thank you very much. Yes concerning the fear on the first wave actually the fear of COVID was quite high because there had been a lot of anticipation especially in my district because like I said I'm in the rural district and we didn't we were the last district out of eight to get heat by COVID and then our numbers just went up so there had been a lot of anticipation and fear coming so after the first wave and which went up about three months subsequently the fear for Ebola was actually higher and that was reflected even in the uptake for vaccination okay because you realize you found out that you know COVID kind of discriminated it was affecting the elderly more and those who already had underlying illnesses but Ebola didn't fear anybody okay and then the symptoms of Ebola were so vivid as well and it perfected in the vaccination because now we also started just about four weeks after the the COVID vaccination started Ebola vaccination also started in Sierra Leone and we're having a higher uptake with Ebola vaccination so that's concerning the fear all right and then a lot of people were also recovering from COVID even though we had some deaths quite a number of deaths but for Ebola it was very bad most people that had it didn't recover then concerning the impact oh yes we did notice because now people were coming in for the regular for the other illnesses the acute illnesses they especially the HIV TB you know the chronic communicable illnesses and whether the restrictions because of the restrictions transportation and all of that by the time those lifts set up and people started coming back people were coming in with complications we had people coming in with worsening heart failure and then for those who are there there's some people coming with resistance to the medication they went on because they didn't come for their medications and the community health workers that sometimes we used to send out there sometimes was difficult to reach them so yes there was health costs concerning that wonderful thank you I want to open it up to the other panelists and I also wanted to say number one thank you to Dr Brando Cantu and to Dr Chloe Chandnam because they have patiently been translating whenever the need arises into Mandarin and into Spanish if anybody does have a question and they want to type it in their own language we will do our best to address that as well and we have many languages covered with our panelists so thank you Dr Otage that was a really comprehensive answer would anybody else like to speak to either of those questions so I would like to say here in North America that the impact of non communicable diseases on their coming back to the clinic has been huge so people did not come to have their diabetes or their hypertension addressed for some for over a year and despite the rise of tally health some people have more affinity to tally medicine than others and some of our lovely grandmothers and grandfathers and great-grandmothers simply don't have the ability to you know interface with tally medicine at this stage so it has been a huge challenge and now we're playing catcher anybody else want to speak to this I am going to open a can of worms now because I first would invite Dr Kinley Booty to speak to this question because it was really in response to her talk and that the response to vaccination after this I'm going to go around and ask each person the response in their context to vaccination because even I mean where I am it has been very mixed so Dr Kinley up to you okay thank you very much Dr Marguerite the vaccination of the first vaccination we received Covishield from government of India which covered whole of the population in March 2020 where our country had a mass rollout of vaccine campaign but then we were supposed to receive the second dose by the end of June that is considering the 8 to 12 week gap but because our neighbor India was having was very much in trouble because of the overwhelming increasing number of COVID patients and the rising trend of the deaths we were not able to receive the second dose from government of India because they were in need themselves but our government explored various other majors to receive the second dose so on the second week of this month our country was very lucky to receive various vaccines from the I think from Germany we received several doses and from government of China and also we so this time we received mainly Modena so Modena I'm sorry the pronunciation is a little different so so our country is considering the mixed mode of vaccination so most of the people are waiting for Modena but some people but our country were very people were very lucky that we have an option to receive AstraZeneca also since we have some of the vaccines received from other countries thank you and most and most people wanting to be vaccinated and were most of the first vaccines were they Pfizer rather than Modena or no the first vaccine was Covishield Covishield also I think that's the same as AstraZeneca produced by the government of India so most of the people in the first of eligible ones almost 95 percent of the eligible population were vaccinated in the first vaccine rollout and till now today is the fifth day of the second back national vaccine campaign rollout so we have almost 80 percent of our population vaccinated so it's mainly because our country is a small country which has a very strong belief in our his majesty the king who has far-sighted knowledge on the pandemic and also our prime minister who is also a doctor so our people maybe it's because of the strong belief in the government and our king that people have come forth to take the vaccination on their willingness thank you interesting thank you very much and I did not know that your prime minister was the doctor thank you that is very interesting what have other people's experience been with their population and whether people want to be vaccinated I invite the panelists to speak and attendees can type in the chat so just as a bit of a Canadian perspective I think that as Dr. Bhuti was saying as well there's a bit of a mix currently in Canada around 70 for just over 70 percent of people have had one vaccine dose of which about 55 percent now are around double vaccinated so when I think the main thing in Canada is that there can definitely be fear and sort of fear of the unknown is what I want to call it where we don't have the education and the knowledge about certain things sometimes we can perhaps make assumptions or listen to whatever we hear first and I think that the having sort of the important education and the knowledge where people can make their decisions has been very helpful it just sort of to give you a bit of a timeline on how things kind of rolled out so the Pfizer and the Moderna kind of came out first in Canada and AstraZeneca was soon to follow and there was when it started off it was given to those from vulnerable populations those being in like the long-term care homes to try to limit the transmission of spread there as well as to our frontline workers and there was a four-week gap between when you could get your first dose of Pfizer and Moderna to your your next dose and that was changed shortly after from extending the gap and I know that that created some fear as well for and some hesitations for some of Canadians and then as well as it was announced that mixing of the AstraZeneca with a Pfizer or Moderna was approved in Canada and so some people went ahead with it and then I know that some people as well were a bit concerned about that and have waited as a result but overall quite a few people are positive towards getting the vaccine and I think that having the education and sort of constant awareness about what's going on and what are the benefits and of course making sure that people understand that there are risks with everything too so that people can make an informed decision has been very helpful. Thank you. What are other people's experience in their own country? I would like to talk. I am Hanne Moussa. I would like to talk about our experience of vaccination in Jordan. Actually at first introduced by the end of December 2020 as Dr Rohini said people they responded differently a lot of fears were raised a lot of rumors were spread around regarding the side effects of vaccination so people they were reluctant to accept the vaccination. At our Ministry of Health they designed a platform and through which we can register to take the vaccine. They prioritized the vaccination first they were given to the healthcare workers and elderly with comorbidities. They were prioritized over other population. Vaccines they were Sinopharm and Pfizer they were given as we know two doses the interval was three weeks but they extend the dose interval later on then actually it runs rapidly a lot of people they are vaccinated now almost four millions of our population they are vaccinated response it's nice now they are reassured from the when they share experience of each other so they get reassurance from sharing experience and they respond nicely now to the vaccination. Thank you. Wonderful thank you. I can share that here in the United States our vaccination our completion of vaccination rate is only 53%. So Bhutan is doing a lot better than us despite the fact that we have access to many of these vaccines we did a tiered approach as well depending on acuity and need with healthcare providers near the forefront and non-communicable disease and then by age as well and we have access to the Pfizer, Moderna, the Johnson & Johnson, AstraZeneca but there have been a lot of mixed messages and it's actually the underserved populations within the United States that have the lowest vaccination rates who arguably are the populations which need it the most. So African American, Latino and low income populations are the ones who have the lowest vaccination rates so it is an ongoing challenge and the messaging has been really important I think it's really important for people to hear from us as family physicians and as trusted healthcare workers also depending on the vaccines. Yes Dr Ateju. Okay yes like I said earlier our Ebola vaccine was rolled up a few weeks after the COVID vaccine because we also had a Ebola outbreak in the neighboring country just after the first COVID wave and the uptake for that is so much you know higher. Now the numbers we have so far for Sierra Leone is one percent just one percent yes of the population has been vaccinated it started with the healthcare workers as well all right and even among the healthcare workers there were so many rumors and you know a lot of myths and hair stays and we were even I must confess we were a bit skeptical especially because you know it's a new technology and also you know so we had SinoFirm and AstraZeneca available and many of us actually decided to go for the SinoFirm because it was the it was using the old method okay basically compared to the DNA but most of the healthcare workers still got it so again we come back to the access because we didn't have we don't have so many vaccines available for the population because they were all donated but even for those that were donated a lot of people were reluctant so right now we're about one percent vaccinated. Thank you, yes, Jose. Well here in Mexico it's kind of surreal because in rural areas population wants to be vaccinated they look forward to the vaccine now we started with the Cancino and the Pfizer-BioNTech and we've continued with the BioNTech vaccine as well as AstraZeneca and SinoVac. Oh in Mexico City they actually have AstraZeneca, BioNTech, Pfizer and Sputnik but it's like I said it's surreal because in the cities a lot of people have have lots of fears unfounded fears and there are even doctors the medical community is like divided into those that are telling the population to get the vaccine to get vaccinated and take care and the other half is telling them that they have to be careful but they should x or y do regarding the vaccine because of the side effects. Now at least in my population in the state of Veracruz that is south of the country older people want to be vaccinated they look forward to it almost 70 percent of the population above 50 years is already vaccinated but talking about young adults from 18 to about 45 or 49 years we've only vaccinated 32 percent of the population so far and not because there haven't been enough campaigns I mean there have been very mischiefs regarding that but no there's people that they don't want to like they are just waiting for this to to have to go away suddenly out of nowhere and that's where we family doctors are trying to insist and convince them that it's totally safe that it's really really recommendable for them to do it and in order for them to take care of their loved ones they should actually do it so it's it's a it's an ongoing battle that we have against these beliefs and these fears that the patients have. Thank you it's so true in so many different ways yes we have one minute so I'm Erefin or Azdan both of you if you would like to contribute that would be great yeah please thank you very much well thank you very much I just agree with my colleagues because yes in Turkey there was Sinovac first of all and the healthcare workers just vaccinated two doses afterwards Bianca just came into the stage and now some of us and also the ones who have got priority about the ages and also the teachers and so on now being vaccinated Suputnik is just a question mark because the government says that this will be just in the new stage that will come but not again no shot has been done so far but maybe this could be so we were a little bit much more lucky to have some more options for the vaccination but as my colleague said the same thing is just going in our country too but the citizens are just getting their appointments and just the vaccinations could be done in the hospitals and also the family health care centers so that's a chance for you and it's a chance for us hi thank you very much I just want to add a little bit about Indonesia so there is 21% of our population who have been vaccinated and they have got the first doses and the second doses there is only eight percent of our population who have been vaccinated for the second doses and our target is 165 million people who will be vaccinated and we have 270 million people in Indonesia and we also have the same problems with any other countries especially based on religion issues so it's all about conspiracy theories we also have that problem generally we know that 76% of the vaccines are being used in high economy countries but low middle income countries are just getting 16% of the doses so that's the problem of I mean that is a huge problem yes no I really appreciate and you are absolutely right and what in a perfect place to really close because I think that the ethics of vaccine distribution and a vaccine uptake illustrate everything that we have spoken about today and again I thank you all for being here both attendees and panelists this is a phenomenal community and I really think that together we can shape the future not only of family medicine but of the global approach to a pandemic like this so thank you all and good morning good day good afternoon and good night to you all we'll see you soon bye bye thank you