 I have some few quick comments on how important it is to look now differently about how to respond to different sorts of emergencies, crises, and how the humanitarian response system now starts to engage in this discussion about chronic diseases. One comment that I want to raise is about all that interventions from, you know, heat instability for insulin or MI intervention, motivation interviews among Syrian refugees for. Mostly all that interventions are not functioning in a vacuum. There's a lot in the new crises of political determinants. There's a lot of social determinants. There's sort of tension sometimes between, you know, refugees and hosting communities. There's a lot of sometimes having like a parallel system, you know, with the national system. A lot of, let's say, overlapping research, you know, or fragmented research, and sometimes without any evaluation component when coming to, you know, big organizations and U.N. agencies. So there's a sort of complex factors that sometimes need to be considered while thinking about long-term interventions or long-term health access when we have such a sort of protracted crisis. I would like to open the discussion now for, you know, so the lady here and then you'll be after that. So my question leads on almost from your comment there, so Emma King in MSF UK. So how do you address questions about sustainability of that level of intervention? So say MSF's not going to be there forever and handing over safely of a project that gives quite a lot of intervention. How do you address those issues? So let's start from Beatrice if you want. No, no problem. So yeah, I can start by that. So of course that's an issue, but I think that's been, if you decide to take the decision of going into non-communal disease care, as MSF did 15 years ago when it comes to HIV, there was a big controversial debate. Are we supposed to do this? But now we're doing HIV projects when we only, when in the very unstable settings where we can only guarantee maybe being there for six months and we're, we can look at, we're filling into a gap of a health need. And even if it's a one-year or two-year gap, we're still affecting mobility and mortality in terms of, yeah, do you want to fill in? Sure, no. I mean, I'll speak particularly for the Lebanon context, I guess, because it's a very interesting context. I mean, the country now has, you know, a quarter of the population as refugees. So it's really quite an overwhelmed country in terms of the burden of refugees that it's facing. And we're really implementing a model of care that's very different to the existing system. So of course there are going to be significant questions on how to hand over that model of care. Yet the way in which we're doing it is really to try and do something that is more cost-effective and rationalised, utilising a GP-based model, so that we could hope that by demonstrating a model that works, it's something that we could work with the existing system to see if that could be handed over to be something that is more sustainable in the long run and in this particular context. Just a quick addedness. We're working together with the Minister of Health with their NCD advisors and hoping to together develop a new model. Lady, please here. Hi, Ruby from MSFUK. My question is for Beatrice. Thank you for a very exciting talk. It could be a real game changer for our management of diabetes in the field. I wanted to ask how the pharmaceutical companies have reacted to your findings and if they're planning their own investigations? I don't think the pharmaceutical companies are already aware of our findings. So this is a close meeting. It's quite new. So the last experiment ran this week. And we are currently writing a scientific paper to be published in a peer-reviewed journal, but it's very early in the process. But at the moment of the study, we asked the pharmaceutical companies if they already conducted stability studies on insulin. And it was a total blocus. We could not obtain any information from them. So that's why we had to perform a literature survey and to do the whole stability study by ourselves because they were not able to give us any results. If I can intervene here. Also, I've heard a while ago I read something about heat instability for measles vaccines. So there's a lot of discussion sometimes about all that conditions that need it now in a different setting. So yeah, maybe all that will be raised in the... Any other comments? No, it's a different context now. Yes, please there. I'm encouraging people in the back. Just to follow up on that discussion, I think it's good to have the data, but then we have to move to the regulatory issue regarding this to allow us to use the outcomes of this study of stability out of cold chain as we have seen for vaccines. We need to have that to be authorized to use it on a large case in country where we work. That's one thing. The other thing is there is a need to standardize the condition on which either pharmaceutical company or MSF or every other person look at the stability study so we can have clear and unified recommendation for the field implementation. Okay, thank you. So, Kiran, please here. No. I hear you, but not there in the back. Yeah, thank you. So thanks very much for those presentations. I think just to pick up on something that Ford was saying and maybe it's a question mainly for John and Philippa. Obviously, you both touched on this in your presentation. There are broader social determinants of health that play here in terms of, well, which represent to some extent barriers to change for the patients you're seeing. I notice that you made mention of sort of stress and mental health issues and also isolation, vulnerability. I just wonder, already you have a sort of multidisciplinary model with counsellors, dieticians and so forth. Are you thinking about more involvement of social workers, for example, mental health officers? What would be your optimal team for managing these patients? Do you want to start? Sure. So, in fact, I only presented a small component of what we do and, in fact, my mental health advisor is going to kill me because I left out a key part which is that we do have integrated mental health care and social workers. In fact, the project initially, the initial emergency intervention had mental health as one of the key components and as time went on and other actors came in, we were able to hand over some components of that but then really our team started to say to us again and it's a very good point, Kieran. I mean, we're seeing this amongst our patients. They're not always able to access the care even though other providers exist and we want to be able to provide it in-house in a comprehensive way. So, in fact, we do have within our team social workers and they do things like follow up the patients who we think need home care or who need referrals. A big component of that is referrals to hospital which is quite problematic there and our social workers are involved in that and then we have some psychologists but also particularly just use of counsellors to support our patients. So, it is very much a multidisciplinary team. We have the community health care workers, counsellors and then nurses, doctors and the patient support education counselling nurses as well. John and Ian, yeah? Yeah, we have a similar right now. We're implementing, we're starting, we're proposing to add mental health to our project and also a mobile home visit unit because many of our patients are not able to come to us and then we come to them. So, we're in the same process of adding those activities. And definitely, I mean, in our refugee context in general, we're certainly more and more having mental health as a key component of the very initial interventions and when you're looking at patients with these complex medical problems that require a lot of self-management to enable that self-management, it's very difficult if you don't take care of their mental and psychosocial concerns that they have as well. It actually has an effect on how they remember the information that comes into them. A patient with depression do not remember the information that you provide them the same rate as... So, we all offer a patient coming back and saying, I don't remember what we talked about last time. That's enough. Yeah, but also, as you mentioned in your presentation, the issues of, you know, some employment, you know, that you cannot have people from the community, you know, themself to be with you and to work with you and that's another barrier to have, like, to build capacity. So, question? Yeah, my question is a bit in line with that. It's about the limits that we face and some of the limitations that the projects may experience. And then, in particular, in terms of lifestyle changes, you know, can we imagine an MSF gym at some point? About it. Or in terms of referrals, you know, oncology, heart operations, you know, where do you stop and what... Where do you think this will lead us as MSF? Yeah, yeah. I mean, I think this is the core... I think the question that everybody is talking about, should MSF do this? Is this MSF? Is it emergency healthcare? I would say that. Yes, but the big question is, it has to be an operational decision. Where does our responsibility end? Are we doing bypass surgery for our patients? There's a need for our MSF doing it. Or should we advocate for other actors stepping in? There always has to be the link with advocacy. No, I mean, I agree. I think this is a discussion we've started to have and it's certainly something that our teams face and every context is a little bit different and certainly a lot of the times we won't provide some of the more complicated or high level care ourselves, but at least we can facilitate the referral and the access to that care where possible. And that's what we try in Lebanon. We use our social workers in our team to try and see what other access is available for things like dialysis, which is one of the big issues there, and certainly admission to hospital and more complex care. But I think this is a discussion we'll continue to have in MSF and as the sort of changes in terms of the global burden of disease and the places in which we intervene come, we're going to have to evolve in that discussion and see where our limits take us. We're now looking at cancer management in terms of cervical cancer treatment and some of the HIV cohorts. We're looking at things perhaps we never thought we would look at before and I think we'll continue to evolve with that. I have a story here, a quick story, about two years ago I was like a newly arrival to Beirut, Lebanon and I had a meeting with MSF staff, you know, was a leader at that time and now he's ex-MSF. So I presented on NCDs in an emergency, on a chronic emergency and in the discussion actually he was so nice person because he said that okay that's very good but it's not MSF so you can say that somewhere else. So I'm happy now that we are here in MSF and we are talking the same issue. At least now we are raising that very important issue. So we have some time for some questions. Yes please there. Hi I'm Ben Holt, the head of the UK digital team. My question is about how MSF shares innovation and technology around the movement. So for example I've worked on an SMS patient system in Zimbabwe which alerts patients to upcoming appointments and reminds them if they've missed them help them reschedule it. It's led to the highest ever treatment adherence in that project and we're now working on the next iteration. The problem I have is then distributing it to other MSF projects where it could be useful and I'm sure there are other similar trials going on. So the question is how can MSF improve the way it shares its innovation and reduces duplication of efforts? Do you want to link on to that? I think we have someone who wants to link on to that question. Yeah yeah. Someone will answer from the audience. Just to help you answer that question we started last year co-organized with OCB a sort of innovation fair where we got the different operational sections together. The five operational sections together and we had a cross-cutting participation from operational directors, logistics directors, middle-managed medical innovation people and we shared the innovation projects that are going on within the operational centers as much as we could. We are trying to keep that momentum going. There's today as you can see I think some of the projects are coming out presented here today and we hope okay this is a publicity plug but we hope we are going to hold another of one of these innovation fairs this year again and and I think that's the space to share these kind of projects because as you say there is a lot going on in the movement and we need to be able to share what's going on and to help disseminate this throughout the movement. And to just add on on that we are actually implementing in a reminder system so we already been doing it manually on a daily basis repining our patients with SMS's before the day before and we're contacting the same day if the missed appointments if they come back so it's a very quick to falter tracing but next week we are implementing an SMS reminder system in our project next week. So the lady there? Yeah hi I'm Inma Gonzalez from OCBA and also from the information systems management platform it's quite a new platform in the movement and also working cooperating with Maya in innovation and also from our perspective we are starting to see and try to how to identify common projects and common initiatives and try to see how we can start sharing because actually that's the weakest point that we see we are doing a lot of enormous efforts and small ones that are very successful but not very good at sharing and sometimes even competing internally instead of cooperating so we need to continue working on that thanks. Yeah thank you thank you so we have online question. Hi there sorry I have a question from MSF Zimbabwe this is for Emily how would you envisage adapting Mac to mobile communities? Have you heard the question? Okay thanks Zimbabwe for the question. It's a good question I honestly don't know I think you can factor migration and mobile communities into models of care by thinking about the timing of the sessions so in southern Africa there's a lot of migration kind of before December so you could make sure that patients have this bigger three-month supply of drugs to see them over the holiday period and I think again it's also linked to gender as well so that might be where the previous question came in earlier and thinking about different strategies for maybe male migrants at different times of year compared to female ones. Okay thank you. Is it far back? Hi thank you very much for all the presentations it's a bit following on from Emily's presentation it's a common question so the common is that I guess introducing new health programming it's always easier in some senses to have a very vertical approach right but then the limitations to that is you already have an overburdened primary health care system and so I like Emily's presentation I like the fact that we're thinking of integrating these new health programming into other existing health programs and looking through a broader lens of chronic disease so my question is twofold one is there other parts of that care model that you have already thought about that could be integrated and also in a wider sense is there also models that we could look at which you have a fully integrated system of various not only just chronic diseases but also other health programming aspects within a primary health care system. If we think about the experience in Kibera I mean it's only the very first year of implementation so I think yeah it's been a good way of integrating the two together I'm honestly not sure what else we could integrate into that model in general I think we just need to see how the next year goes and then think further about it. We have time for one more question before closing Kyanna again. Okay thank you I know I've already had my one question so thanks for the second it was to pick up on what Ariane said that you know where are we going to put the limits in in terms of NCD programming and I think it's it's sort of a remark that I think that here we see we've heard about three very different models of looking at how we can deliver NCD care and already we can see that delivering NCD care is very intensive requires a lot of treatment support and potentially could be expensive so it's just a remark that I think how are we going to set the limits it's through conducting these well controlled pilots in very specific settings and it's through it's not applying this these models absolutely everywhere now because we really need to learn from these sort of flagship projects and so it's really just a request also to the panel who've been involved in these projects to rigorously evaluate these projects and really draw all the lessons we can learn from this because this is going to help us in limit setting and this is going to help us define where we can have added value at a cost that we can accept. Yeah, any comment for the person? No, I completely agree. I think that that is the key thing is we need to really be maximising what we can capitalise from these and then we need more examples as well so these are very specific contexts and we need to learn we have the very different context of sort of Middle East refugee setting and then the stable African slum setting we're starting to look in other settings but I agree it needs to be done very systematically and really trying from the beginning to make sure we set it up in a way we can learn the lessons. The emergency context is the big one that I see at the moment and in Ukraine we're being faced with this with a high burden of NCDs but we're running mobile clinics so again it's a very different setting to the stable clinics that we have in the Middle East where we don't have access to we have very limited access to investigative capacity and so we need to see how we can do it even in a much simpler manner again with mobile clinics and perhaps disruption to care because of conflict there were we are looking at things like telephone follow-up of patients and we're doing that in Iraq as well with our mobile clinics so really trying to innovate in many different ways to bring the care to these settings and can I just add on quickly and I think your point about being systematic is a good one but also I'd stress the flexibility and as much as you can have a model such as the MAC or a support club for people with HIV in South Africa I think being able to kind of pick and mix in a way and take the bits that work for your own project is definitely the way to do it and not feel scared that oh no I don't want to do this because you've only done it with over 25s or something I think being flexible is definitely beneficial I think that you know turn us back to the first presentation the keynote speaking you know about the big data and that's how we need more in terms of you know better and new which is not always you know that we have data now start building this data but still we need to know more about that how we can do the best and useful intervention the last word all the presenters and I thought it was interesting that we had a you know the innovation can sometimes exist in doing in not doing something so not cold chaining an item rather than inventing new and applying new techniques but I think there was a very interesting it's going to be a very interesting field for myself but what I'm proud of is that we're engaging and we're finding out about our limits rather than being stopped by questions about the limitations that we will inevitably face so thank you very much for that and particularly thank you Dr. Fouat for chairing this session in a very interesting manner an announcement here about the conflict and health journal they released call for paper about NCDs in emergency so please if you want to have a look here and you have the pressure outside so thank you very much