 There is a treatment exceptionalism for people who use drugs, one which does not respect our fundamental rights nor equity. As a current treatment treats us as subjects to control rather than as any other population that has a right to health. So I'm really pleased to be co-chairing this session. Of course we'll have a panel of speakers that will be sharing their perspectives and recent development of tools from both practitioner and client perspectives on OAT. And of course these insights will be critical to listen to, to make the treatment system the way it should be. So I'll just pass over to my co-chair. Oh, hello. Hello, I'm Dr. Christos Coimtidis. I am the National Coordinator for Addressing Drugs of Grease. I'm an addiction psychiatrist in profession and I practice in the UK and I have the policy role in Greece. It is a great honour for me and Greece to co-sponsor this event. Part of our efforts to meaningfully involve the civil society into the development of policy implementation and evaluation. Not an easy process, I have to say. I'm very pleased for the event today. I have to say that the starting point for me is that the provision of treatment for people who have a drug problem, substance use problem, is not a charity from the part of state, it is an obligation. It is an obligation that relies on the human rights access to health. The balance between regulations that control the professionals and the rights and responsibilities of the people receiving treatment is at times delicate and relies on clear rules, information and mutually agreed terms. In several countries it's called care plan, in other countries it's called treatment plan, whatever it is. Clear rules are important and to that effect the initiative that the civil society has taken to that effect in today's event. I hope that will contribute to that discussion. So give it back to Judy for introducing the panel members. Thank you Dr. Christos. So first off we have Dr. Andrew Scheiber who will be joining virtually. He's a medical doctor by training who works in harm reduction research, programs and policy in South Africa and the region. So thank you for letting me join today. It's fantastic to be part of this session. I'm going to speak a little bit around the opioid agonist therapy training program, developed by UNODC and WHO. And as we know, opioid dependence contributes significantly to morbidity and mortality. And the use of contaminated injecting equipment spreads the blood-borne infections, particularly HIV and viral hepatitis. And we know that opioid agonist therapy is very effective for the treatment of opioid dependence and is an effective harm reduction intervention. We know that OAT improves health outcomes and social outcomes and it also can improve people's adherence to anti-development therapy and other chronic medications. There is very good guidance available on how to implement opioid agonist therapy in a range of contexts, guidance from the World Health Organization, UNODC and also collaborative guidance on how to develop these interventions and provide them in partnership with community organizations and networks. However, despite this guidance, we know that coverage of OAT is really far from what is needed. The 2022 global state of harm reduction shows us in this map presented on your screen just how few countries provide opioid agonist therapy. Those that are gray, there's either no data or no OAT services. And in the light green, there's only at least one OAT service in a community setting. The few countries that are dark green are where OAT is available in the community as well as in prison. And just looking at data from 2016-17, at that stage, there were only 20 countries around the world that had at least 40% coverage of OAT. And we know that the 2025 target for the global AIDS strategy is to provide 50% of people with opioid dependence with access to OAT. So a huge significant scale-up is necessary for public health impacts around opioid dependence and HIV. This training program is based on a tool that was developed collaboratively between UNODC and WHO. And it's intended to support professionals to establish and deliver evidence-based opioid agonist therapy. It aims to provide practical guidance on how to start, establish, roll out and sustain quality services. And it's a focus on OAT in the context of HIV or viral hepatitis programs or in drug treatment settings. Important to note, it's not intended to be a clinical training because that can be subsequent and there is other guidance and resources for clinical training. And it doesn't focus specifically on the needs of providing OAT in the context of prison or in closed settings because of the unique circumstances of those environments. The target audience is largely for health policy makers, administrators of health institutions, as well as health managers. The process was established and followed the guidance of a working group that included representatives from UN agencies, civil society organizations and networks of people who use and inject drugs. There was a drug desk review of available guidance and other resources. There was consolidation of information from selected countries where OAT is available and is being scaled up, as well as synthesis of this information to develop a draft document which was reviewed, analyzed and finalized. The tool is structured in several chapters. Starting with an introduction, later there's a presentation of a framework around how the different components are presented. Then there are separate chapters for different phases of an OAT program. And then there's one chapter that looks at some of the nuances and issues of importance for providing OAT for specific populations. We have included various case studies that give examples of how countries in different contexts from Southeast Asia to North Africa to East Africa have developed an implemented OAT and scaled it up and shown to be an effective intervention. The main content is structured around various how-to questions, providing simple guidance, clear information and also reference to more detailed guidance for specific issues. We've included a series of videos that are really testament to how OAT works. We've included the voices of people who themselves have used and benefited from OAT. We've included some interviews from organizations working in civil society as well as technical experts and clinicians to reflect their experience in the country's experience of OAT scale up. The module focusing on the framework takes an approach of how OAT programs expand over time, starting with initial groundwork, planning, scale up, moving towards sustainability and the four main components of an OAT program. Importantly, including engagement with people who use OAT, engaging and obtaining leadership and support, components relating to financing, the workforce, strategic information and medications, and also looking at elements of service delivery. The training program initially was developed to be delivered in a virtual format and has since been adapted to enable face-to-face training. It is based on the tool and the package involves a slide set with training guides, as well as a range of interactive materials. We've aimed to include participatory methods and in the face-to-face version, the gender program is tailored to allow more inclusion of local content and more time for engagement and discussion of key issues. The process to date was a two-year development process with initial manual development and then training tool development and subsequently the starting of some of the training. The virtual training has been held with a group of stakeholders from UNODC as well as from Pakistan and the first face-to-face training happened in November last year in Egypt. This year there's been a training for stakeholders in Mozambique to prepare them as trainer trainers for a series of events that will happen in that country. And later in this year there are face-to-face and virtual trainings planned for several countries including Zimbabwe, South Africa, Mozambique, India, Laos, Tanzania, Tunisia and Iran. So this has been a collaborative process and really grateful for all the organizations and individuals involved. I really hope that this is something that can be used to increase access and scale up for this life-saving intervention. Thank you very much. So it's fantastic to see these very practical technical guidance tools developed by WHO and UNODC and importantly they were developed in partnership with clients. I know there wasn't enough time to see the video examples but having seen them before, you know those video examples and testimonials really bring to life how critical well-developed OAT programs are. So next up I'd like to introduce Richard Healy. He holds a PhD from the National University of Ireland. He'll be providing a service user perspective but also the perspective of a researcher whose research has covered an exploration of narratives of service users through a human rights lens. Thank you. It's a real pleasure to be here and speaking today. I found myself in a funny place. I've a lot to thank Metadone for. You know I got a PhD through Metadone. I'm a father through Metadone. It's changed my life dramatically. It's done so much good things for me. But yeah, so much of my friends back at home aren't sharing the same victory in their own lives. The same outcomes in their own lives. So we would be from a service led, called the service users rights and action based out Dublin. And we have inadvertently stumbled upon a model that has been used for service users evaluating the services themselves. So how did this come about? So it basically consists of service users, former service users, service providers found 2012. And we've published, I published a piece about a year ago called, it was called, and what I noticed was that nearly everybody in the community all over Europe were identifying with what we were finding in Dublin. We're identifying with the same things that we were finding in Dublin. That Metadone had become very controlling in people's lives. There was no reintegration after Metadone in people's lives. And we weren't seeing any of this. So how did four service users really get this done? And I'm being asked to kind of translate this model into larger audiences. And I'm kind of a little bit embarrassed a little bit because there's very little to it. It was a very simple thing that came about. We're four or five service users with about 20 years each under our belts of using Metadone services in Ireland. We got together. We realized that there was four main problems with panoptic services in Dublin. So there was no meaningful relationship with the GP. Frequency of your analysis, your analysis was just, was based on everything. No choice in treatment. We were operating on human rights lands under the right to health, Economic, Social and Cultural Rights Article 12. And we carried out four pieces of research to trace, if people are aware of that right, Article 2 is Progressive Realization. Where it allows states to provide the highest attainable level of health care dependent on a state's resources. So what we wanted to trace the narrative of drug service users was we were able to trace a week. We were able to trace research carried out after a few years. And to save these four primary key underpinning damaging parts of Metadone were still being carried out, which was your analysis, no choice in treatment, no independent or robust avenue for complaint and the frequency of your analysis. So we carried this on and you can skip on to the next one there, yeah. So we carried out the research and what we're finding is, and this is where I found myself in a really difficult part, because I'm being critical of something that has been so empowering in my own life. It's allowed me to do a PhD. It's allowed me to speak over here. But yet, if we can see the stats up here, most people in Ireland are, if there's about 12,000 Metadone users at the minute, 600 on Suboxone. So it's primarily Metadone we're talking about in Dublin. And at the minute we would have, it's totally based on your own sample. There's no relationship with the doctor, there's no, you'd very rarely be asked how you are. So that wouldn't be, that wouldn't come into it whatsoever. No meaningful review with your doctor. So what we have found is that we're getting a very ageing metadone population in Ireland. Yeah, I've researched what we've found is that we've, there's no meaningful review. We've got supervised analysis stops so that there's a far more, there's no power imbalance when you're engaging with your doctor. Your doctor is speaking to you as a patient as opposed to someone who's in treatment. So that whole word of being in recovery has been now being replaced by empowerment. And who you are as an, as, I wouldn't see myself in recovery. I would see myself as taking the medication every day to allow myself to operate a pretty high standard in life. You know, so unfortunately we don't see that a lot in Dublin. We find highly entrenched with your analysis, highly controlled, social controlled mainly. All set on contracts, no quality of life, no reintegration. And we've no, there's no good outcomes. So what we're ending up, what's ending up happening is we are having an increasingly large metadone population that's aging and that's not moving forward in any way. There's no reintegration. Where we would start with reintegration would be housing, job, whereas metadone in Ireland stopped people from doing this, unfortunately. And this is where I found myself at that little ambiguity in my own life because it's helped me, but it's blocked so many others. And it's not metadone. It's not the medication. It's how it's been dispensed, unfortunately. Unfortunately. Thank you. Thank you so much. It's really incredible research and definitely, you know, something very much worth disseminating more broadly. And I think it's so powerful doing the research, but coming from that lived experience at the same time. So I'll just. Richie, thank you very much. And now I'm going to introduce Christos Anastasiu. Christos is from Greece, as the name says. And he is a representative of the Euro input. I know Christos very well from his work in Greece and our times positive collaboration times less so or challenging. But that's the point of all days to enter discussions at the times can be difficult and challenging. Christos going to talk about the OAT client guide and the positive solutions to OAT literacy rights from a Euro input point of view. Christos. Thank you very much. Ladies and gentlemen and friends beyond the binary. I'm Christos from Athens and European OAT project manager of the client of a client OAT service. This service started in Greece 27 years ago. I was back then I was a 246 client in an experimental unit in Exarchia. I have been stable since 2004. I'm living proof of the benefits of OAT and the possibility of positive change from the streets and the drug skin. We create a family and with my wife who is also in OAT and now we have a daughter is 18 years old. Also the last 10 years we managed to create the first network of people with drugs in Greece, which called Pearnups. We managed to connect with all international and European peers and colleagues. This connection skyrocket our knowledge and productivity and gave us a motivation. We feel an obligation to assure that services become better, more efficient and more accessible to customers. Since the beginning of the pandemic, we recognize the important to renew the advocacy for people in OAT. We started to research for the creation of the OAT client guide. We talk all over the world with colleagues and experts involved in OAT services and advocacy. Since we recruited people in OAT in pilot countries to form the OAT project team. The objective of the project is to present in an accessible manner the best practice starters for pure diagnosis therapy based on professional guidelines and science. To describe starters for the provision of OAT that are consistent with the human rights principles, it also requires that the primary objective to be the health and well-being of the patient, not the cost of the convenience, to support the value of meaningful therapeutic relationships between people with opioid dependency and their OAT prescribers and their OAT team. To develop a self-version of the new normal for the OAT provision based on dynamic partnership between people with opioid dependency and those who design, manage and deliver OAT services, we are also to assure that services users are involved in every decision-making process that affects their treatment. Next slide. So this is the client guide. We developed this OAT client guide based in a research written from our piece from Canada. It designed to be tailored and translated for use of different countries. We work to secure the sponsorship from governments, provide the professional partners, and this requires negotiation. Our Swedish version has only three OAT options, while the German one has seven. We want to provide people from OAT with a great statement of their rights and the information leaflet. And to create a meaningful therapeutic analysis in OAT, we need to understand our rights and have confidence that raising issues about the treatment quality will not result in treatment sanctions. Next slide. Policy makers and clinicians need to better understand that client education is a priority. Coming up the streets, people are looking to make positive detains, but they may not understand the drug treatment system or OAT medication and they may worry about discrimination from healthcare providers. Correct scientific information is vital for empowering people with opioid dependency to get more out of OAT and drug treatment. There are five main factors that typically need to be approved in OAT. It's whether the well-being of the person, his income, his living environment, his confidence in his department and the social interactions and less isolation. Having proven on some or all of those factors is the head of the successful treatment. Clients of OAT sanctions can be accorded to form groups aimed to their growth. Next slide. Quality and status of the delivery of OAT is well described in so many different UN and other technical guidelines. We know that OAT medications are highly effective and we know that works in terms of dosing, psychosocial support and other empowerment strategies. We need people in OAT to be well informed and engaged in their own healthcare. Having drug user advocacy group for people in OAT is important, quality support structure and the European office, our client guide has a strategy to help us create a meaningful therapeutic analyser so we can truly set what we need together. Thank you. This is the team that makes the OAT happen in seven different languages. Most of them you know them. I don't want to say each one. Thank you. Thanks very much. Sorry my minister couldn't make it. She was called away at the last minute so I'm here on her behalf. My name is Alison Crockett. I'm a whole systems unit head for the drug positive vision in the Scottish government. So it's really just to welcome this short video that is going to be shown by a guy called Duncan Hill. I believe I don't know this and it's just really to say that, well I guess to put it in context there he is the very man. Just to say that we have in Scotland though introduced as part of our drugs mission medication assisted treatment standards and they really are based on a number of principles which is about creating an environment where people can access services quickly where they can access them with dignity and respect where they can have some choice and where they are given the support and their wellbeing is properly considered and I do think that this initiative will very much contribute to our success in the Scottish government of being able to successfully implement our standards. So just to say very much welcome this initiative, very much welcome the work that you're doing and very much look forward to seeing them rolled out in Scotland. Thank you. Can we have the video now? My name is Duncan Hill. I'm a specialist pharmacist in substance misuse in NHS Lanarkshire in Scotland. In Scotland we're fairly fortunate we have specialist pharmacists working in all but one of the main land health boards at the moment so there's 14 of us but we also have a wider network beyond that. The reason I've come to speak to you and introduce how we're using the OAT client guide today is we connected to Matt via a long way and that's what I'm going to explain to obtain and agree to change or adapt the client guide to a more local Scottish kind of version that we could distribute to patients in Scotland. What set it all off was there was a paper done by the Scottish government and SDF called Staying Alive which started off looking at tackling drug related deaths in Scotland. As we know we've got a fairly substantial challenge and our rates of death are tragically high and are three times higher than that of the rest of the UK and multiple times higher than the rest of Europe. And in the Staying Alive document it mentioned developing or having a leaflet for patients so they could get informed decision making and what treatments offered and what benefits were. This was then backed up when the 10 MAC standards were developed. Now the MAC standards are medication assisted treatment standards. There were just 10 of them that Scotland have launched in the last year and we're now actively working towards them. The standards were found by an initial 10 standards and then they went out for consultation including peer consultation and they came back and they were formulated and standard two of this looks at informed patient choice of treatment. Then when we were looking through the leaflets that the addiction services have and all the drug companies have and all the other organisations nobody had a single quick leaflet. There was lots of leaflets available all in individual treatments. There were some were very very technical, some were very simple but nothing that combined everything all together. So our alcohol and drug partnership in Lanarkshire were really keen that we had this in place both to tick the boxes for the Staying Alive document when we're tackling drugs related deaths but also it ticked off the MAC standards. Number two where we could give information to patients for them to go away and actually have a think about what they would like to be treated with. So the ADP obviously very keen on using this and I set off trying to find something I had the individual leaflets I didn't have anything combined. So as I said the specialist pharmacist we have a group of us so we all communicate regularly and discuss things. So went to them to see if anybody else had a leaflet that combined all the treatments that nobody did. Then went back to the Drug Death Task Force at the Scottish Government and local ADP and drug related death groups as well and nobody in Scotland had a combined leaflet on different treatment options. So then had to cast the net a little bit wider in contact with some colleagues down south and that's when I was quite fortunate that one of the people I had reached out to recently reviewed the Euro End Put leaflet on the OAT Guide which Matt had been involved in developing. This was great because I met Matt previously and would work on a couple of conferences in the past. Reached out to Matt, Matt came straight back. It was still at the final stages and Matt and the Euro End Put group were quite happy that we took the leaflet and adapted it for some of the terms were more or less appropriate for the Scottish audience but also some of the contents and the contacts we changed them. So once we had the finalised leaflet which changed it not significantly quite a few minor changes but it was more just as I said it was some of the wording that was used and we have kept the essence of the leaflet written by peers for peers. We contacted a couple of the organisations such as Advocacy, the Drugs Scottish Drugs Forum, the Drug Death Task Force and Scottish Families Affected by Drugs and we've got their agreement to have their contact details onto the back of the leaflet making it much more for Scotland but it takes basically the patient through a number of the different options and treatments that are available and we've also kept in some of the ones that are available in Europe but not available in Scotland such as slow release morphine but again that's something that we might eventually move towards so the fact that we've already highlighted that this could be a potential treatment and a leaflet it means that we're open to discuss that with the patients going forward. It's great to hear about how the resources are being used. So just turning to Paula Kearney from Ireland as our last speaker she's a community development worker who has a history of incarceration and is now a human rights and drug policy advocate pushing for better access to health and rights for women who use drugs. Thanks Paula. I'll apologise before I start because I've been not in a city Dublin accent so if anyone can't understand put your hand up and I will slow down a bit. As it says in my name's Paula Kearney I'm community development worker from not in a city Dublin and I'm passionate about human rights and drug policy changes for people who use drugs but particularly for women who use drugs. For over 20 years in my life I was also an active addiction myself and I have been on every OIT available in Ireland from Fiseptone, Metadone, Dahola, even Bilvedal but we're very fortunate in Ireland that we do have OATs because I do recognise there are many countries that don't so I wouldn't have been able to move on from using listed drugs if I hadn't got the option of OATs so I wouldn't have been able to go on to university and get the qualifications required for me to walk in the sector that I do. I'm very nervous when I'm talking. As a walking woman and a mother I've had major struggles with moving on in my career regarding treatment like having to get up every day and go to clinics so the fact that Bilvedal is available in Ireland I know it's only available on trial at the moment but it allows for people to move on their lives and not have that daily struggle if getting up and going to clinics and sort of taking that part of someone's life so it has had major improvements it means that you no longer have to explain whether it's to your boss, whatever making them excuses to go to clinics people can get up and move on in their life but up until last year I walked in an amazing service in the Nartana city called The Sale Project and it's a project that works with women who use drugs or women that are in recovery from drug use but I've seen force hand do you know the extra struggles for women that they have when it comes to getting recovery like women who use drugs that judge much more harshly than men are that's stigmatized really badly and then if they're a mother that's stigmatized even further it's just an extra level of shame that's placed upon them and then they end up internalizing that shame which makes it very hard for them to move on in their lives excuse me because of that stigma it frequently leads to them staying in their addiction because they know that once they register in an OAT clinic that light been shunned on them and then shunned on their mother in skills as well and it's not like it's like as if a person who uses drugs is automatically seen as a bad mother when that's not the case but flexibility is also an issue for women many women who try to enter residential treatment they face barriers because they're usually the carer of the family even in cases where they may be parenting with a partner do you know that there is two-parent household there's usually an addiction on both sides and the women end up I'm sure any of us that are mothers here know that regardless of what we're doing we still have to get up get the kids to school if I'm talking too fast just kind of let me know but you know getting the kids to school doing the housework and for when a country woman who uses drugs a lot of times she's also the breadwinner in the family she's the one who earn the money you know and for it like to feed our kids but also to feed our habit but also our partner's habit in many cases as well and that definitely leaves her in a very precarious situation because particularly if a woman is on methadone and she's gone to the clinic five to seven days a week she can't really take up employment so she's held in that space and it leaves her in a precarious situation because then she has to sort of use informal ways of getting money and for many it could be shoplifting it leaves sex walk and that again leaves her vulnerable to HIV hepatitis C and all the issues that come along with her sorry most of the time excuse me for a minute got lost but as well it leaves her open to jail time you know I mean criminality and jail time but as well now like a lot of the women that I would have walked with would have been starting to get a bit of stability in their life and then they'd end up getting into a little bit of trouble going into jail and that stability is taken from them because they may have been on the weekly takeouts in the clinic but then once thank you but I'm a bit nervous I'll be around to look for shakes but then once she ends up going into prison that weekly takeout that she's had again that bit of sort of normality into her life is taken from her so if she's missing clinics or anything like that there's a risk of her relapsing when she comes out and as well as that there's a risk of her tolerance being low as well and all the usual issues that come but if there's young children you know what I mean and the woman does miss the clinic again them risks of relapsing women who use drugs as well they experience a lot more gender based violence than women in general but there's a different view on them they're all not seen as complicit victims they're not seen as a woman who has gone through domestic abuse or a woman who has been sexually abused or anything they're not seen as innocent victims and this stops women from actually reporting because if they feel that when they report to the police again there's the chances of social workers and all women are less likely to report so there needs to be a sort of really understanding of the different issues that women have you know like them things that you really need to take into account that it's not just as straightforward as it is for men who use drugs do you feel that is like even when it comes down to reporting the police place a lot of blame on the woman as well because a lot of times the argument may be over drugs or whatever so they're just extra barriers that women do face that's what I'm saying the drug use comes under scrutiny if they do report it to the guards and again they have to start proving themselves and that whole part of them being a victim from them yeah but sorry about this I'm a little bit mixed up on me ting I should have just read I hate reading I get a little bit lost but yeah so as I was saying the women who do use drugs and are going through domestic abuse in Ireland there's no escape for them because if a woman is on OAT or if a woman is using drugs women's shelters do not take women in Ireland when it comes to drug use I don't know whether that's an issue everywhere but in Ireland they don't take the men and that even comes down to a woman being unmeted on so there needs to be services tailored to the needs of women tailored to the extra barriers that women who use drugs face and there's not enough of them I'll speak for Ireland because I don't really know as well as that there is also a huge homeless crisis now in Ireland at the moment and the negative repercussions for women who use drugs within that is really bad because a lot of women end up in emergency accommodation and if they may be talked into I'm going to use this voluntarily handing over the care of their children to family members sorry one more minute to family members and all but then when it comes to them getting their children back because they need stability in order to get their children back but if they're in an emergency accommodation and they haven't got care of their children they no longer fit the criteria when it comes to the council for their three bedroom house or whatever is required so then they're going to catch 22 that they cannot go on and take their children back unless there's stability there but then the other one that the children have done so apology for all that is running me up there see I didn't hear any re-speech but yeah as I was saying at the beginning we are very fortunate in Ireland to have OAT services but women should be able to reveal the treatment of their choice like as Richie was saying I'd be part of the service users rights and action myself and there are many women who are being given methadone and feel that the doctor doesn't listen to them when they say they want to detox that autonomy is never there for them they can never make them choices themselves or even if they want to choose other OAT services within them because as much as we have different alternatives it's predominantly methadone because that's a cheaper version as well they feel that you don't have a say in their own treatment plan doctors need to give some autonomy to service users and allow them other forms of OAT and when drug policy and drug treatment policies are being created there needs to be a focus on the additional needs of women who use drugs childcare services need to be provided so that you know women can't seek support but it also ensures that going to an OAT service isn't part of a child's everyday life do you know that and there's nothing wrong with bringing a child to a clinic but you don't want that for a child every single day and I'll end with this this year's team for International Women's Day was to embrace equity and we need to consider that there are additional needs for women so we want to have a fairer policy for women who use drugs we need to embrace equity and provide the right supports for people sorry for going on I think we did a really good job with time we're pretty much exactly on time so thank you so much for all the speakers for all the excellent interventions and also staying within the time frame I think there are a lot of important insights and it showed the range of value that peers bring in terms of research also providing technical resources and technical expertise that is grounded in lived experience I just finally just really want to emphasize your point as well Dr. Richard Healy when you talked about the ambiguity so I also think as peers we are caught in this of course being really grateful and appreciative of having access which many people do not have it is life changing but I think we are invested in critiquing it because we want to make it better because there are times where it can be very punitive and all about control so just to emphasize the importance of partnerships working across all stakeholders to really improve the way OAT program services live it designed and delivered and just thank you your input as well for this excellent side event Could I have one minute just came to my mind as a doctor you referred quite a lot in your relationship with a doctor and so forth and I have to say that stigma exists not only to people receiving services but also doctors working within those services there are times in certain countries that are not looked at as good as the rest of our colleagues that's number one number two is that unless you are well trained in your trade in your science you can be easily guided by your own preconceptions and you can easily be afraid of the person you have in front of you you might not be confident enough of how to mediate between risks from or side effects from the education or how to navigate through the system so education and training of the doctors with health professionals providing the services is crucial and is something that we can work to advocate you can work together to advocate on that and the third has to do with the system where these services are operating if the system is looking for a mistake from the side of the professional to criticize them and take the licensing way then of course they will be very very conservative into cut corners or take an initiative to address your needs so it is not you and us who are brought together in to promote in better services better training and better understanding and collaboration and thank you for inviting me this amazing event