 Hello. Good morning. Good afternoon. Good evening. My name is Dr Kim Yu and I'm excited to be here today. I am the convener for the Special Interest Group in Health Equity for Wonka. I am joined here by multiple of our young doctor movement leads and excited to share with you health equity around the world. Dr Sankar Randene Kumara is here to give an introduction and Dr Zainab Muhammad is also here as well as several others. And so I wanted to share a little bit about our Special Interest Group on Health Equity. Our Special Interest Group really focuses in on providing support, education and really thinking about what are the things we need to do to be able to bring health equity to our nations, to our countries, and how can we share information that will be important for us to be able to move the needle. We have done lots of work when it comes to the health equity, as you can see in the following slide. We move forward one slide, including health equity trainings, implicit bias trainings, and have done collaborations with WHO digital media teams and others when it came to COVID vaccinations and misinformation about the COVID pandemic. We are working on a series of health equity cross nations lectures that we have been doing at previous Wonka meetings, and looking at health equity impact assessments which you'll hear about later today as well. You can see some future plans there and lots of us will meet at the Wonka World Meeting in Sydney and also in Wonka Europe and other regional Wonka meetings. And so I'm looking forward to meeting you there at those meetings and also several others who are very active on our Wonka SIG including Dr Viviana Martínez Bianchi, and Joy Magambi from Africa and others that you saw in the photographs previously. I'm going to pass this time on now to our Wonka YDM leads. Dr Zena, would you like to take over? Thank you. Thank you, Kim. So thank you for the wonderful introduction and thank you also for collaborating with the SpiceDude for this webinar. So I'm sure we're going to learn a lot from you regarding health equity and all the presentations that will come forward in the webinar today. Yes, I am the Wonka SpiceDude Chair for South Asia region. So this is just a small introduction of what SpiceDude is all about. So these are kind of kept flags and a picture of flags that all the countries that are involved in our region, which are a part of SpiceDude, Sri Lanka, Sudan, Nepal, India, Pakistan, and Bangladesh. So these are the active members of the SpiceDude movement. And we have, so this is a small picture that I've kept showing how we conduct our regular meetings every month. It's on the second Sunday of each month where we keep our regular meetings and discuss the ongoing activities that you want to do in the SpiceDude movement. So we have, yes, we have Dr. Gobi, Dr. Seryan, Dr. Asitad, myself, Dr. Gunjan and Dr. Rohan. So we have a couple of people who also would be a part of the webinar today also and who always work proactively for the SpiceDude movement. Moving ahead, I have just shown a picture of a couple of activities that we do nearly regularly on every monthly or quarterly basis, which involves regular CPD activities which have been done by all the various countries of the SpiceDude, as I mentioned. So a couple of activities are done by India, which they conduct classroom sessions every monthly. So we have lounge sessions by the SpiceDude team Pakistan. So we try to conduct CPD activities with the young doctors and then we have GP's cafe from the Sri Lanka side for the young doctors. Also we have physical FM 360 exchanges and a couple of these exchanges had been done previously before COVID, but after COVID the physical exchanges were gotten limited. At that time we tried and arranged the virtual FM 360 exchange programs and then we did a one with the European young doctors movement and there was one we did with the Raju Kumar movement. So that was one good experience where we tried to explain virtually how the family medicine or how a GP practice is done in other regions. So those are some of our ongoing activities. We try to organize regular webinars in collaboration with other SIGs and stuff. And along with that we try to collaborate webinars with on important days like for example, diabetes, cancer days, world diabetes day. There was one which was conducted previously done by the SpiceDude movement Sri Lanka, which was hosted by the SpiceDude movement Sri Lanka. But it was a regional webinar on the world safety day for health at work. So that was one good session that all of us had attended. Also we provide scholarships for the young doctors in order to attend Wonka conferences because that's one thing that we believe that it's one platform which unites us all as well as it gives us great opportunities to meet. So young doctors to meet new people and meet young doctors from other regions and other countries. So that's one good experience for them. We arrange, try and arrange scholarships for them. Also, we have a SpiceDude Star Award. So the winner of the SpiceDude Star Award then goes on ahead to as a nomination for the Wonka World Rising Star Award. So these are a couple of ongoing activities. And that's about it. Thank you so much for letting me speak for a couple of minutes. So hopefully there'll be a pleasant experience ahead and hope the webinar goes up really well. Thank you. So I think it would be over to Naseem for introduction of Dr. Nicholson. Thank you very much, Dr. Zalena. Can you all hear me? Yes. Okay. So I'm Dr. Naseem hosting the webinar today with Dr. Kim Yu. I belong to Islamabad Pakistan. I'm working as a family medicine consultant here. So welcome you all on board. I would like to now begin formally the program starting with Dr. Nicholson's presentation. Dr. Nicholson is a family medicine specialist at the Anika Health Clinic LANG under the Malaysian Ministry of Health. She's a fellow of the Royal Australian College of General Practitioners and a member of the Academy of Family Physicians Malaysia. She has been serving in primary care for the last seven years. Welcome on board Dr. Nicholson with your presentation. Thank you, Naseem. Hello everyone. Thank you for joining us here today. I'm Marina Anthony Nicholson, a family medicine specialist from Malaysia. Today I'll be speaking on the importance of committee engagement in promoting health equity. Next slide please. Here is the outline of my talk. Firstly, I'll paint the picture by defining some common terms. And then I'll speak about the importance of committee engagement in promoting health equity, the heart of this talk, and finally I'll share some examples of committee engagement. Next slide please. Let's start with the first part. What is health? Health is a state of complete physical, mental and social well-being and not merely the absence of disease. What then are health disparities? Health disparities are preventable differences. The keyword here is preventable. In health outcomes experienced by specific population groups, these outcomes may be measured by indicators such as disease prevalence and mortality rate. These preventable differences may be caused by social factors such as unemployment, education status and housing. So these non-medical social factors that influence health outcomes are termed social determinants of health. Next slide please. When these factors cause unfair outcomes in people's health, it's called health inequity. Health equity, on the other hand, is what we aim to achieve when everyone has the opportunity to be as healthy as possible. Next slide please. Here's how these terms are related. Social determinants of health, which are the conditions in which people live, work and play, lead to health disparities, preventable differences in health outcomes, which in turn may result in health inequities, where one group is unfairly disadvantaged as compared to another. Next slide please. Here's my favourite slide. This picture shows how health equality is not the same as health equity. Health equality as seen in the upper portion of the picture is providing everyone with the same bicycle without considering their ability. A grown man, a teenage girl, a child and a differently able person are all given the same bicycle. Equal distribution of resources does not reduce equal outcomes. Some people just need more than others to achieve the same level of health. In the lower portion of the picture, that picture explains health equity. As we can see, each rider is provided with a bike that matches their sizes and abilities. When provided with specialized bikes that were tailored to their needs, everyone was able to achieve the same outcome. Next slide please. So then, how do we make health equity a reality? Having painted the picture, let's move on to the second section. The role of community engagement in achieving health equity. There are three critical practices identified to advance health equity. Strengthening the capacity of communities are among the three. Next slide please. Health equity is a complex problem and it may seem like we need complex solutions to solve the problem. However, in reality, the answer lies simply by utilising existing resources. What then are these existing resources and how do we utilise them? Number one, by strengthening our existing primary health care platform. And number two, by engaging the community to bridge the gap between health care systems and the people. Next slide please. To engage your community, we have to engage the stakeholders. So who are the stakeholders? The stakeholders include political leaders, health care workers, religious leaders and many others. No man is an island. Everyone is part of a community. We too are all part of a community at hand. Every single person here may play their part in promoting health equity. Next slide please. So now that we have an idea of who our stakeholders are, what are the advantages of engaging them? The three main advantages are, number one, because community members know their community at its core, it enables changes within the community that can lead to health equity. Number two, it works with building health systems that are sustainable and efficient. And lastly, community engagement promotes involvement of the community in public health programmes. Next slide please. Having identified the stakeholders and benefits of community engagement, how do we do this practically? So there are four main approaches, each with increasing levels of community engagement. Number one, community-oriented. Number two, community-based. Number three, community-managed. Number four, community-owned. At the level of engagement deepens, the leadership, knowledge and skills of these community members increases. So let's explore each approach further. The first approach is community-oriented. Here the community is informed and mobilised to participate in a concern with strong external support. Next slide please. The COVID-19 vaccination programme, which in many countries requires community participation to curb the pandemic, is perhaps the fastest example of community-oriented approach. Another example, in Malaysia, we have the National Health Training Initiative. It's run by the government, country-wide, and is aimed at screening those above the ages of 18 for non-homunicable diseases. It's often done as an outbreak programme at parks, shopping malls and factories with resources supplied by the government, until most officers here have our own relatable examples in our own country. Community-oriented is a very common approach and many public health engagement efforts are focused at this level. The second type of engagement, community-based. This is a deeper level of engagement. In this approach, the community's concerns are heard and they are consulted and involved in decision-making. Interventions, too, come from within the community. Here, external support is minimal. Some examples of community-based approaches in my country are, the community's views are heard when locating health clinics, having templates available in local languages, and engaging translators at healthcare facilities when dealing with patients who do not speak the same language. Also, most of our primary health clinics have an advisory panel which consists of community leaders selected from the local area. Regular meetings are conducted between health clinics and these leaders to listen to our community's voice. Many health promotional activities such as cancer screening programmes are also organised by these advisers, and they are held within our community with support from the government. Often, these leaders are also recruited to help address misinformation and myths among the communities. This is useful because these leaders know their community best and are trusted by them. The third approach is community-managed, where there is collaboration from the leaders of the community and decision comes from the people itself. In this approach, there is a higher level of engagement from the community as compared to the previous two. Issues concerning this approach are issues concerning pre-requisites for health, such as lack of housing, water sanitation and unemployment. Here, the community comes together, prioritises issues affecting them and comes up with solutions. Next slide, please. Next slide. Thank you. The fourth approach, community-owned, is when community assets are fully mobilised and the community is empowered to develop their own system and sustainable mechanisms for health promotion. Here, external support is only part of the network. Problems that can be addressed using this approach include environmental degradation, climate change and poverty. For example, the community is involved in the law of policy-making process. Community-owned is the highest level of community engagement. To summarise, there are four main approaches to community engagement, each varying in the level of community involvement. Nevertheless, it is important to remember that different problems require different approaches. Having set out the what, the why, the who's and the house of community engagement, in conclusion, communities have the power to help their members achieve health equity and they should be empowered to do so, more power to them. I'll end my talk here. If you have any questions, please feel free to email me. Thank you. Thank you so much, Dr. Nicholson, and we are excited to have our next presenter, Dr. Hanine Moussa, who is a family physician at the Jordanian Ministry of Health and is the Alrazi representative of a Jordan team. She's a trainer for healthcare providers on intimate partner violence, a clinical supervisor of educational programs for family medicine residents, and actively involved in awareness campaigns. Thank you, Dr. Moussa. Thank you, Kim, for this nice introduction, and thanks to the Spice Route Movement and Wonka YDM to organise this webinar. I will talk about the role of technology in promoting health equity, and as we are addressing the equal access to healthcare services in improving health outcomes and having better quality of life, it's important to talk about how does technology promote health equity. Next slide, please. Next slide. First, by expanding care access and reducing billing of state. So virtual visits actually, they address the time and transportation costs and follow up their patients throughout the care journey, not only expands the care, but also opens up more beds for patients in need in critical care. And actually, when the patient's primary healthcare provider connects with the specialists virtually, it will provide immediate diagnosis and a treatment plan rather than referral that might delay the treatment. Next slide. Next slide, please. Promoting patients to report social determinants. No, no, no. Promoting patients to report social determinants of health, like food insecurity or healthcare access barriers that care team is empowered to intervene when needed. This study, for example, concluded that text messaging, it's an efficient way to communicate with patients during the COVID-19 pandemic. And it also applies even after the end of the pandemic. So communication with patients through technology provides emotional support, through encouragement, detect transportation or childcare issues that impede in-person visits, assist access to food, identify medication on adherence due to cost issues, and provide education about diseases with short videos and graphics. Next slide. Enhancing patient engagement. Actually, according to the CDC, growing number of evidences shows that more engaged a patient is more likely to have better outcome. So digital health increase the engagement by providing better understanding of the patient's health condition and avoid confusion in the care plan. And when designing the digital health tools, many issues should be considered, like the patient-centric design. So the digital health tool should be flexible, consistent, and user-friendly. On the channel strategy, digital health tool should provide many options to respect to patients' preferences. So we find patients prefer emailing, others prefer to be engaged in social media. Multilingual and cultural adaptation, and this is important actually for companies, global companies operating across different regions. So high-quality translation should be provided to improve the health literacy and increase the access. Diversity, equity, and inclusion, like text size, font colors, ease of use, guidelines like the website access guidelines, which actually should be available to all regardless of ethnicity and disability. Next slide. I guess there's one before about capturing more accurate data to provide more targeted personalized care solutions instead of general information. Next slide. Experts agree about many of technology benefits, but as well as there are some challenges have been identified and we need to deal with it specifically, like the additional costs for families, building trust between patients and healthcare providers, accuracy of the information published. Next. The increasing complexities and uncertainties of both digital technologies and health make the landscape of digital health uncharted territory in terms of research. So digital health, it's a new research area and we need systematic approach, systematic research to understand, to have better understanding of the effectiveness of digital health in improving health equity. Next. Many journals actually provide the platforms to public research, to publish research in the field of digital health, and they also provide an open access to content to all stakeholders responsible in the digital health care, like frontiers in digital health. Next, please. Next. Like frontier in digital health and Lancet digital health. Briefly, I will talk about digital health tools in my country, Jordan, previous slide please. I have many digital health tools in my country. First of them, Hakim, which has been launched at 2009. It's a computerized record system for patients through which the primary healthcare physicians can navigate lab results, imaging notes of the patients without missing any data. So we can stay on the track with our patients. And the patients can sit on appointments through many sites, one of them Hakim, another one called at Zubbi. Another program called HDA, or Huda, through which patients can review the lab results and have interpretation, so they have better insights about their disease. And patients with the chronic disease, they can receive their monthly medication by ordering them on Hakim, and so they receive it wherever they are. Finally, as technology and telehealth continue to grow and advance, it's important to ensure that no one is left behind. Thank you very much. Thank you. I would now like to invite Dr. Gabriela Pesensia for her next talk. She is a family medicine practitioner, currently a post-doctoral fellow with the National Clinician Scholars Program and clinical associate faculty at Youth Department of Family Medicine and Community Health. She has a master's in applied science in population health management and has used this training to lead community, engage research to map systems, their assets, and evaluate the impact they have on improving community-level outcomes. Thank you for joining us. We welcome you, Dr. Debraida. Hi, everyone. I'm happy to be here, and I'll be presenting on social determinants of health. I'm just waiting for my slide to appear. Yes, there it is. Thank you so much. As Asim said, I am Gabriela Pesensia, family medicine doctor in the United States and also a post-doctoral health equity research fellow here at Duke University. Next slide. Thank you so much to what some of our other presenters have done. I just want to set the stage with some terminology, especially here in the United States. We've had an evolution of the terminology that we currently use, and so I just want to share how we currently talk about social determinants of health. Social determinants of health is the more traditional term that has been used. It's been defined by WHO as the conditions in which we live, grow, and the outer structures like systems and policies that affect that. And so the issue with this terminology is that determinants is a very fetalistic term, meaning that individuals have little power in changing what happens in their future because these social factors are determining what happens in their future. And therefore, there's been this change to discussing more social drivers of health rather than determinants of health, meaning that these drivers can influence or impact their health outcomes, but there are things that individuals can do to change that. However, social determinants or social drivers are not positive or negative inherently. Some people are born into conditions where they work, live, grow that are positive. And therefore, talking about social risk factors truly identifies which ones of those factors are negative or can have negative impact on their health. And finally, not all social risk factors translate to immediate social need. And so social needs are what people need in the moment to improve their health. For example, if they have housing insecurity, food insecurity, those might be things they need immediately, whereas if they're having trouble paying with their utilities or transportation, but they have someone who's helping with that right now, that might not be a social need in the moment. Next slide. So social risk factors, just to go through them, I think many of you could think of these examples in your own countries. So I just want to describe how this played out during the pandemic here in Durham, North Carolina, especially in the Latinx population here. So for example, transportation, a lot of the Latino, Latinx community here in North Carolina was essential workers. We have a lot of people working in factories and agriculture and restaurants. And so people relied on public transportation and during the pandemic, public transportation had less routes. And also, you know, the people using it for the most part were essential workers that also had limited access to protective equipment, masks, etc. And so it was just a higher risk situation for everyone. Access to food in the United States, there weren't national programs to help people get food to their homes. And so if someone tested positive for COVID, either they had to break their quarantine to go get food at the grocery store or stay home with limited amount of food. And housing insecurity in the United States, the price of housing has gone up 75%. Whereas the average salary for an individual has gone up about 50% with inflation. Therefore, the salary hasn't caught up to the rise in housing prices. And therefore housing insecurity is at its highest that it's ever been. And so this is something that has been an issue during the pandemic post the pandemic. And especially for my guys minority populations, access to housing, housing loans and opportunities have been reduced. And then other things that were bought up during the pandemic are things that just access to health care. So in the United States, we don't have a global health care system, and therefore insurance access to insurance is not guaranteed for everyone. And a lot of people, a lot of people, for example, have high deductibles, copays, etc. Or just have general distrust of the health care institutions because of bad experiences they've had, either due to racism discrimination in the institutions. And another access that another access issue that came up was language equity and by language equity. I mean, having interpreters having, you know, interpretive services whether through an iPad, a phone, etc. For people who did not speak English, and especially during the pandemic, as many of you can remember, there were limited amounts of people allowed in the room, sometimes none, just the patient. Now the patient communicate for themselves or advocate for themselves and are relying on a system that doesn't have good interpreter services in the moment and therefore they are completely isolated and removed from their families in that moment, leading to a lot of trauma for these families. And bringing back issues of this about I see those are disappeared family members, which is something that has happened historically for Latino communities in their home countries for a long time. Next slide. The historical context is very important and this is something that is likely not unique for United States, but especially in the United States is important because the countries that people immigrated from and the areas of the United States that they immigrated to and the laws in those areas have a high impact on poverty rates and wealth inequality over generations. And I can share a personal story about how this happens. So around 10 years ago not too long ago I was applying for medical school and looking for housing for myself. My husband and I worked with a real estate agent. She took us she picked us up at the hotel and took us to some of the properties and as she was taking us to these properties. She said, you know, I'll let you I'll tell you this because your husband is white. But traditionally, in real estate you'll see that we don't put up signs for sale or for rent, because we want to make sure that only the right kind of people are having access to these not these homes in nice areas. And I was a little taken aback by that and asked what do you mean. And she said, Well, we want to make sure that we keep the neighborhood safe and protected from people who don't belong here. And so we only put up signs, we don't put up any signs you have to contact a real estate agent to be able to know where these properties are. And so I was shocked by this very clearly discriminatory practice. And so was my husband who is Cuban American and therefore is lighter skinned appears white. But this woman thought that she could say this because my husband quote unquote loved white. So that's an example of how opportunities for housing and being in a safe neighborhood and being in the neighborhood with good, you know, local schooling, for example, is limited to people that have different skin tones or different backgrounds. Next slide. This is an example of a paper showing how the historical context is important. And so, Rachel Hardiman and Tyson Brown are some of the leaders in this research in the United States and this is a paper describing ways to improve measurement of racism in the United States and at the bottom you can see that they mentioned historical context and geographical context specifically. And if you click one more time there's another paper that will pop up. There you go. So this is a paper actually measuring whether health outcomes are different based on spatial and historical racial context. And so they found that yes there is a direct association between the area that people immigrated to and the racial context in that area of history of racial, racial inequality in that area, and how that predicts future health outcomes. Next slide. And so, it's important to think about racism, especially in the United States and there's different forms of racism, but racism is one of the major factors that can contribute to health equity. And so, when we talk about racism, I think sometimes there's a little bit of confusion about the different types of racism. One structural racism, which is the laws policies and systems that are put in place that affect marginalized minorities communities differently. And then institutionalized racism is racism that is more specific to an organization. For example, if your workplace has laws that affect, you know, people based on their race ethnicity differently, that that's a form of institutionalized racism. And then interpersonal racism is what people typically think about when they think about racism. So that is, you know, one person's conscious or subconscious bias affecting the way they interact with others. And then there's internalized racism, you know, when you've been in a system or a society that constantly says that people like you that look like you and from your background are not as worthy or as of value as others. Then you start to internalize that into your own beliefs about yourself and your family and what you're capable of doing, which then leads to further negative outcomes. Next slide. So this is important because it has impact not just on the person experiencing it, but also for generations later. And so I just want to show two quick examples of how this can have multi generational impact. Number one is a lot of studies in the United States and likely outside of the United States have shown that parents who were exposed to a high number of aces or adverse childhood events, when they were children will likely have children who experienced high level of aces of their children. And so these eighths or adverse childhood events it include things like abuse or neglect as children younger single parents are living in communities with high crime rates. And so this is important because you, you would hope that just because one individual experienced it that that would be the end of that cycle but isn't necessarily high level of aces and parents often predicts level of aces and children. This is a mechanism by which mental health and substance use disorders are more prevalent in populations have higher social risk factors. Next slide. Another example of how racism and and social risk factors can have multi generational generational impact on health is epigenetic changes. Epigenetics is changes in methylation, or other aspects of the DNA that occur in response to stress and other external factors, and these epigenetic changes can be passed down inherited and through genetics. And so you can see on this image on the right that, for example, if a mother experiences a lot of stress while she's pregnant. Those DNA changes are passed on to the infant. It can affect the metabolism of that individual, that individual, then as high levels of cortisol insulin and higher blood pressure. And then that can be perpetuated to the next generation and each of those individuals are experiencing their own stress right. And so, in the United States, most individuals are told to report their race and ethnicity. So, by race, usually means white, black, Asian, etc. and ethnicity means Hispanic, not Hispanic. And so, in the United States, if you're, if you're looking at Hispanic individuals or Latino Latinx individuals. There's evidence to show that individuals that are Latino Hispanic descent that self identify as other or black as their race have worse outcomes than individuals of Latino Hispanic descent that consider themselves white. And so, a lot of this might be racialization externally based on skin tone and appearance, and how that impacts the stress experienced by these individuals, and therefore affecting health outcomes longer term. Next slide. One for you. Thank you. So, what are we doing about this? So, at least in the United States, and like many other countries, we're trying to record and track social risk factors using ICD-10 codes. In the United States, traditionally in the healthcare system, there wasn't much focus on social risk factors. And so, now a lot of healthcare systems are trying to invest more in social workers, case managers, and there's an increased interest in community health workers, something that many other countries have had for a long time and shown has great outcomes in the United States that hasn't really been invested in. So, now there's a little bit more interest in that. And then increased engagement with community-based organizations. Again, other countries have been doing this for a long time in the United States. Social and community benefits have always been very separate from the healthcare system, and now there's a growing realization that that is inefficient and ineffective. And so, healthcare systems are trying to collaborate with community-based organizations more. And then, insurance is starting to think about ways to reimburse for addressing root causes of disease. And so, there's conversation about whether insurance is really the right way to promote this, but in the United States, insurance really dictates, right? And so, the government really dictates what happens. And therefore, if insurance can reimburse, you know, hospital systems for investing in sidewalks or parks and neighborhoods to increase physical activity and prevent diabetes, then that saves the insurance company money and saves the hospital system money and prevents worst health outcomes for communities that experience social risk factors. So, that's another potential way of addressing this. And I think that's the end of my presentation. Next slide. The last slide just had my email address, so feel free to email me and also be in one of the breakout rooms if you want to talk about this more. Thank you. Thank you so much, Dr. Plascencia. And we're so happy now to have our next speaker. And Dr. Gobith from Sri Lanka. And so we'll wait for our slides here. And Dr. Gobith is a family physician and visiting lecturer at the Department of Community and Family Medicine at the University of Jaffna in Sri Lanka. He's the in-charge physician at the MCD in a healthy lifestyle department at the district general hospital in Negombo in Sri Lanka and serves as an executive council member of the Wonka Working Party on Rural and also is the national chair of the Young Doctors movement and is involved in the spice food movement as well for Sri Lanka. Dr. Gobith. Thank you for the opportunity and good evening, good afternoon, morning everyone. May I audible? Yeah, okay. So health equity challenges faced by the lower middle countries. That's I am going to talk for the coming 10 minutes. Next slide please. Next slide please. Actually, I'm going to talk about the health definition, but still, we'll talk about the health is the fundamental right to be still the half of the population not receiving the adequate or essential health care services. Likewise, this is a health equity. So we are everyone given the definition but still, we have seen a lot of disparities are there in the month region or in the race or whatever that. So we are going for the next slide please. Next slide please. You want to this next, this one, this next. Yeah, this, this one, yes. Yeah, from this topic, the previous one. Yeah, so from the talks I'm going to talk about some of the disparities in the health and health care one of the lower countries. I'm going to talk about the socioeconomic status and poverty, population and aging, disease burden and health spending and health care system supporting and health information and data. So we will see what we want. So please go for the next slide please. Thank you. This is Dr. have he has talked about much about the health disparity and traveling by the social and economic integrity, even though so I just give the some overview like, so this is not only direct to the health but a lot of other parameters that come on that like stability, neighborhood and physical environment, education, food security and community and safety social context and mainly about the healthcare system, maybe about the, the health outreach and all, please go for the next slide please. Next slide. Yeah, the poverty is a major factor in determining the accessibility and the quality of the healthcare. The poverty and low income status are associated with the various healthcare outcomes, including sort of life expectancy, higher infant moderate rate and material moderate rate. You may have seen the graph like the national poverty line versus GDP has a charted here so all the bottom line the most of the low middle income countries are spotted. Please go for the next slide. This is the second reason maybe the population and aging. You may see the from the first graph. So the from Boris nation have the more jungle population than for the population region. We are they have the mainly with the population. So in the meantime, so if we have this primary like so but population and aging in the in the low middle countries are going as a democratic shift in three times of very fast in going and the permit are shifting from this picture to the elderly population as well with the background, you may have seen the other picture from the population of how the age population having a death and disability among the other region. So even for the decades, so it's still same, the higher death and disability rate in the low middle income countries. Go with the next slide please. Next, oh yeah. So this is the main one for the low middle income country may talk about that. This is burden actually the computer is both demographic and if you don't want to change the software isn't rapid shifting the disease profile in the many low middle countries, especially this transition go from the burden from communicable to non communicable disease. So we will see the some example from the next slide. This is the same picture I have shown previously. So from this given the multiple reasons so maybe the causative agent so that everything converted maybe social economy status, low housing like housing facilities water sanitation food security and health coverage for underdeveloped public health services, everything contributed to the more inflexible disease and malnutrition in the most of the poorest nations. So please go for the next slide. Yeah, why I talk about the infectious diseases that the communicable diseases. Now the pattern is shifting the non communicable disease like even with the in addition we can say assessing the healthy option, healthy, democracy, aging population and a lot of causative has to pack onto the shift to the from the communicable to non communicable diseases in the disease burden please go for that. Yeah, this is a graph that we can see from the given reference so you can see porousness and have the more inflexible diseases compared to the high nation, even from that we can see even the other non communicable diseases also how this charted in the picture please go for the next one. This one again with a double burden so like that's from the pediatric population and the geriatric population has shown the both effect on the infection diseases are moving the red color you may see like a blue color is even moving towards to the the elderly age population. So if we compare from the poorest nation to high nation you can clearly see how the infection diseases and that both even the non communicable diseases and carcinomas of how the prevalence are in the different set up in like this, please go for that. Next slide. Yeah, that did that so we already talked about the poor social economy status and health expenditure and this is burden, even though that the government health spending for that remain in low in the four nations. So you may know that the average spending for the health in the lower million countries around $23 per person per annum, likewise in the US government maybe that's a 2000 figure 2008 kind of 60 per person, like the UK government spent $2695 per person. So it did like that so already there's a issues they are related assesses to the preventable primary care. So in the poorest nations or low in the countries, it's developed the delayed diagnosis and treatment buys. So in the further burden to the older disease, disease pattern or in the healthcare burdens, please go for the next one. Yeah, this is a chart again so about the how the health expenditure with the GDP, so average $260 per low middle income countries, while the IACs are in 5000 towards a huge disparities about the spending health for that. Please go for the next slide. Again, this is again the last two decade if you see the chart like that's even though we are trying the low middle country trying to put some more effect on to the health financing but still it's not yet beyond the five or 6% of the GDP while the high income countries they are starting from the 6 to now they are going to pass away about the 9 or 10 and so this is the clearly show how this we spending the low middle countries are spending the expenditure to the health data outcomes. Please go to the next slide. This is the final one you may know everything has to even I have mentioned about the poverty or even for disease burden or whatever the financing but everything has to be done by this healthcare system. We should have the proper healthcare system maybe the world's nation have this especially maybe the board that the law spending or whatever that so that they have the very fact that healthcare or maybe underdeveloped public healthcare system maybe having that it may further burden with this age population and with the maybe with the geography pattern and the this was a war and to my own conflict, maybe everything contributed to the more and more difficult with this that health care distancing this, this low middle countries, please go with that next slide. From this now after now we talk about this the all the conditions, what we can what other courses can be contribute for the disparities. So from that so WHO has given that the recommendation how we have to do the building blocks to that so we have to consider the service delivery we had to do even for curative maybe the primary care or maybe the preventive care services and workforce you may talk about the workforce. You will be the developer country may have the one doctor for 520 population while the developing countries have the one doctor for 15,000 population so with that huge disparity with this looking after the care for their own population. Likewise, we can talk about the health information system. This is a very huge topic. You know, I'd already talked about the disease burden. So this is a now around we may talk about 90% of the disease burden come from this is the low middle of country, while the data or the research or the but I put the information to the the world around maybe only 10% from them as well like the even though the who need the grant or anything like that so it has mainly talk about 10 to 9 gap. So actually I'm going to talk one of the this 10 to 9 cap in the one guy Sydney. So if you are interested you can join the as well and and the main important essential rocks actually the list of some of the essential rocks should be available for the older available older population and the world to give the universal cover a but still be unable to provide it that in the low middle country. Health financing I talk about that leadership and governance actually this is a very important one because even though even though they are the course nation may be here a little on the budget for the health expenditure but still their policy sense should be there to to cater the even available sources so that be there. So please go with the next slide. Yeah, so on top of this even though we have talked about disparities are they are low I list out that but this is the pandemic show and the mode spread is what how the world is different from the poorest and highest in during the the pandemic you may know the first picture one of the clinic as we are you may know that we may not receive the adequate PPV so actually this is the PPV made by the one of the one of the couple of the back for the we are used for the garbage so there's a low back use test to teach as a PP like this you can see the other side. There's a one of the nursing officers using the face shield made by the headboard so we are cut down and use it that's how that even for the small usage of this instrument or equipment has to be lack of in the in the lower country especially test very worse on during the covid and we all talk about the vaccine in the equity so you can see actually how the world has purchased the vaccination and that you can see the book and the right hand side and left hand side how they actually need the more than 18, 18 years of older population so how they pump the old vaccine to their countries with the wealthy nations. In the meantime, other poor nations are desperately searching for the vaccine or other medication and all so this just for the example for that so that given an example from the beginning of the state as and then all the disease were double burdened because of this communicable and non communicable then the expectation maybe fact went at all and developed healthcare facilities, healthcare system, everything contributed again to the disparities on to the middle income countries. So please go for the next slide. So with that one so then the WTO commission was also determined on the health development mechanism how to do this one with reducing the gap so they have started from the beginning the basic like so they thought of like improve the daily living so without having the proper shelter food and water that we can't be giving the health is impossible so they have to they should like a living condition be improved and like we saw the distribution power money and resources should be allocated equally maybe I don't know how to do that even from the world but still it should be there at least two in the fair manner and also the measuring understanding the problem and assessing the impact action so we should first get the information then only we can go from with that so this is a background so we had some issues and so we have found so what to do like that so please go for the next slide. Yeah, there's also we can talk about so even though that's close a primary care would be answer for the outcome the disparities in the low middle income settings I think really we had talked about clearly about the community oriented primary care other models how we can use it in the low middle low resource setting to overcome these disparities to at least to give us some sort of a junior set of health coverage in the poorest nation and that's for me next time please. Okay, this is up to now so if you have any question we will take in the break out from out there. Thank you. You may contact through this go without to the to the robot out there. Thank you. I would like to welcome Dr. Marina as our last speaker. Dr. Marina is a family medicine specialist from Bosnia and has a governor she's a national delegated national exchange coordinator for Bosnia and EYFDM since 2019. He's passionate about health promotion prevention lifestyle medicine women's health public health and health inequities. Thank you very much Dr. Marina for joining us today. Thank you very much. Good morning, good day and good evening to all of you that's listening now. And I'm going to talk about the impact of racism and discrimination on health outcomes. Next slide. First of all, let's start with the definition of racism. And it can be defined as organized system within societies that cause avoidable and unfair inequalities in power, resources, capacities and opportunities across racial or ethnic groups. It can manifest through beliefs, stereotypes, prejudice or discrimination. Next slide please. The definition of racial discrimination done by international convention on the elimination of all form of racial discrimination is any distinction exclusion restriction or preference based on race, color, descent or national or ethnic origin, which has the purpose or of nullifying or impairing the recognition enjoyment and on equal footing of human rights and fundamental freedoms in the political, economical, social, cultural or any other field of public life. Next one. Next slide. How can it impact on health. There are several recognized pathways. First of all, it reduces access to employment housing and education and increases exposure to risk factors. Here it has adverse cognitive or emotional process and is associated with psychopathology. It also is contaminant with path of psychological processes. It diminishes participation in healthy behaviors and increases engagement in unhealthy behaviors, either directly as stress coping or indirectly we are reduced self regulation. And also, it produces physical injury as a result of racial motivated violence. Next one. Racism is positively associated with poor mental and poor physical health outcomes. Next slide. What are the health outcomes and the diseases that can be affected. Diavascular diseases, hypertension, diabetes, asthma, obesity, immunization, maternal and reproductive health and also child care. Next one. The health care system can be a part of structural racism and discriminatory practices like systemic racism, for example, linked to where services are located or requirement for accessing them. Also like implicit bias, missing for clinical practices, discrimination by health professionals. Next slide. We all know that one of the sustainable development goals is achieving universal health coverage and deleting health inequities that are driven by discrimination. The people that are of global concern are indigenous people as people of African descent, Roma and other ethnic minorities. Are unjust, preventable and remediable. Next slide. What are the actions of primary health care in the improving health equities. It is political commitment and leadership governance and policy framework frameworks engagement of community and other stakeholders. Primary health care workforce, physical infrastructure, medicines and other health products, purchasing and payment systems, digital technologies for health, system for improving the quality of care and researchers monitoring and evaluation are one of the actions that can improve. Next slide. Where is the role of family doctors in deleting racism and racial discrimination in health outcomes. These are the campaign pillars of this year's Wonka World Family Doctors Day. And I would like us to focus on community engagement where we family doctors act as advocates for our patients for our communities and work to address systemic barriers to accessing quality health care. We do it like a promotion of health and wellness in the communities through education outreach and creating community partnerships. Next slide. And for the end, before I thank you for the listening, I would just want to quote a man that you all know about Martin Luther King Jr. that said that our lives begin to end the day when the day we become silent about things that matter. Thank you for listening. Thank you so much Dr. Ivanovich. And we are really excited to have all of these wonderful presentations and wanted to go back to really think a little bit through some of the things that have been discussed in some breakout rooms. Before we go to breakout rooms though I do want to recognize someone very important to our group. Sankar, could you come back on and maybe if we could take the slides down so we can see everyone and have Sankar give a few words before we go into breakout rooms just so everyone knows we will have breakout rooms. Everyone will be in English and Chinese and we will have number three in Spanish. And so for those who require language translation, please go to those rooms. And you can join the breakout rooms after Dr. Sankar gives us a little report. Thank you, Kim. Actually I was thinking of giving the word of thanks but however I think it's better here. First of all, I would like to thank you, Kim and also Zainab on behalf of the Wonka special interest group soon it will be a working party, a special interest group on health equity and also the spice food, the young doctors movement of South Asia for organizing this webinar, YDM webinar in collaboration with the working parties and the sick, the number five on behalf of the young doctors movement. And I think health equity is a massive topic, but very, very important topic and as young doctors who have less discriminations with regard to the regions, other religions, ethnicity or agenda, because we are the people who can lead this, I'm sure, because we are the people least have brainwashed and least discriminations because we work together as one whole unit, right. So, thank you very much and we enjoyed the talks. All five people were very excellent speakers and very informative and covered vast area within 10 minutes time each and everyone I'm very happy. And let's have the discussion going on in the breakout rooms. And thank you very much and enjoy the day. Thanks. Thank you so much, thank you and thank you everyone else. Thank you for joining us if you're joining us on Facebook live and for those who will be catching the recording on YouTube and on Wonka's Facebook page as well later. We want to thank all of our speakers. And for those who have attended the meeting we have had over 40 people just so everyone knows. Join us for this presentation that has spanned many time zones and if you think about the work that we do as family physicians and family doctors throughout the world. We are bringing health equity to every single patient and every single community and every single country that you live in. Thank you for the work that you do. And we look forward to seeing you at the next meeting. Yeah, I will create the breakout room now. Gopit, the one Anna is for, it's Anna Sophia for the Spanish one. Yeah, yeah. Okay, the first one. Okay. And by the government and the and the and the money and the amount and these expertise which is dedicated is still, you know, far less than the actual need. Although many charity and welfare institutions have been set up some private organizations are already working and they've reached the root of areas now as well. Like as family medicine has that we do not have a structured family medicine system, yet in our country all over, except for a few cities for the main cities only. But still, the private organizations which are already, they have started working in the rural areas and have established three systems so that the women so that the women's health and you know the public health in general doesn't get otherwise. So things are, they are, they are putting an effort we are putting an effort rather would say, but still, there's lot to be done. So, they are just trying to collaborate with the, with the health care with the authority of our country, and they're trying to make things possible, particularly with respect to family medicine because obviously primary healthcare system is the backbone of any community. So, we are trying to establish that that in our, in our country. Thank you, Naseem. Thank you for your contribution. And now I think it should we go on to group room to. So room to I guess honey was a facilitator there. If I'm not mistaken. Hello everyone. I point the group a little bit late. So I point, but we'll discuss points regarding my the lectures I have about the to equip the digital tools and promoting health equity. I think this will make the will increase the access to health care services, especially in a middle and low income countries by providing hot spots to access the care through them. We should provide the families with the tools and network to make the health care services accessible via digital tools. I would talk about the disparities in health care services due to social economic status and we should work hard by make the insurance coverage more comprehensive. Thanks, I mean, thank you so much for your contribution and for your discussion. I'm sure it must have had the audiences also moving on we have a group room three. I think in my list we had Gabriella in room three so but I'm not sure whether that was the real room three or not. Yes, that was our room. And so we had several questions about the presentations that we discussed including which social risk factor is most important out of the list and at least in the United States with a lot of evidence to promote addressing housing insecurity and that that then improves other social risk factors however it all is based on people's individual social needs and so if housing you know they're sleeping on someone's couch, then they may not need housing specifically in that moment they may need food or transportation We were also talking about specific recommendations for integrating social risk factor care into universal health coverage. And so the most important first step to doing that is getting policymakers and decision makers interested in doing that, because if they're not interested, then there will be little community engagement and therefore effectiveness of those programs. And so trying to discuss how to get decision makers and policymakers more interested in community engagement and integration of social risk factors in universal health coverage is key to making that happen. And we discussed what ACEs or adverse childhood events are most important to address. And that one there is no specific data or research to say that one is more important. But of course remembering that this is from the lens of a child. So anything that affects a child directly or that affects the parent's ability to care for that child is something to focus on. And of course, trying to improve all of them as best as possible, which is very hard. So those are some of the questions we discussed in our room. And thank you everyone for the participation. Thank you so much Gabriella for the wonderful discussion that you have done and facilitated on all the talk and all the contribution that that you have done for the webinar. I loved your talk also moving on to room for I think it was go bit. No, it was, I think it was us myself Sankha and Nick, and Madina I think all of us were in room for if I'm not wrong. Yes, right. Yes, we were in room for. So Maria, do you want to go ahead. Regarding what we talked about. Yes. First of all, we didn't have much time but as we discussed we discussed that the people of some ethnic groups and minorities living in some countries, even that they have the access the full access to health care. They do not use it because they do not know their rights properly. So we need to communicate with the leaders of those minorities to get them know what they have and how to improve their health. And what we also started to discuss was the trust that we need to gain with those ethnic groups in order to improve their health. And if I add something, it's all about how social determinants of health would affect health outcomes I mean, even you have total access to health and health equity. And there are no discrimination still, there would be problems if the other factors have problems like education just as Maria taught correctly. Yes. Okay. So are there any other rooms or I think we were done with room for rooms I guess because I think a couple of participants had kind of Yes, actually that the, we have closed down the fifth and fourth to six, because there's no participant. I was there only in the fifth. But anyway, I think only four has discussed that I think we had a great discussion even here just into that from the whole fall. What do you line up. Okay. I think let's move on with the five ones. So I think we are about to end the session to for today. And it was wonderful connecting with the SIG on health equity wonderful connecting with Kim and everybody who is associated with that special interest group of health equity, I think that was, it was a wonderful, wonderful session. And I'm sure all the participants have attended the session today they must have had a good time and they must have benefited with all the conversations and all the talks that the speakers have given. Thank you so much, Gabriella, Dr. Marina Nicholson, Dr. Marina Ivanovic, Gobit, and honey, honey, yeah. So, all of them for contributing and agreeing to do such wonderful talks, which have benefited the speakers, which have benefited the participants for today. So I would like if I can't see him, if she's anywhere, let's say a few words. I am here. I am here. Okay, okay. I just couldn't say. Let me just, if you can take a good picture of all of us. Sure, that sounds good. And I did want to let everyone know that those QR codes that you see there are for different projects that the special interest group in health equity is doing. We will also be reviewing those at the Wonka Europe meeting in Brussels, Dr. Viviana Martinez Bianchi, who you can see right there, Vivi. She will be representing and hosting that meeting. So if you will be at the Wonka Europe meeting, please do join her at that meeting. And if you'd like to actually be a part of it. Please do scan those QR codes, which Zaynab, if you could go back to those QR codes, that would be great. They are three separate ones, and we will be sharing this information too in the YDM groups, so that you can have this available to you. The first one is just the link, which you can find on the Wonka website if you just Google how to join the SIG on health equity. You can join there or scan the QR code. The second one is a more in depth interest form that will let us know your interests in health equity. And then the last one is actually doing health equity impact assessments and a survey that we are doing for that. We'd love to get more involvement from all of our YDMs and all our Wonka members throughout the world. And I am excited that hopefully we will see you in Brussels or in Sydney, and I'm going to pass this back to Zaynab. Okay, thank you, Kim. Thank you so much. Thank you, everyone, and thank you, especially our translators Sheryl and Anna for doing a wonderful job, for doing a wonderful job. Thank you so much. So I was, so we are about to end, so I was just saying if you could have a nice picture of all of us, it would be a good remembrance. Thank you so much for joining the share and so that we can have a good picture. And there are a couple of people who haven't turned on their cameras but that's fine. Thank you so much, everyone. Thank you so much. Thank you. Thanks a lot. Thank you. Salam. Thank you very much. Nice. Thank you. Thank you. Thank you very much.