 Hello, everyone, and welcome to today's session of the Harvard Medical School Organizational Ethics Consortium. I'm Kelsey Berry. I'm one of the co-chairs of the consortium, along with my colleagues Charlotte Harrison and Jim Saban. Today, I have the honor to be your moderator as we hear from a panel of experts on their work bringing disaster and public health emergency ethics into rapid response ethics consulting for essential industries during COVID-19. So before we get started, a quick note about this series, the Organizational Ethics Consortium, which is now in its seventh year hosted by Harvard Center for Bioethics, aims to build a learning community of practitioners and scholars around the emerging topic of organizational ethics in health. Our programs this season have examined the ethical role and responsibilities of various health system players from hospitals to insurers and drug manufacturers and how these organizations can contribute to a foundation for health and flourishing in their communities, especially when they find themselves caught in the crosshairs of longstanding social injustices and emergent public health crises like COVID-19 has been. So how do organizations chart a course forward by discerning the values that ought to guide them, making hard choices in the face of conflicting values, and then putting these choices into accountable action? How can they do right and earn trust, both externally from those that they aim to serve and internally from those they rely upon to function? And what happens when organizations that don't make health or health care their primary business are nonetheless called upon to protect the public health in the face of a shared threat? So that brings us to today's program. COVID-19 has pushed us all to confront the fragile underpinnings of society's business as usual and to see in stark relief the labor that goes into keeping the populace healthy, fed, cared for, and safe. What does industry owe to secure the health of our essential workers? Today we have the rare opportunity to learn from a newly constituted ethics advisory committee based in the Global Center for Health Security at the University of Nebraska Medical Center, which has generated a rapid response process to feel these organizational level ethics questions and others throughout the pandemic. So before we proceed, just a word to the audience about your own participation in the program today. There are two main ways to participate. One, you can submit questions for panelists at any time using the Q&A feature that you'll see at the bottom of your screen. And then two, once we do turn to Q&A a little later, we'll also invite you to use the hand raised function found at the bottom of your screen again to signal that you'd like to speak. And then you'll be called upon to unmute and share your comment or question verbally. We also welcome you to use the chat box at any time for general comments or reflections or if you have any technical difficulties that need to be addressed. So I have the privilege of introducing our panelists now. We'll start with Abby Lowe. Abby is the Director of Ethics for the Center for Preparedness Education at the University of Nebraska Medical Center. And she's co-director of the National Disaster Medical System Infectious Disease Training Program for the Global Center for Health Security. Ms. Lowe works at the intersection of ethics and health policy within infectious disease outbreaks. And her research focuses on ethics preparedness in bioemergencies. In March of 2020, she convened the Global Center for Health Security Ethics Advisory Committee with experts in disaster and public health emergency ethics with the intent of providing guidance on emerging issues related to the COVID-19 pandemic. We also welcome today Kelly Danine. Professor Danine is the Director of the Health Law Program and an Assistant Professor of Law at the Creighton University School of Law. She holds a PhD in healthcare ethics and her JD from St. Louis University. And she also practiced nursing for about a decade, over a decade in fact, prior to pursuing these degrees. Professor Danine's research is highly interdisciplinary and it focuses on the impact of decision-making by policymakers and providers on healthcare quality. Her current work focuses on opioid and drug policy and decision-making for patients with highly stigmatized conditions, including pain, substance use disorders, and serious mental illness. And finally, we're glad to welcome Matt Winia. Dr. Winia is the Director of the Center for Bioethics and Humanities at the University of Colorado and Professor in its Schools of Medicine and Public Health. His career has included developing the American Medical Association's Institute for Ethics and founding the AMA Center for Patient Safety. Dr. Winia's research focuses on methods to improve the practical management of ethical issues in healthcare and public policy, including understanding and measuring the ethical climate of healthcare organizations and systems, ethics and quality improvement, defining physician professionalism, and inequities in health and healthcare, among other areas. He's a past president of the American Society for Bioethics and Humanities and is current elected fellow of the Hastings Center where he also serves on the fellow's council. So we're very honored and thrilled to have the three of you with us today to learn from. So I'll turn it over to Abby to get us started. Thanks, Abby. Thank you for such a kind introduction. I'll go ahead and start sharing my slides. I presume someone will tell me if you're not able to see, but thanks again for having us today. I'm going to go ahead and start by kind of describing the landscape within the Global Center for Health Security, who is the convener of the committee. So just a few. Oops, I'm so sorry to interrupt. I'm just struggling to see your slides. I don't know if anyone else is having the same problem. So if you would try sharing your screen again, then we'll go. Absolutely. Thank you for telling me. OK, Kelsey, are you able to see what I have on the slide? Yes. On the screen. And now are you seeing that in the right view? Yes, I am. Perfect. Thank you for working through those difficulties with me. OK, so I'll go ahead and kind of give you the opening remarks, which really contextualize the committee's work within the Global Center for Health Security and within the COVID-19 pandemic more broadly. And so just a few words to begin about the Global Center for Health Security. The Global Center for Health Security at the University of Nebraska Medical Center with its clinical partner, Nebraska Medicine, stretches really from bench research to boots on the ground response efforts. And also spans the hands-on training. And the core mission of the Center is really to innovate and advance preparedness and response in emerging infectious diseases and catastrophic public health emergencies. So again, as I want to stress here, it's a very operationally focused entity and encompasses bioperparedness, infectious diseases, special pathogens research, education, and clinical care, which includes the biocontainment unit. And so I kind of have up on the slide, you'll see a schema for the biocontainment unit, which I think is something in terms of public health emergencies, something that maybe Nebraska is known for. And you kind of see on the left-hand side some training exercises along with photos of Ebola virus disease patients that were brought back during the 2014-2016 Ebola virus disease outbreak. So just to give you a little bit of a sense of what we do at the Global Center for Health Security, I think it's also home to the training simulation and quarantine center, which features the nation's only federal quarantine unit. You can kind of see on the right-hand side of the screen is a photo from the quarantine unit. You can kind of see what that looks like it's not too exciting. Maybe what's more exciting is what's on the left-hand, which is a little bit of an overview of the history of quarantine efforts at Nebraska. So quarantine and monitoring for seven repatriated US health care workers with high risk EVD exposure, as well as then a similar effort for health care workers with exposure. And then I think moving into the landscape that we are now with COVID-19, we were able to partner with federal agencies to support federal quarantine of 57 repatriated US citizens from China. And we were then again activated to quarantine and the biocontainment unit facility for the care of 15 US citizens that were evacuated from Japan during the onset of COVID-19 pandemic. You can see on the right-hand side a photo of us doing transport for those efforts. And then on the top hand, a lovely note from some of those quarantined and their stay given to those who gave them such great care at the unit. All of this really kind of leads up to what we'll be talking about today with essential workers. The work that happens in the biocontainment unit, the work that happens in the quarantine unit, part of the cornerstone of that is really around infection prevention and control efforts. And so the Global Center for Health Security has a team of infectious disease and infection prevention and control experts. And these experts have been really involved in the development of protocols around infection prevention and control. They've developed the OSHA and CDC infection prevention and control guidance for a bolivirus disease. And in the COVID-19 pandemic, this team of experts was working really closely to provide technical assistance to different industries, notably meat processing and really working to observe best practices for these industries and collating them and developing guidance and recommendations for mitigating risk of COVID-19 in these facilities. Global Center for Health Security has produced COVID-19 playbooks that are really intended to provide those best practices and recommendations for industries to minimize risk to employees, to communities, and to reduce disruption to business operations. So here's where we start to come into the picture and intersect a little bit in this work. And I tell you all that prior knowledge just to give you a sense of the landscape that the ethics committee came into and really the kind of work that we were looking at. And we had had a couple of issues flagged early on in the pandemic and a couple of colleagues and I from the Global Center were working through things and we thought, this seems like a really appropriate place to bring in a committee that's really tasked with providing guidance to the University of Nebraska, Nebraska Medicine Response Teams, federal state and state public health teams and external academic partners as well, and aimed at providing guidance to any stakeholder group as requested, but also with the intention of disseminating knowledge as appropriate and necessary for those that we've been working with and for gaps that we saw in the literature. So I wanted to, as we kind of move into Matt and Kelly's presentations, talk a little bit about what an ethics request and what that looks like on the front end. Obviously, hopefully I've kind of conveyed that this is a very interdisciplinary space, this is a space that's operationally focused. So what does that look like on the front end? And so I'm using the request for meat processing that came into us. Really the initial request was just to come on the technical assistance site visits with the team that was going to those site visits to go to the meat processing industries and look and be a part of that work. I think they recognized, the team recognized that there were issues of social vulnerability, of power differentials, but didn't necessarily know where we might go with that. So I went along and really worked closely with a colleague from the Center for Reducing Health Disparities who's an expert in agricultural health and safety to think about what we need to be looking for when we're thinking about that worker perspective. So I asked questions about policies, sick leave, the resources for isolation and quarantine for workers, worker education, really in concert with that colleague to get a sense of that worker perspective. In April, 2020, again, as part of the work that my colleague for the Center for Reducing Health Disparities had set up these virtual sessions again with the intention of drawing out the community's perspective of hearing the worker voices in the middle of this really evolving environment. Obviously, April, 2020, it's a really saturated landscape with a lot happening and a lot of emerging issues, evolving science, guidance that's not quite there yet. So really wanting to draw out that worker perspective and bring it into the conversation formally. So at that point, I'm working closely with the committee and one of the suggestions of Matt was to kind of think about a stakeholder analysis, to think about looking at this landscape through breaking out the component parts of stakeholders and be able to see where everyone sits within that landscape. We also formed a committee work group to tackle this request specifically, which is something that we've done as a committee. I'm sure Matt will speak a little bit more about that to tackle the issue specifically and have dedicated people who are committed to taking calls to working on writing, et cetera. But with that stakeholder analysis, we were really able to get an understanding of the entire ecosystem or as much as we were able to in the short condensed timeframe. Everything from again, incorporating those worker perspectives, hearing from community organizers about what was going on in the community, thinking about the impact of plants shutting down, the economic impact of plants shutting down, the impact on worker families of plants shutting down and production slowing, having a broader impact to farms and ranchers where they're invested in a certain level of animal production. So it was a very big kind of wily thing at that point. In April, 2020, we then had a committee, the committee was briefed by the infection control experts to really get a sense of what they wanted from us and how we could best help and support. And one of the things that started to become a theme was thinking about prioritization of all the different efforts that we could take on, what would be the pillars of infection prevention and control that are supported by the ethics analysis that we would do. And I'm sure Kelly will talk more on that later. And then again, as I had mentioned over the course of this slide, the close collaboration with my colleague from the Center for Reducing Health Disparity, she came and briefed the committee on her work and her research, which she had been able to quickly put together a worker survey and get it out with 600 responses from workers across different states in the Midwest, which was really valuable for our committee to be able to really understand that worker perspective. And with that, I'm gonna go ahead and actually, I apologize, I advanced too soon, but we're gonna go ahead and launch a poll. I've given you a lot of information, but if you were part of this committee and we're two months or a month into the pandemic and we're working on COVID issues and you're presented with this request to support an interdisciplinary team with issues related to infection prevention and control, for meat processing workers, would you have accepted the consultancy? And yes or absolutely yes or yes, but I need to know a little bit more, probably not or no. So this is definitely, I'm anxious to hear the results of this because this was definitely something that we talked about quite a bit as a committee, really trying to understand how we could support this request. And I think the pandemic has of course presented us all with a lot of unprecedented work and unprecedented events. And so we were at the early stages of that and trying to figure out whether or not we would step into this space and support. And I will say time was an issue here, right? The guidance was needed really immediately or as immediately as we could get it. And so there was a bit of that in our deliberations. So I'll go ahead and it looks like the polls closed. Do I, is everybody able to see the poll at this point? Yes, yes, awesome. Okay, so it looks like quite a few of you would have said yes. And quite a few of you would have been on that point where I believe a lot of committee members were yes, but a lot of angst or maybe wanting more information on it. And some of you are saying probably not, probably would have moved on from that. And maybe with that I'll go ahead and I'll pass it over to Matt to kind of give some of his thoughts on that as he enters into his part of the presentation. Thank you, Abby. The way we're organizing this today is Abby I think has provided us with really nice context of sort of the environment in which we came but I do also want to reflect back to March of last year, right? We had our very first meeting this week. Of last year, which is relatively early. So we were asked about this issue. I just want to encourage people to think about the no and probably not options. Because we were asked to think about this issue and after all we're a bunch of bioethicists and public health ethics people, clinical ethics people and the question of entering into this sort of political arena where there's a lot of power dynamics at work here and there was a great deal of uncertainty about how transmission was occurring and so on. So I'm going to speak a little bit now about the process through which we decided to go ahead and do this. And this really became in some ways a paradigm example of the, I'm not sure what the right word is. I want to say chaotic, but it wasn't chaotic. It was diffuse. It was diverse. It was a set of requests and topics and work products that was really coming from a variety of different directions and therefore ended up taking a variety of different forms. And so my task today is to speak a little bit to how the committee created itself in some ways or recreated itself after the initial work that Abby and the group had put together. And then Kelly is going to, Danine is going to speak more to the actual content in terms of the meat processing work. I argued that today we ought to spend a little bit of time on process in part because I'm a huge fan of the Harvard group and the work that you guys have done over the years in developing a really useful process for doing organizational ethics case consultation work. As you all know, there are not that many people who do organizational ethics consultation and the process that you have developed has been really influential for many people, myself included. So I wanted to spend a minute thinking and talking about the process that we ended up adopting because it was in part based on what you have put together and then it was in part an expansion on what you all have done or a diversification of what you all have done. So you see on the screen here the folks who are currently on the committee. The committee didn't start with exactly this composition. I alluded earlier to the idea that we sort of helped to create ourselves. We started with a group and then after the first few meetings, we realized that we were missing some expertise and some background that we really wanted to have on the committee. And so we started reaching out to additional folks to bring on as we recognized what the types of requests were that we were going to be seeing. Can you go to the next slide? I think, yeah. So we did spend a little bit of time and Abby already mentioned how pressed we were for time. Again, remember back what things felt like in March of 2020. So we were very pressed for time but we did spend explicit time of the committee thinking about what is the expertise that we ought to have around the table. Even as we were starting to receive requests for guidance and even as we were writing things, we were bringing a few new people on. So we ended up with the committee composition that you see here. And this was essentially created as a spreadsheet. Individual people obviously can tick multiple boxes but I think if I were setting up an organizational ethics committee, I would do this exercise and I would do it at least twice once before you put the committee together and again after a little bit of time and experience in working with the committee and seeing what types of requests you're getting. So that's just an operational thing but Jim and I have been through this exercise once before with a group that we worked with at the AMA and having an explicit conversation about who needs to be at the table and who sort of ticks which box ended up being quite valuable. Next slide, please. So this is a busy slide and I'm not gonna speak about everything on it. I just wanted to point out, I wanna use this slide to make a couple points. Number one, we ended up getting requests for guidance from a really broad array of individuals and it ended up sort of expanding even more over time. So we had state leaders, we had people from the university, that we kind of expected but then we had union people, then we had people from the community, then we had advocacy groups. So I'll have another slide about this in just a second but just to emphasize the diversity of the people coming to our committee with questions and things that they just wanted to talk through. And I think anyone who does ethics consultation will not be shocked by this but one of the tasks of any ethics consultation service is to help the people who are experiencing some kind of ethical distress, formulate their distress into a meaningful question that you can actually deliberate around. And so we ended up spending some time on that and we realized maybe this is unique to the pandemic and the speed with which things were happening. Sometimes people had a question we were not gonna be able to answer right away. Sometimes people needed at least some interim guidance even before we could get the full committee together for a deliberative time. And sometimes we would end up with a question that individuals on the committee were really engaged with and really wanted to dig in deeper. And so not only did we have a diverse array of requesters of people coming to us and some diversity in what they were asking us for, we also ended up with a tremendous diversity in the products that came out at the other end. And some of that was driven directly by what the requests looked like and what the person was asking for. And some of that was driven by the work of the committee itself and I'll just say the passion of the people on the committee for the work that we ended up doing. So the reality is we ended up with academic publications which no requester had asked us, would you please write a peer reviewed article about this? But we had a very engaged committee and ended up producing peer reviewed publications as well as for example, things like a worker training program component that was around helping workers to see the ethical dilemmas that their bosses, that the management team was facing in trying to develop policies in the context of the pandemic environment. So those are the points I learned to make here. Can I go to the next slide please? This is again the process of the meat processing consultation which we're using as kind of the paradigm example here. As you saw on the prior slide, there have been requests around a number of other topics. But if you look just at the meat processing request, it pretty quickly diversified into the rapid feedback to the site visit team. And then a formal consultation report which was, I'm trying to remember now Abby, 20 or so pages, it was a substantive report. And then that ended up leading to a set of collaborative projects with the National Institutes for Environmental and Health Sciences which included as an example, the pedagogical product that I mentioned a moment ago, this training program for meat processing workers around the ethics of decision making in their work environment and what their rights and responsibilities are and why sometimes those are constrained and so on. So you can see how one question from an initial requester would, for a couple of different reasons, either new requesters jump on board because they see what we've done and they come in with another question or another request or because people on our committee saw the value and really wanted to expand in one domain or another. And perhaps the best example of this sort of winding path would be the National Academies of Science, Engineering and Medicine framework on vaccine allocation where we were explicitly requested by a couple of different groups, community groups, would you please make some comments to the National Academies as they're developing this framework because we wanna make sure that the worker voices is being heard as these allocation frameworks are being developed. So that was not the intent of the original requester but it was a spinoff and it ended up with our committee making recommendations to yet someone else's committee. So next slide please. So this is just to summarize a wide array of requesters and a wide array of products. Many of those products driven by the form with which the request took but some of them being spinoffs that were generated out of the passion and engagement of the committee members themselves or people who saw the committee's work and then came to us to say, would you also work with us on this related product? Next slide. These are some of the manuscripts that are either published or in review and you'll see that the top one is about meat processing workers but there are a couple of other examples that we could have given. We're focusing today on the meat processing work. Next slide. I think this might be the slide where I turn things over. So this is the cover of our consultation report on meat processing. And with this, I will take you away from process and hand you over to content and the expertise of Kelly Denene. All right, I am just as I'm beginning to share my screen here. And again, like Abby, please let me know if it's not showing up for you. Can you see that Abby? Yep, okay, great. Okay. So I'm gonna take over and talk about more of the substance of the report we've put together initially before I do that. Kelly, sorry to interrupt. We're seeing your presenter view, which may be fine. But we're seeing your notes in the next slide. Oh, okay, let's see. Let me try this again. Sorry, slide show. Still seeing it? Yeah, you may have to stop sharing and then reshare to the screen. Or how about I just do that? Is that better? Yeah, there you go. Okay, great, sorry. There's always something even when you think you've got it all together. So before I get into this much more, I just wanted to say, of course, thank you so much to the consortium for inviting us. Thank you to Christine Mitchell for suggesting us and to Kelsey, Jim and Charlotte for putting in so much effort to help us craft exactly how we wanted to approach this for you all today and to Ashley for keeping everything working, despite my best effort sometimes. Okay, so I wanna talk about the context we were dealing with because for most of us, honestly, on the committee with a few notable exceptions, we didn't know much about meat processing. And so I'm gonna assume for the sake of argument that many of you don't either. So I wanna give you a little background on the context in which we were trying to make some recommendations. Okay, so first, the meat industry. This is a multi-billion-dollar industry like lots of other corporations in the last decade to two. It has consolidated around the hands of a fewer number, very powerful industry leaders. It is also a major part of state and local economies in some states like Nebraska, right? And it's a critical part of the food supply chain. At the time we got the request, there were a number of news stories about as a result of some of the outbreaks and the decreased number of workers and a few plants had been shut down across the country. That was leaving farmers as part of the supply chain making very difficult decisions about euthanizing whole heads of cattle and other animals because the supply chain couldn't keep up. We also know then in April that Ben President Trump signed an executive order declaring meat a critical and strategic material under the Defense Production Act. And that was broadly interpreted as a mandate to keep the plants open no matter what. So we knew that shutdowns were not going to be part of the possible options as they would typically be, right? In this kind of situation. And then a word about the workforce. So the people who work in the plants are from groups that have already suffered from decades to centuries of structural and institutional discrimination. Up to two thirds of the workers in Nebraska are immigrants or refugees. And in some cases they may even make up, in some cases those without a legal authority to work in the United States may make up the majority of the workers in any given plant, okay? So we know that the workers are in groups of people that already have terrible health inequities for access to care for a lot of reasons including fear of immigration enforcement. We also know that most of the workers have personal financial and food insecurity, meaning they don't have some of the options that people in more professional fields such as nurses and doctors have about avoiding work, right? They also don't have the benefits like paid sick leave or paid time off in order to do that. And then there's the nature of the work. We know that the meat processing work is grueling physical labor with a lot of injuries pre-pandemic, right? We also know that this work takes place in large warehouses in highly congregate settings. It's very difficult to social distance. The folks that work on the lines, the assembly lines are shoulder to shoulder. The temperatures are cool and the ventilation systems we have come to find out all make transmission easier. Okay, the workplace culture is very hierarchical. There is an authoritarian in some ways, the line supervisors, the sort of middle management and the way that we might think about it in some places and of course it varies, right? But in some places it's been reported that it's typical that they're sort of a ruler onto themselves and pre-pandemic right production has been sort of prioritized over most other things. And so people get folks in those supervisory positions especially get reimbursed sometimes for how well their production level, the extent of their production levels each day. And then we have a pandemic during a federal administration and in many of the states in which meat processing plants sit, you also have state orientations that are pro-industry decidedly deregulatory, right? So we knew that we probably weren't going to have a swift response from the federal government to protect workers at a minimum. And of course we all can remember because it was yesterday and also three decades ago last year and it continues the state of rapidly emerging evolving information about the virus, the transmission, the harms, et cetera, right? One more note before I turn to the next slide I just wanted to point out that in Nebraska, for example, at one point in May, in Nebraska, people who are Latinx or non-white Hispanic identifying make up about 11% of the population in May of 2020, those groups made up 48% of the state cases. So there were significant disproportionate effects on these groups and a lot of it was tied to meat processing. And just cannot emphasize enough the impact on the meat processing industry. There was a point last spring where Amazon rightly got attention because they had 20,000 cases among their workers. But just to put it in context, Amazon had has three times the number of workers than is in the meat processing industry and they had half as many cases at that point. So really a lot of cases coming out of meat processing plants, okay? So with that in mind, the committee structured their question and there was a question in the chat and I just addressed that a little bit but I'll defer to the question and answer period where I think Abby and Matt probably can do more justice to it. But yes, very often we get contacted and the ethics committee has to sort of work through and then with the requester, what is the question, right? And I know this is familiar across healthcare as well, right? So this was the question we then came up with. So what strategies and interventions can most effectively and ethically reduce the risk, okay? And then we looked at what values are we going to highlight that ground these recommendations? And we looked at and relied heavily actually on the American Public Health Association's Code of Ethics but we looked at of course health and safety which includes effectiveness of course and health justice and equity in particular. Knowing the relative disadvantage many of these workers were at made it very important that we attended to that in a way that was fair and we chose the word fair pretty deliberately knowing that fairness can be interpreted in a lot of ways of course but we also wanted to resonate with our audience, right? So talking about social justice may not have had the same impact let's say than talking about basic fairness to people. And then we'd looked at community values and I think in a lot of ways although we didn't make it explicit, right? I think we all thought about these values being relational but we looked specifically at community values of interdependence, solidarity and mutual respect, right? And grounded a lot in reciprocity which could span sort of the community values, right? And justice. So that's why I put it in the middle. So the idea that these workers are sacrificing a lot and they're taking on risk, right? And they're doing it to keep things moving, to keep meat production going, to keep those federal, state and local economies going and they're owed something in return. They're owed basic protections and measures that are within the capability of these industry leaders to do to minimize their harms and promote care and treatment as much as possible. And this I just wanted to show you and I'll put up the webpage at the end for the center but we've done a number, I'm totally taking credit, nothing to do with the infographs. They're beautiful, Abby and her group did them but did some infographs to break things down into one or two pages for folks. So this is an example of one of them for the meat processing industry. And so we took the values that were guiding our recommendations and then put them into what we call our three pillars of ethical infection, prevention and control measures in the meat processing facilities. So the first pillar is onsite prevention. Of course, to reduce harms to these workers and to reciprocate for their sacrifices, the minimum necessary really is for these facilities to implement the administrative and engineering controls that have been recommended in the guidance from the CDC and OSHA. And that includes providing adequate PPE and adequate in context means adequate for the work these workers are doing, right? So if they need more than one mask a day that's what's owed to them. There's also an issue with something called line speeds and that's literally the speed of the assembly line the meat goes by on. And there had been some actions, some regulatory actions in the last decade or less that had allowed the industry to speed those lines up which can be associated with injury. It also means the workers have to be closer together to catch everything and perform their task as the meat goes through on the line. But given the need to social distance and put in those administrative and engineering controls we recommended that they needed to reduce those line speeds and that had to be evaluated probably on a plant by plant basis but even though the law said they could go faster it just was ethically inappropriate for them to not slow them down and let the workers take the precautions they need. We also know that and I don't, sorry I went forward too soon but we also know that there are a multitude of languages and dialects spoken in the plants. And so that means that there have to be ways to communicate in appropriate ways with those workers and that's gonna require collaboration and a lot of times with public health departments and community advocates to make sure that information gets conveyed in a way that is understandable. And that's also true for worker education on infection prevention. We also know that there are sometimes as I sort of mentioned earlier with the supervisors there's sometimes shadow policies that would emerge. So if a plant said, hey, we're gonna follow all these CDC OSHA guidelines but the supervisors are very much been in a mind frame for a very long time of production. So yeah, the policy says this but I want you to meet production. So we recommended that the facilities really attend to this and make sure their supervisors were communicating and acting on the policy and that they not be rewarded for productivity so much during the pandemic. We then looked at offsite prevention, providing adequate housing. So many of these workers live in crowded multi-generational households where should they be exposed they cannot quarantine properly and if they should fall sick they cannot isolate properly. And of course we know the crowded housing in and of itself is a risk. So we suggested that the plants maybe in partnership with some government and even some universities work to provide appropriate housing that allows people to quarantine and isolate as needed. There's a lot of group transportation so to look at alternatives for that so that people are, you know four or five, six people aren't crowding together in a car to get to the plant. And again, to partner with public health departments and community organizations to really do culturally and linguistically appropriate outreach in the community so that they can protect themselves both at work and in the community to sort of understand what steps they can take to protect themselves. And finally pillar three which we call treatment and remediation that even though there's an existing policy of not providing sick leave or to those plants that do provide sick leave sometimes operate in a point system and you get a point for missing a day you know, and those points for different things like that and so they'll add up and it'll be an automatic termination, right? So of course that incentivizes people to come to work sick so we recommended strongly that they suspend any penalties, any point system to provide sick leave during the pandemic and also to suspend attendance bonuses. Of course what happened after the initial outbreaks is some plants put in attendance bonuses because they were short on workers so they said, oh, we'll give them bonuses to show up but of course we know that that's exactly the opposite of what you want to do to effectively reduce transmission and prevent harm to these workers. We recommended no cost confidential testing both surveillance and symptomatic. And finally to provide health care for those who develop COVID-19. Of course, many of these things would not be in the purview of an employer in normal times, but a pandemic's not normal time. So it is appropriate that the industry bear, yes, economic burden in exchange for the sacrifice that the workers are taking on. All right, and with that I'm sure there are plenty of questions because the best I could do is give it sort of an overview. Here's the website. If you're interested for the Global Center you can see a lot of the reports and those great infographics that I was talking about and that here are email addresses. But with that I'll turn it back over. Thank you so much. Thank you so much, Kelly, Abby and Matt for kind of walking us through and really I think peeking behind the curtain in two areas, right? First, how you're fielding requests for ethics support during the pandemic which I'm sure many in our audience know from their own personal experience are kind of coming in from every corner sometimes in an overwhelming way. And then also how we can think about the industry's obligations to essential workers and kind of what went in to the decision-making process for thinking about infection prevention and control and the role of process as part of that kind of decision-making. So I won't say anything more because I really would like to bring in Rakhia Yerbi who has generously agreed to serve as our discussant today and to share her reflections on this unique work that you've been doing. So just a moment about Professor Yerbi. Rakhia is a professor of law at the St. Louis University School of Law where she's a member of the School Center for Health Law Studies, co-founder of the Institute for Healing Justice and also director of the Center for Policy and Equity. Professor Yerbi is a specialist in racial disparities in healthcare, the political economy of healthcare and social justice in medical research. And she's really dedicated her career to securing the health of vulnerable and marginalized communities. So we are so glad to have her. And I'll just say that noting kind of reading a little bit more about her work over the last several days just to say that her research portfolio and work with community groups really demonstrates this consistent advocacy for equal access to quality healthcare, health and fair wages for racial and ethnic minorities, women and the poor. So you're very happy to have Professor Yerbi with us. Professor Yerbi, would you like to jump in? Thank you. And I want to thank you for allowing me to participate and for the members of the University of Nebraska team for asking me to participate and give comments about the work that they have done. I think that looking at the materials that they have submitted and that are on their website, I do have just some quick points to think about just generally and particularly in terms of what they said that really led the consultation, right? That they were asked by either particular meat processors or the industry to come in and provide some feedback about that. And so two of the things that I think about that we should add to the discourse is that if these industry groups, companies are asking for help, then they need to really be the focus of the response. And what do I mean? And so you've talked a lot about the things that they could do, right? On-site prevention, off-site prevention, but it's talked about in a very different way, a really focusing on and part workers, right? And so changing the language and the focus to talk about organizational responsibility, even including that language in the consultation because that's who asked for the consultation, right? That's who is actually implementing it. And what are the ways that we need to change the organizational practices, the organizational culture and even the ethics around that, right? And so I'm not saying you didn't do that, but framing it in very different terms, right? Even in terms of sort of saying the workers are bearing the burden, right? That the organization should bear the burden, particularly under public health because they have the most power to control the population versus the individuals. And so just thinking about that language, I know we're all in public health and we tend to focus on individuals, right? In terms of isolation, quarantining, and I really love pulling some of the business literature organizational site to think about how we can talk about organizations and how they actually move forward and how they practice. And so I said that and now because my time is limited and I would love for us to talk about that more, I wanna shift now to talking about ways though, we can also include community. And I saw from the notes that you talked about, initially you were asked by the industry by a particular organization to come, right? And so you weren't asked about the workers, but I think it's so key to talk about the ways that they need to be empowered to be able to assist in limiting the spread of the disease, right? And that really does kind of feed back into the organizational structure that at this point, when you have workers who are being infected, those are the voices that you wanna listen to as an organization to say, okay, we try this, it's not working. And so we as an organization are going to empower you and give you a space to be able to say those things, to be able to listen to you and to let you lead changes in what we're trying to do as an organization. And I haven't seen that, right? I think, and you, I think most of the people who are on the committee know the work that I have been doing with Professor Seema Mopatra, who's also a member of the committee. And what we've highlighted are a lot of gaps in the industry and a lot of failures of the government to regulate them. What I would love if we all step back and sort of said, okay, look, we know it hasn't worked. We're quite clear about what hasn't worked. So moving forward, what are the changes, not only in the regulation structure, the organizational structure and with workers that we can put in place right now to help everybody move forward, right? And so I think for me, one of the ways to do this is to incentivize workers, to be able to participate as full members of this change. And so, you know, in LA County, the Board of Supervisors created employee safety councils that just was within the county. I would love if the same thing happened within the meat processing industry that they actually formed councils of employees that could talk about the things that are happening. I think we've always tended to focus on PPEs and paid sick leave. And I'm loving the fact that you're focusing on the points, the penalizing points and testing because all of those things haven't worked. But one of the things that we haven't even begun to discuss widely is aerosol transmission, right? And the fact that meat and poultry processing plants perhaps are hotspots because they have colder temperatures, right? All these things that we're not getting to because we're so focused on, I did this, I didn't do this, right? And liability. And so I would really say that we need to change the focus and become true partners in this. But everybody has to have some form of power and that really is key with the workers. And we need to change the organizational structure really of understanding that we are in this together. And so the ways that we get out of it is by working together. The last thing I'll just highlight and then I think, no, two points that I wanna highlight. And notice that you put in there about incentivizing companies to comply. And so I think we don't need to in the sense of they've made lots of money, right? But what I say that we need to do is to talk about how that money can be best used for the safety of the workers and to continue best business practices. Lots of companies, after the executive order, you can see doubling of profits, increasing of share prices. And so why not use that as a way to fund the things that you need to do? I know some companies or shareholders are starting to sue around some of these issues. And so even the shareholders recognize that the profit should be used to lead to better outcomes for all of us. And so I want to sort of play upon that and think about the ways that we can use the profit as a way to better support workers and better support the communities, right? Because as you mentioned, it is not just the workers, it's a part of the community. And if you support and build those communities, then that just helps your business. And I don't think we're getting that across. And then finally, I really would want more discussion about how it's had a disproportionate impact on immigrants, people of color, women, and those who usually don't have power. And why that's key for me is because even sometimes when we talk about educating workers, it's really not about educating workers, right? It's more about empowering them in places where they have no power, right? So just saying alone that supervisors should educate workers about paid sick leave doesn't help if you're not actually going to recognize, value them and abide by those policies, right? And so discussing that as part of this issue to me is so key because we are treating them differently than some other workers, right? And we talk about it in meat and poultry processing plants, but to me, I also see it in the healthcare context. There is retaliation across the board, even against doctors and nurses, but it's a very different discussion and protections and outcry for people who are low wage, right? So the people who are cleaning the floors or giving the trays. And I would say it even is the same thing perhaps in meat and poultry processing plants when we talk about the supervisors who are able to stay sort of safe. And then the workers who tend to be women, people of color undocumented who are bearing the brunt of the problem, right? So I would love us to be more explicit about that because then I think that goes to supporting the need for an organizational shift and for more empowerment of the workers. So with that I'll stop and I'd love to continue this conversation and then hear more questions about some of those issues. Thank you so much for Kaia for that thoughtful commentary. I think that you're drawing the parallels or kind of the connections between what's going on in a different sector or a different industry than perhaps that which many of us are familiar with from our own work in organizations that we're part of is really helpful for us to start to think about what would our organizations look like? What would they be doing differently including in their main missions if all workers' voices were equally heard and hierarchies of voice weren't as strong perhaps in those organizations. So for those who joined the event late I will just encourage you if you have questions based on what you've heard to please put them in the Q&A box. We'll take those up in a moment. And then also I'd like to just start the Q going for anyone who'd like to raise their questions or comments verbally, you can hit the hand raise function and we will call on you to contribute verbally. But before we kind of go to all of your thoughts I did want to give our speakers, Rekhaia and the panel a chance to ask any questions that you might have of one another. I'll ask Abby a question. And I was just gonna say I'll ask Rekhaia a question. Go ahead Matt. I just wanna make sure I remember correctly my recollection is that the request at the meat processing came from the UNM team that was doing site visits. So it actually was neither the workers nor the meat processing management who was asking us for any advice at all. And this was one of the things we had to negotiate pretty early on is it wasn't the people we wanted to give advice to were not asking for our advice, right? And they certainly weren't asking for us to give them advice on their morality. So we had to figure out how to frame this in a way that it could be heard and assimilated and used. I don't know how well we accomplished that. I suspect not perfectly. But it was a topic of early conversation that we were trying to give advice to a group of people who had not asked for our advice and specifically had not asked for ethics advice. They had asked for public health advice on how to prevent transmission in their site. And we wanted to help them see that worker health onsite was related to community health offsite and that care for patients who became sick even though they didn't normally provide health benefits was useful to them at this moment. Maybe they would never provide health benefits and they disagree with employer provided whatever. Caring for people who are sick with COVID was in their self-interest. So we did end up sort of framing things with an explicit thought to how do we appeal to the values that matter to the audience we're trying to speak to? But by the way, I'll just make a pitch. I heard an amazing episode of Hidden Brain the other day called Radically Normal about social revolutions and it explores this question because I think ethicists deal with this question a lot. To what extent should we say exactly what's on our mind be very blunt and honest about the language we're using? And to what extent should we shape what we're talking about so that it's more assimilable, so that it's more hearable? And does that harm our moral integrity our own personal integrity if we're compromising the language we use so that we think it's easier for the other person for the audience to hear? And I'll let you all go listen to the Hidden Brain. It's a wonderful podcast. But this episode, it was just earlier this month. It was about how LGBTQ activists essentially won the country over and the different strategies that were used and what their relative effects were. Well, I'll hop in and thanks, Matt, for that. And while you were talking, I thought, oh, just remembering some of how the request came in and again, that really saturated landscape of so many issues happening in real time, us working through in April, 2020, are they, do they have masks? Do the workers have masks? Do they not have masks? What's happening right now while this is all unfolding in front of us? And I think, we focused a lot on the idea of interdependence of that these interests are all really aligned in a lot of ways at this moment in time. But what Rakaia, what you just said and what I was going to ask of you is, I really loved how you articulated this idea of really creating an organizational shift, but these are such entrenched practices and longstanding issues. And so it made me curious to want to hear a little bit more about what are the steps of those organizational shifts from your body of work as you've observed? So I'm going to speak to learning about this as I have been working on governments, local and county governments using racial equity tools to achieve racial equity. And what you see is an organizational shift, right? To beginning to have training, to beginning to normalize, even talking about these issues. And I want to say that I think a part of it is really beginning to have the discussion, right? In multiple different ways using different kinds of language. And as you mentioned, interdependence, I think is a beginning. I think also talking about, and this is why I highlighted just the lawsuits by the shareholders and the push for the human rights, reporting is that this is something that people within the organization want, right? And so when you think about shareholders, when you think about all the various different levels, government, that these are things that they want because they believe it is best for the community, for the company overall, you know? And so beginning to talk about those in ways and very intentionally and over lots of period of time so that they begin to become ingrained, right? And so no change, and that's what you said, right? No change happens overnight, right? Even the meat and poultry processing sort of plants didn't, they weren't staffed by racial, ethnic minorities and immigrants, right? They used to be great jobs and then there was a shift but that shift happened. And so being very intentional about shifting back. I think also what I wanna highlight sort of came from what Matthew was saying about who asked for the consultation initially, but then who is using the consultation and some of the work that you were putting out. And I can tell you it's the meat and poultry processing companies, right? And so most recently, after they were called to DC to testify, I mean, you know, DC Zoom to testify, I noticed that they started using some reports from the University of Nebraska to say, hey, we're doing a great job, right? And so if they're gonna say from the reports we're doing a good job, then it has to be about but what are you doing, right? So you're going to use our reports which you didn't ask for to show that you're doing a good job, but we're saying that you need to actually do this and this is what you haven't done, right? But in the last part about it, I would say is that, you know, I don't know if it's just this industry but it's for me and organizations that just saying you did this, you met the standard is enough is not enough, right? And so always trying to be at the forefront of innovation and improvement is key. And so I think that is a part of the issue too of saying, no, okay, you might have done it this way for a number of years, but guess what? It's not necessarily working or it can be better. And so these are the ways we should get you to think about innovation and change because so much of what we are doing changes, right? So much of internet and Zoom and everything is changing and companies are trying to stay up with that. So why not do the same thing on the worker field in terms of protections? And so that's just, I've given you sort of lots of different language around it. And so that's what I think we should highlight to them as well as equity, right? I think that is really key too. So I'll stop there. This is such a thoughtful exchange and so I hate to stop it right now but I do think that if we turn to the audience questions perhaps even more things will come to the table. So generally I would ask Charlotte and Jim if they'd like to ask a question as co-chairs of the consortium. Charlotte or Jim, do you wanna ask a question now or should we table that until the audience has a chance to ask theirs? The one question I'd throw in is an invitation. 18% said they would probably not undertake this consultation. And since we know there have been lots of impediments to the development of organizational ethics it would be very valuable to understand what are the hesitations that that 18% felt? Thank you, Jim. While perhaps if anyone wants to raise their hand and to share some of the impediments that they were thinking of, I think that would be great. But I do see one hand raised. Oh, Matt you're kind of doing it physically but okay, I do see one hand raised which has been up for some time. This is Lisa Lehman. So Lisa, if you wanted to just share your comment or question, you should be able to unmute. Oops, do we lose Lisa? Sorry, just, can you hear me now? Okay, great, it just took a while to unmute there. First of all, just thank you for such a wonderful presentation on such an important issue. And just it's fantastic to see the depth, the sensitivity, the breadth in which you address these issues. I wanted to build on Matt's comments. And in particular this question, I think that as ethics consultants, as ethicsists, we want to have an impact, right? We want our thinking and our approach to actually make a difference in terms of what people do. And many of the suggestions as was pointed out were not typical for what employers might expect. And maybe the employer wasn't the person who even requested the consult here. So I'm wondering if you can speak to a little bit. I'd just love to learn more about what actually happened in practice. Were the recommend, how were the recommendations received? And in retrospect, would given that the responsivity or lack of responsivity potentially to the recommendations, would you have approached it differently in terms of either the content or the language in which you shared it or the reasoning to try and persuade people to act more ethically in the ways that you were suggesting? Abby, do you want to start? Matt, do you want me to start? Okay, yeah, sure. I don't know where you are on your Hollywood squares, I'm pointing to it right now. Okay. All right. Lisa, thank you for that question. I should have been writing it down, but I think from my perspective, working with the Global Center, I felt like it was impactful to be able to come into that space when you're thinking about power differentials, when you're thinking about social vulnerability and really the collaboration with Athena Ramos, who works in the Center for Reducing Health Disparity and works closely with Ag Worker Health to be able to kind of come together and think about the issues and be able to kind of then take them to folks with infection prevention and control expertise and kind of try to do something more holistic. Would we do it differently? Maybe there would be moments. These were in moments where I think people really were listening and trying to figure it out. They were trying to figure out how to handle this. And you also have to remember that meat processing plants at that moment in time were really experiencing massive production loss as a result of infection rates and hotspots in facilities and fear. So I don't know if that answers your question, but maybe it gave Matt enough time to come up with an eloquent answer as he usually does. No, I think that, I do wanna bring us back to March and April of last year when plants were shut down. So it was to some extent an opportunity. It was a moment when the impact of failure to do the right thing with regard to public health was hurting. And so it's not the case that everyone did everything we asked. And to Jim's earlier question about what were some of the things that might have held us back from jumping in on this. One of them was we were pretty aware that OSHA was not gonna issue any emergency rules. So anything we did would have to be couched in a way that it would be usable by the audience that hadn't asked for our advice. And that might mean that they would use our report as cover for whatever it is that they chose to do or not do and say, hey, we're being ethical. And Jim, you'll remember actually years ago we worked on a report about ethical decisions in making coverage decisions at plants. And we had a guy there from the United Auto Workers who really didn't want us to write a report because any report we wrote, he felt would potentially be subverted and used as cover by automakers in what he saw as purely a power relationship that had nothing to do with ethics when it came to what got covered under health insurance benefits. And I think that same dynamic to some extent played out here where you could make an argument that anything you say that puts this into an ethical frame is liable to be used subsequently by... And I think Rukai just mentioned that it may actually have happened that way that they may have pulled pieces of this report and said, look, we're doing this and this that makes us ethical. I actually didn't see that, but I'd be very curious if that's recorded anywhere because certainly they did not do everything that we said would be advisable. But we also didn't say you must do these 10 things or you're unethical, right? Because we were trying to appeal to values that were shared and that we thought might drive them to what we saw as both better behavior, more ethically justifiable, and also from a public health standpoint in the midst of a pandemic, really self-interested behavior. And one of the things that has happened with the pandemic, of course, as we've seen in multiple domains, things that many of us have long thought are in the long-term self-interest of various actors are now also in their short-term self-interest because this is playing out so fast that things that normally, if you wanna make the argument that everyone ought to have health insurance, you can't get a better circumstance than a pandemic where everyone who doesn't get care poses an immediate threat to everyone around them. So we had this moment where we thought we might be able to move the needle and help folks to see the value of providing better coverage, providing better sick leave of not using line speed waivers, right? There were a variety of the point system, all of those things. I think many people felt like those were bad ideas to begin with. They were harmful to workers. They were harmful to the work environment. They caused death and illness at the baseline, but suddenly the pandemic just, you know, shown a spotlight on it. Yeah, and I would just add a couple of things. I mean, agree 100%, we always run the risk whether it's ethics recommendations or, you know, law that that gets transformed, like minimal compliance suddenly becomes the ethical thing to do, right? And this is sort of the widespread problem. So I think we were aware of that. The other thing is though, I think we were under no illusions that we were suddenly gonna write a report and then, you know, the whole industry would be like, oh, it's the ethical thing to do, you know, but I do think it, you know, and maybe this is wishful thinking. I'm hopeful that for those who were really interested and certainly some were really interested that it gave them a way to think about doing what was in their long and short term interests. And the other thing I'm really hopeful to find out down the road and we may not know for a while, but, you know, I'm just coming up with this analogy a little bit with as we have changed things during the pandemic for people with taking medication for substance use disorder, for opioid use disorder, we've allowed a lot more telehealth and now there's talk like, hey, we thought this was a terrible idea, but we found out it's not such a bad idea and maybe it is something we should just make possible all the time and like along the lines of what Matt said, I'm really hoping that maybe they found out like it's not impossible to operate without a point system, it's not impossible to provide sick time and still keep production at a acceptable level and hey, maybe our employees a little bit happier and feel a little bit better about work and maybe production's going up. Again, that's a dream, I know, but it'll be really interesting to see what practices stick around and which are quickly abandoned. Thank you so much. I wonder Charlotte, you've been tracking the Q&A discussion if there's any question that's popped out that you'd like to raise for the panel. Well, thanks Kelsey and thanks panel. I think you have addressed some of the questions that people were raising. One was about a stakeholder participation in the consult in some ways, I think adding to Rukia's comments and wondering how did you think about the role of the worker's voices or worker representation in the consult? And I think I would add, you know with the experience of this consult behind you, how would you think about it in a future consult? I'll start us off and then anyone feel free to add. I think that's why the collaboration with Athena Ramos as I kind of mentioned was so powerful because she had deep connections within the community and we were able to hear through her what people wanted at those community organization meetings. There were four of them launched which we were able to, I was able to attend and hear what community organizers were thinking and saying and the perspectives there. And then through the survey that she had sent out we were able to kind of hear more from that perspective on that. But in terms of having an actual worker at a committee meeting or anything, I don't know, you know there's a lot of trust that has to be built. And it's why it's so important to work with community organizers and so important to be able to kind of have those seats at the table. And so that's what we did to really kind of try to hear at that moment in time again what they were thinking and the perspectives that they had in mind. I think that's really helpful in the person asking the question was comparing to what might be done within an institution in an organizational ethics consult. And what you're highlighting is when you're scaling up to a whole industry crossing several states and you're trying to get the kinds of input that you need, what are some different devices that made sense in the context you were working in? So yeah, do you wanna add? I'll just make one quick addition because you had also mentioned Charlotte what would we maybe do differently? I think if I were going back and rewriting the report I probably would have put in some illustrative quotes from that had been heard from workers. I honestly, I probably would have also put in some illustrative quotes from managers throughout the report sort of highlight, call quote type things. This was not a formal qualitative research but I'm aware of how powerful a quote can be sometimes in helping people to see and hear what you're trying to say. And I think if I were rewriting it I might have put in some call quotes. Any other comments from the panel? As we have only a couple minutes left I think we all wanna thank the panel for the incredible range of action that you undertook here and thought and for identifying the challenges that really continue and trying to be able to respond to what is really a failure of public governance with an ethics consultation. I'm gonna ask Jim Saban to give us a wrap up with a couple of comments and then we'll conclude with an announcement of the next month's Org Ethics Consortium. Thanks Charlotte. So this was a fabulous presentation and discussion. So thanks to everyone. Abby got us started by pointing out the way in which this whole process began with the boots on the ground approach. It was through the ID consultation to the industry it was the opposite of an ivory tower approach. This was not academic ethics coming in and preaching. It was the boots marching from the frontline into some ethics questions. Matt gave us some very good lessons for organization ethics work particularly the diversity of skills needed. It's a broader range of skills that OE calls for compared to clinical ethics. And this was an ongoing process that got a lot of attention from the group. There was a snowball effect that I think will happen in other venues. Once the ethics process was out in the field all sorts of folks started to knock on the door with requests that weren't formulated necessarily in ethics language but they brought up problems and issues which the committee had to work with to turn into viable consultation questions that they could respond to. I wrote down a quote from Kelly that I think we should all put on our bulletin boards. We wanted to resonate with our audience and that was really central. Hearability, Matt brought in that term. Hearability was crucial here. You were talking to supervisors. You were talking to workers. You were talking to government people and they all hear, they have slightly different languages and the hearability process if this is gonna be useful at all is crucial to pay attention to. We're not starting from an off the shelf ethics text. We're starting from looking at the receptor sites in the folks we're working with. And Rukia put it all in terms of looking for potential structural and systems changes. That's where the large impact for the long-term are available. And she emphasized again and again the component of accountability. We're not just speaking words to the wind. We're speaking to systems that have public responsibilities and articulating those accountabilities is key. And finally, last month for those who were part of our previous session, we also took up a consultation with a for-profit entity and it was a small biotech company compared to a humongous meatpacking company. So it really spans the range. And then 10 or 15% in a survey said they would have hesitated to participate and it was the same fig leaf concern that our ethics consultation could inadvertently in terms of our own intense intentions be used to put the wolf into sheep's clothing and to claim virtue where virtue is not what was being demonstrated. So thanks for a fabulous opportunity to look into the process of consultation in the most complex imaginable environment. Hats off to what you've done. And further thanks and just a tip off for the April session in the April consortium, we're gonna shift our focus from public health to precision medicine. Although we will be continuing to look at ethics related approaches when important values issues are not being addressed by law or regulation, sometimes appropriately and in other ways, perhaps not so. In the area of precision medicine when novel therapies are being created in our healthcare institutions, what sorts of oversight can be effective at the organizational level for both the science and the ethics of innovation? So the date will be a month from now, five weeks from now, April 23rd, July 30th Eastern and we hope to see people there. Thank you again for joining us, panel and audience and for all your engagement with this crucial public issue. Thank you.