 Good day everybody. I'm Gareth Manning, Wonka's CEO and a very warm welcome to this, the sixth in a series of Wonka webinars. Today the topic is rural issues linked to COVID-19. I think it's fair to say that rural and isolated communities suffer even more through COVID-19 as it's yet one more of the social determinants which impact so severely on their lives. So this will be an extremely helpful and instructive session. Today's webinar will be moderated by the chair of Wonka's working party on rural practice, Professor Bruce Chater, and he has put together a truly global panel of doctors and nurses to talk about the issues. The panel will be introduced as we go along, but I especially want to welcome Professor Michael Kidd to this webinar. Of course Michael is a past president of Wonka and now principal medical advisor and deputy chief medical officer at the Department of Health in Australia. Welcome Michael. Most of today's session will involve a series of presentations but there'll still be an opportunity to pose some questions to the panel either through the chat forum on Zoom or via the Facebook live streaming and Pratush and Sanka will be monitoring both. Questions will be moderated as usual by our president elect Dr Anastav Dal. But first before handing over to Bruce I'd like to welcome our Wonka president Dr Donald Lee for his opening remarks. Good day everybody. Good morning. Good afternoon. Good evening. Welcome to the sixth Wonka webinar. Next slide please. Family doctors continue their massively increased workload as we face the COVID-19 epidemic. I'm proud of the level of support and collegiality displayed within and across our member organizations and from region to region. Family doctors all around the world are disseminating scientific advice, clinical updates, reflective messages and professional support through their social media links and connections. The Wonka webinar is a platform for all of you to share experiences, relay information and to keep in touch with each other regularly like family members, urging courage, offering mutual support in these extraordinary times. Next please. Processing a broad range of skills family doctors in rural practice provide comprehensive and irreplaceable care to rural communities. Rural practitioners deal with clinical uncertainties every day, managing patients who present with unspecific signs and symptoms and often have limited resources, equipment and support from other specialists. It is in part because of our ability to manage clinical uncertainty. Family doctors are well adapted to cope in times of acute uncertainties such as COVID-19. This webinar will enable rural doctors from around the world to describe how they are preparing for protecting against and dealing with COVID-19. The session will allow sharing of initiatives, limitations and concerns and explore how rural health systems prepare for the future in the COVID area. So now back to you Graf. Okay thank you Donald. Well without further ado I'll hand over to Professor Bruce Chater and his team. Thanks Bruce. Thanks very much Garth and welcome to this webinar hosted by Rural Wonka and and Parent Wonka. Thanks to Donald Lee and PressElect and the staff guy for their support in these webinars and particularly for having one focused like this on rural issues. I'm Bruce Chater the chair of Rural Wonka, the Wonka Working Party on Rural Practice. Many of you have known me for years you'll be wondering whether you'll be whether I look slightly different. Yes the beard has gone as only appropriate for fitting a proper fitting face mask. So even my beard is a very minor casualty of this COVID epidemic. Little did we realise last year that what was over the horizon when we look forward to the 17th world rural health conference in Bangladesh. Our wonderful colleagues in Bangladesh and South Asia worked hard to develop an exciting conference but this was overtaken by COVID-19 and its devastating effects on the community. Like many other aspects of our lives. Next slide please. We had to go through how to get this online and so we had the issue of COVID-19 over our head in doing that. This is the first step in rolling out a virtual conference to respect what has happened to our colleagues in Bangladesh and we thank very much Zakir Rahman and his young and very enthusiastic team who've been working with us to have this conference and now to have it virtually through this and other webinars. Next slide please. What we're talking about tonight is in tonight my time and many of you in different time zones is a variety of issues. There's some COVID issues around the patients obviously who are affected by COVID, the practice, how do we cope and care for those patients, COVID care, the variability that there is with COVID across the world. Concurrent issues such as pregnancy and other concurrent conditions. Very importantly those things that are displaced by COVID issues, the usual care that we provide, the public health issues that access for people into those services and also the migration issues. The migration back to country, the migration from country to country. Medical education issues, how do we get a virtual medical education situation, a medical course, postgraduate training, the economic issues that I think all countries are now struggling with and the future issues. What's practice going to look like after COVID? What's going to be different? Will some of the changes that have happened stay or will they move back to the way we were? I think most of us suspect that there will be changes but what those will be can be hard to predict. So as a rural resident and rural doctor I've faced, pondered and addressed many of these issues in my own practice and in my hospital. I'm so looking forward tonight to hearing the experience of others from around the world who face these in their own environment. I'm having uploaded a more detailed working list of some of the issues. If Harris can get that up on the chat for us hopefully there'll be a link there for that and you'll be able to hopefully look at that list as a prompt to your questions. We've assembled a really great panel tonight to from around the world to touch on all these issues followed by a chance for you to answer some sorry to ask some questions and for our panel to answer those questions. We've got two ways that that will happen. There'll be a Zoom chat and a live feed on Facebook and we have Sankar, Radona Kumara and Pratush Kumar monitoring and feeding these to Anastav Dal who will pose the questions to our panel. I'll just introduce the panel now to you and then we'll very give very brief introductions between the various presentations. We've got Michael Kidd who's already been introduced to not only as a former president of Wonka but a deputy chief medical officer in Australia leading policy interventions. Desmond Bois featured in the New York Times recently and had six patients on ventilators in the USA. John Wynne Jones our former chair has been keeping on a finger on the pulse around the world and sharing our humanity via rural health Wonka, Ms Saleni. Zakur Rahman has seen the toll in his local community and his colleagues. Joseph Vidal Alabaal has been helping contain the virus in Spain. Gobbath Ranas Singh Am, sorry Gobbath, I have troubles getting my tongue around the Sri Lankan names but has been on the front line in Sri Lanka so thanks Gobbath. Nagwa Higazi has been leading the emergency remote teaching in her school and student support in Egypt. Maiara Floss has been advocating for her rural communities in Brazil. Ji Gu has participated but in the specific prevention and control work in the grassroots level in China. Susan Thomas is a nurse who's been on the COVID-19 front line in general practice and a lead for eight practices working in a small primary care cluster in South Wales and Henry Lawson has been helping contain the virus in Ghana. So I'd like to pass over now to our panel and I'd first like to invite Michael Kidd to give you his presentation. Welcome Michael. Thank you Bruce and thank you for the opportunity to join with everyone today and thank you to Wonka and to Donald and Anna and Garth and Harris and all the Wonka executive for the great work you're doing continuing your advocacy for family medicine around the world and thank you to everyone for listening in for the extraordinary work that you are doing protecting the health and well being of your individual patients and your communities in countries all over the world. It's been so inspiring to hear the stories of many of you coming through the Wonka publications and from your colleges and societies so thank you for all that you're doing. If we go to the next slide Harris I just thought I'd provide a very quick overview of what's been happening with the pandemic in Australia like many countries we had a very rapid rise in the number of cases and then we've seen that fall off as the country has gone into lockdown and just over the last few days we've seen the lifting of some restrictions but a very tentative lifting. We've had about seven thousand cases right across the country and just under a hundred deaths from COVID-19. Move to the next slide Harris. Part of my work with the Australian government has been a responsibility for part of the leadership of Australia's national primary care response and one of the very first things we did was to set up a set of key principles about what should happen in a primary care response and I wanted to share those with you. The first was about recognizing the critical role of family medicine in protecting the most vulnerable people in each of our communities from the effects of COVID-19 and therefore why family medicine is an essential part of any country's response. The second was making sure that we preserve the functional capacity of family medicine to keep providing care for our patients with acute problems with chronic disease problems with mental health problems needing preventive care and so forth all the work that we normally do but recognizing from the experience of past pandemics and epidemics that often more people have significant morbidity and mortality related from other conditions rather than related to the infectious agent so the importance of keeping family medicine functioning during a pandemic. The third was recognizing that many people will have mild symptoms and these people will be managed by their family doctors in the community and so ensuring that we were equipping and educating our family medicine workforce to look after people and the fourth was recognizing that people working in family medicine and primary care adjusted as much at risk as healthcare workers working in hospitals and other settings so the importance of personal protective equipment being available to people working in family medicine and primary care as well as people working in our hospitals so that we can protect our workforce right across the nation. The next slide please Harris shows some of the interventions which we've been doing in Australia. We've introduced telehealth for all family doctors and as you can see we've had nearly 10 million telehealth services delivered to Australians over the past eight weeks. We've had the national helpline with large numbers of people dialing in for assistance and advice about whether they should get tested and where that should take place. We've established nearly 500 respiratory clinics in metropolitan regional and rural settings right across the country and very importantly these clinics help to segregate people with respiratory symptoms from people with other conditions and so many of these clinics are set up and run by family doctors across the country including many of our rural family doctors and finally the amount of infection control training which has been offered with online training to protect our workforce in family medicine in aged care disability care as well as in our hospitals. The final slide just shows a couple of images from our respiratory clinics which have been set up on one side you can see the details for clinics set up in metropolitan South Australia and also in rural areas just with advice for patients about how to access these clinics the sort of services which are being provided and then an image of one of the clinics set up in a series of demountables and I think you can see there Ewan McPhee who I think is actually online at the moment the president of the Australian College of Rural and Remote Medicine who's one of the family doctors in Australia who has picked up the challenge of offering a respiratory clinic for the people in his community. So that's where I'm going to stop Bruce but thanks for the opportunity of joining. Thanks very much Michael and thanks very much for your leadership in Australia and in fact obviously now and in the past your leadership around the world. The next person to present is Desmond White. Desmond was a came to my attention as someone in the featured in the New York Times over recent times and he had to deal with a group of patients in a very small rural hospital in Indiana so over to you Desmond to tell us what your situation was. Thank you Bruce. Hello everyone my name is Desmond and I'm a hospitalist mainly working in rural health care. First I'd like to thank Arul Wonka for giving us the opportunity to participate and I would like to start off first by telling you a little bit about Margaret Mary health and then go into a little bit about our experience with COVID-19 as a rural hospital. Margaret Mary is a 25-bed critical access hospitals. The previous slide please Harris. Margaret Mary is a 25-bed critical access hospital. We have four ICU beds. Our scope is primarily outpatient services and we also have a fairly robust oncology center. The picture on the left there's a pin on the map. Batesville is located somewhere between Indianapolis and Cincinnati and the closest major international travel hub would be Chicago and that's toward your top left of the picture. The population here is approximately 6,500 people and the city has a total area of about 16 kilometers square. The picture on the right shows our emergency department entrance and the COVID-19 drive through testing tent. Next slide please. About the COVID-19 crisis at Margaret Mary we first had a positive patient around March 13th and then a big surge happened towards the end of March lasting until sometime late April and what we would see is that patients would present with approximately the same constellation of symptoms. You have shortness of breath, you have nausea, you have diarrhea, myelogias of fatigue and then they will be found to be quite hypoxemic. Virtually all patients had the characteristic chest x-ray findings that we see with COVID-19. The diffuse ground glass interstitial pattern as seen on the picture on the left and after being admitted many of them would decompensate within 24 hours. Their follow-up chest x-rays would be much worse. The image on the right is the same patient approximately 17 hours later and these patients would end up being intubated for imminent respiratory failure. Next slide please. There were numerous clinical challenges in caring for these patients. First our ICU is typically used for patients you know needing close monitoring or for those on medication drips for rapid atrial fibrillation or diabetic ketoacidosis but with COVID-19 we actually ended up with more ventilators being used than actual ICU rooms available and even ended up having to use rooms on the medical surgical unit. At one point we had used up all six ventilators available and approximately 18 out of our 22 patients had a range of respiratory problems. Secondly the amount of test kits available for COVID-19 was extremely limited and on top of that the initial turnaround times would range anywhere from 4 to 12 days after sending out the test. Another big challenge for us was when we ran out of our typical sedatives like Propofol, Midazolam and we had to start using drugs like dexmetatomidine, ketamine and even paralytics in large quantities which is something we typically don't do. We were fortunate enough to have our emergency docs and anesthesia department help us out with things like intubations and some vent management and this was indeed a blessing as one afternoon a patient self-extubated and while a team was in his room getting him re-intubated the patient next door somehow managed to disconnect his own ET tube so thus a different team had to scramble and respond to that situation and this would not have been possible if only one physician was on duty. From the administrative side of things there were also challenges. Our CEO Tim Putnam spoke of not just flattening the curve but also raising the bar which meant that as a healthcare system we needed to prepare as much as possible to be able to meet the increased demands of the crisis we were facing. There was the creation of a search plan to increase capacity from any from our existing 25 beds all the way to 70 beds convert our obstetrics unit to another patient care unit asking primary care doctors to help out in the hospital hiring more staff securing more equipment and also deploying much needed telemedicine services. We also took the initiative to meet with the larger hospital systems in the Cincinnati area and kind of work together such as being able to transfer our sicker patients to them where they could get comprehensive critical care support experimental treatments or in turn accepting some of their less critical patients and offload their facilities if they were at capacity. Next slide please. Despite the challenges and uncertainty during this crisis there were definitely some bright spots and positive highlights for us. We were able to utilize an innovative invention called the intubation box. You can see that in the picture on the left which I'm sure most of us have seen. This can help to contain most of the aerosolized virus and spreading during intubation. A bright spot for us was certainly being able to get our local community informed and involved. Below you can see some pictures the middle one is words of encouragement left by the community at the entrance of the hospital and then the picture on the right is one of many instances of free food delivery delivered by local businesses to the hospital staff and finally we also managed to develop a COVID-19 resource website which was publicly available to the community. You know all in all this shared experience definitely brought our team closer together and we made it through that tough period with many many lessons learned. For anybody who's interested the New York Times published an article highlighting some of the challenges faced by rural hospitals in the U.S. and we were amongst the participants. Link is at the bottom of the slide. Thank you very much for your time. Thanks Desmond and I think you've shown us what it's like at the front line. I will ask people I notice some questions coming in one from Rick there about lessons that have been learned. So please keep those questions coming in and our team with Sunker and Pratush will be collecting those up for you and feeding them to Anna. Talking about bringing all the information together John Wyn Jones from isolation in the UK has been doing just a fabulous job for us getting both the facts and the humanity together. So John tell us what you've seen in that last couple of months that you've been doing that. Thank you Bruce. I've spent the last eight weeks scanning social media on the internet. My aim was to find relevant news opinions scientific papers education and resources for rural health practitioners around the world. My initial concern that there was not much out there and there's an infinite amount of information. People are getting information overload and the World Health Organization calls it an infodemic. So I saw my role as someone to navigate the labyrinth on behalf of my colleagues in rural practice. I've collected information I've sent out to daily newscast or a blog. I'll leave the poetry out this time because that's another story. Reading through the literature there are three things that I became aware of very very quickly. First of all this is a new disease. It's changing all the time. It's certainly not flu. Secondly this is a nasty disease. It's brutal out there. Health care professionals are witnessing experiences that none of us none of us experienced doctors have seen in our lifetimes. Frightened people are dying. They're confused terrified and separated from their loved ones and thirdly there's no sense to this disease. It defies logic. It differs from country to country in region to region. I compared the figures from rich western Europe which has been particularly badly hit with those of south asia and particularly with my colleague British Kumar from Bihar. He describes a different story with fewer deaths, fewer infections and a disease that impacts more in young people than older people. There's so much to this disease that we don't know. Let me try and describe some of the major topics that have filled the COVID-19 news headlines in the scientific community over the last eight weeks. No particular order and I'm sure I've let some out. First of all fake news. Even WHO and UN are concerned about the impact of fake news on the scientific response to the pandemic. It's clear that it's very disruptive. Bad science. Poor research is being put up on the internet. It's not peer reviewed and it's just been posted online. There's a lot of anger out there. It's aimed mainly at policymakers, managers and governments. The public and healthcare professionals feel that they've been left down. Worldwide PPE is still a problem from the richest countries to the poorest countries. Lines of supplies are stretched, competed over and there's considerable amounts of racketeering and healthcare professionals have died as a result of it. Information mainly sadly comes from rich countries or I've tried to incorporate poorer countries as well. There are major concerns on the impact of this disease on rural areas where demography is different and resources are limited and that's in rich and poor countries. Patients are frightened or they don't want to bother their family doctors so they're not attending. So people are saying where are all the diseases? Where are the strokes? Where are the things that we normally see? Migration is an issue. There's special concern about impact of the disease on rural healthcare systems and in particular in the US strangely. As COVID threatens rural areas hospitals are closing down because they're becoming bankrupt and staff are being laid off. There's also mounting concern about the disproportionate impact of the disease on certain racial groups, indigenous populations and the poor. It's very interesting that MSF have been actually sent into the Navajo Nation. The worldwide emphasis on COVID is having a major negative impact on greater killers such as tuberculosis, malaria and HIV and these diseases seem to have been sidelined. Mental health's a big issue now and into the future. The countries that cope with Ebola, SARS and MERS seem to have managed better and much space is given to international and internal politics and certain politicians and I'm not going to mention any names spent fill a lot of the news. So as a timeline I've seen a change in the internet content. Initially we saw resources, practical solutions and positive thinking. As time moves on we see blame, despair and anger. There is genuine concern for the future of rural life, its impact on services, economies and jobs. The news now is dominated by concerns as to how will it all end? Will there be a second spike? Will the virus ever go away? Will there be a vaccine and if so when? What will be the cost in rural health care systems and the jobs and the economy and will now be the new normal? To finish I've been aware of many personal and heroic stories, examples of great humanity and compassion in awful circumstances. The doctor who managed a small hospital entirely on his own with little in the way of resources. The young newly qualified GP from Brazil sent out to an area with no previous experience and significant COVID infection and yet she coped. The doctor who was so ill that she had to go to bed with COVID but continued to try out her patients from her bed because there was no one else to do it. Nurses, doctors and not only health care professionals but cleaners who camped out in caravans so as not to infect their own families. Staff using their own mobiles so the dying patients could be connected with their families for the last time. Health care professionals who kept working despite no adequate PPE or support and health care professionals who gave their lives when they knew they were at risk. This disease has brought the worst in a few but the best in many. It's been a privilege to spend the last eight weeks in the digital world. Thank you. Thanks John. Harris has just asked me to cross to him because he's got some news about some Zoom issues and then we'll be crossing straight to a video from our Bangladesh colleagues. Harris? Yes, good day everyone. My name is Harris Lizdykis. I'm over viewing now the technical aspects of our webinar just to let you know that we were aware of some technical issues with Zoom. Kindly if you cannot see our screens or you cannot listen our audio of course you cannot listen to what I'm saying right now but kindly update your Zoom client to version five from the website of Zoom or alternatively you can just follow the stream of the live stream on Facebook on our page. It's facebook.com slash wonka world slash live. There there are no issues technical issues that you can watch the whole webinar there. That's it for me and thank you. Thanks Harris. Can we run can we run the video please if that's possible? Okay with that opening we'll go across to Zakir from Bangladesh and Pramik and Keren Rural Health from Bangladesh to you Zakir. Thanks Bruce. Thank you all. Well, mask is better than ventilator. Home is better than ICO. Let's start our stories. March 28, Jamal at 32 years day labor came to our clinic with history of fever for three days and my colleague received taking history and after examination advised him for whom quarantine. He replied how it's possible being six member family lived in a less than 200 square meter room how I maintain social distancing before COVID-19 we will die rather hunger. Any of you wish or some experience next. So most of you next Harris most of you guys heard about PPE but it's very hard for even our doctor and healthcare worker. The previous slide a young lady done genomes sequencing of COVID-19 and we are doing so many lot. Our doctor introduced ivermectin and doxycycline with some patients and they hope it will work for COVID-19. So we have some innovation in small country there is eight most populous country. You know social distancing we are not maintaining because densely populated people but our parents will try to follow our inspection and we are trying to managing PPE as well as to serve our colleagues those who are despite PPE serve the nation. Next, Harris. Harris are you hearing. So when patient comes to us we maintain a trials like others we maintain a she tries like that with epidemiological history high risk and no clear epidemiological history but fever, median risk and others are low risk. We received a patient in April 2nd retired banker and with respiratory distress fever and loose motion and ultimately diagnosed as positive COVID-19 by RTBCR and advice to whom isolation. He maintain it and within two weeks he get well because next we only encourage severe respiratory distress and oxygen situation less patient to come to hospital or admitted to hospital when the situation and you see we have so many COVID-19 dedicated hospital. This hospital is I remember visited by my friend John and guard last year on the eve of World Rural Health Conference in Dhaka. Now the 400 bed teaching hospital along with 100 bed isolated COVID hospital and me when in action and when in plan or holidays next please. So testing testing and testing by WHO and everybody know that we need it but sometimes test is managed by other people and done and test positive they hide it because of social discrimination you know by media and ultimately they infect the society and it sometimes hampered their last program like in graveyard or something others so they hide it and they infect our doctors as well next please that is so these are our health fighter doctors they are very near to us they died they are sad their patients until their last breath we salute them we mourn for them but you see the left side 100 faces of our future they are growing up they are still they're doing a lot we are very proud of them and they all are inspiration for rest of the globe they are doing active part for our health system though we have so limited limitation but we are doing well and they are doing well for our preparation conference but they are now certified volunteer for COVID-19 they help government toll and they help in telemedicine some of them giving other social issues they for those who are vulnerable or need that's the issue we are not treating the patient being a female physician you know we are doing other things they are sometimes very important than giving the prescription of treatment like that and they are very doing well they manage ambulance and they are helping people to come to hospital and then health awareness and these people are making the video I am doing nothing they are making the video next please next here is and we share everything for betterment of our people and definitely we will work together and we will win over COVID-19 so many a disaster we face so it may take time it may take people but once we win over COVID then what about post-COVID thoughts all my family medicine colleagues you are doing lot but any thoughts from us thank you all thank you very much for patient saying thanks Sikur and it reminds us of the sacrifices of rural doctors all around the world and those of your colleagues and obviously our thoughts go out to them and their families but also all of your patients and the particular issues that there are in lower middle income countries with social distancing and I'm sure we'll have some discussion around that our next speaker is Josep Vidal Alabaal who's from Spain just has been involved very much in the epidemiology in Spain and also in his own small hospital which has transformed quite markedly since the crisis so over to you Josep oh hello good morning from Catalonia Harry if you can put the slides yes next slide well as probably you know Spain has been one of the worst affected countries in the world next slide and particularly my nation Catalonia we had lots of cases in mid-march and especially in my own area in the Catalan Central region this is a small rural area but although the regular reality should protect from COVID because we have less population density we had lots of cases of COVID and this phase a huge challenge for us next slide because what happened it can vary well very suddenly so we had many many health professionals affected either by infection COVID-19 but most of them they were quarantined because we didn't have protective equipment at the beginning or we didn't know that we were dealing with so many patients with COVID so we had to quarantine a lot of health professionals so what we had to do is we had to close many small practices mainly rural practices because we didn't we didn't have a staff to just to run them so we have to concentrate all the health services in in big health centers in the in the medium cities and it changes this changes everything because what happened is that we have to reduce phase-to-phase visits we had to separate possible COVID cases from non-COVID cases and we have to concentrate on on doing home visits and then on the top of this we had a huge problem with nursing home we have lots of cases in nursing homes and this also affects the primary care teams because we have to over the health care in the nursing homes so we had to deploy teams to go every day to all the nursing homes in the area just to give to give medical support next slide please what what has happened basically as I say we had a huge increase in non-phase-to-phase visits for the first time in primary care in Catalonia we had more non-phase-to-phase visit than phase-to-phase visits it was the first time it happened so basically which time which type of non-phase-to-phase visit we had we had of course telephone calls we used we are using a lot the telephone calls because we are trying patients but we are so because in primary care we are doing all the follow-up of all the COVID cases that are there at home or they have been discharged from hospital so every day we follow up all these cases just using the telephone we we are using virtual visits something that we had before just it's like tasks like rapid prescription signals we are using e-consultations that we had this but we are not using it a lot but now we are using e-consultation to send signals to send rapid prescriptions patients can send us pictures and we can reply to them and for the last two weeks we we had the video consultation as well next slide please Haris this is important because the e-consultations and the video consultations they are part of the electronical medical records so they are secure what we write in the in an e-consultation it goes to the electronical medical records so it's a secure way to send pictures to send rapid prescriptions next slide please and here is how you can see in this graph it's very clear because in the blue blue line is a face-to-face visits and you can see how they drop from mid-march and how increase the telephone consultations they are the green lines and also that the purple lines are the e-consultations so you can see the huge drop in face-to-face visits and the the increase in non-face-to-face visits next slide please what will happen in the future well the future in the present I think that nothing will be the same for I think a long a long long time because it will it may take a long time to go back to the pre-COVID situation so it is clear that we'll have to do fewer face-to-face visits we have to do this because we cannot have many people waiting in the waiting room my time is up sorry and what we'll have to do is to increase telemedicine services for this is important just to involve patients also we need to train professionals because this is a different way to to do consultations so we need to train professionals and we need to be sure that there are not inequalities in accessing these telehealth services so I think it's important just to avoid having inequalities next slide please and thank you very much for your attention. Thanks Jose and thanks to your team obviously and all the work you've done with that. Next is is Gobbath Ratnasingham who's from Sri Lanka. Gobbath's been on the front line in some of the hospitals in Sri Lanka dealing with some of the cases and also preventing obviously the spread so over to you Gobbath. Good evening family doctors on the front line, slide please. Sri Lanka is an island contributor population of 22 million from there 70 persons are living in the rural area and have a great network of free public and primary care facilities so there has been place many measures to control the pandemic condition such as closure and limitation at the end point like as a island country we don't have the borders and we cut down the airport and ports also screening process has been placed they are to find out the important cases the local cases also traced through the community screening and country was a lockdown for the more than two months and also effective quarantine isolation processes are being implemented as the family vision on the front line as you can see the picture so we still do all routine works in a modified manner the in the left side we do the limited face-to-face consultation with the precautionary and infection prevention measures also we increase the telemedicine and tele-consultation via audio and video platforms this is one of the that mobile app and all so it's a free accessible to the public and also the art of home visits on practice for the emergency basis overall as a physician we do all the health needs for the community over the great pressure next step please at the community the awareness program and contact tracing has been arranged the first picture is the we are visiting the contact tracing and subsequently they are being underwent uh testing and subsequently patient are isolated and this is treated in the hospitals and other pictures are from the cold center and the whole and coordinated center are effectively assisted by the medical students and community health workers they are doing a tremendous job here and the medication and essential are delivered to the doorstop in the help of uh volunteers health officers and poster department also here i have to mention the non-communicable disease health only condition and aged care services are maintained without interruption next step please yeah preparedness action plan was developed to face the pandemic condition in the hospital as well there are many diseases in the hospital were named around the country to treat the patients and this is a new disease so additional draining hard allocations medical supply and testing for facilities are pre-imposed you can see the picture from the left side that the other patient and visitors are kept in the temporary shelter they don't they have trash according with the symptom and history and they are sent for the respiratory or mental respiratory treatment pathway also we arrange the telecommunication facilities as well we always do the preventive and infection control measures next next slide please uh how we prepared in fact the professional meeting and local international collaboration with the sharing experience are conducted regularly also the guideline for the primary care physicians and dental practitioners are developed with the approval of minister of health and it was updated these are the pictures with this our one of the spice food dunk doctor's movement also the exclusive meeting uh and also the public awareness has delivered through the available media and source of fat food you can see i'm up there the tv and and also in the live facebook and also the one car website we do as next slide please next slide please the likewise other part of the world we too had a lot of challenges during the pandemic there as i said there are so that your personal protective equipment and essential further noted you can see the left side this is we have used the protein as a alternative and we made it the pp the minister doing my sample collection before that later we all managed with our own innovation and product local production in additionally increasing desktop infection long working shift family isolation burnout and efficient well-being finally we are already here in the game against the deadly virus and we will fight with the last and serve the world next please let me repeat that additional way to say greeting when i come i do one namaste happy family doctor's day which is coming in two days thank you thanks govath and and really inspiring what you're doing there and i think the innovation that that shows with rural doctors and the the ability to adapt to difficult circumstances is is truly amazing so thanks for that talking about adaption we're going to now go to nagua higazi who's on our council and from egypt and involved very much in family doctor education how's that adapting nagua hello everyone um medical education during the covid era had been witnessing a dramatic changes i'm going to talk about our experience specifically about our school experience with nearly around the 6000 undergraduate medical students uh our half decade learning management system had been abandoned and it had been heavily used with a paradigm shift from the luxury of e-learning as an educational choice into an e-learning as a solid choice actually this had revealed a lot of points that need to be addressed for an example amplified in equity if you are going to talk about amplified in equity we have to understand that 70 percent of our medical students are using the learning management systems via their smartphones and they don't have laptops also we have to understand an important point that one third of our medical students are living in a ruler area and is that that problem once there was a dropout of the assignments and follow-up complaints from our students due to the limited resources and demographic character characters in that places for an example electricity cut down weak internet coverage and technological issues in comparison to the urban area so there was an educational equity in equity between the urban and the ruler students due to the technological infrastructure and economic status uh how that had been solved with actually the materials the e-learning materials had been provided to our students on dvd and they had been uh exemption from the online assignments recently they were unable to come and take these materials because of the lockdown and because of the inaccessibility to get them so uh we are facing a lot of problems this is one of them which is the virtual learning if you are going to talk about another issues is going to be the uncertainty we are living the uncertainty period for us and for our students and as you see as a director of the medical education and human resources development center in our school we had to declare that to our students and to be transparent with them we are uncertain and stressed as much as they are because we are living uh exceptional moments at this period next please Harris during these periods we have to understand that our students are facing um uh stressors because they lose their compass in the roadmap and that's why our vice dean for educational and student affairs had been addressing our students with each important decision next next please yes thank you as a part of the mental issues here we have to be taking care of the psychological well-being of our students this had been done through different things for an example we have been doing live streaming videos using our psychiatrists a psychological doc physicians with us who had been addressing our students how they can cope with the stressors they are having the ministry of health and population also here had launched a hotline for the healthcare professionals and also for the community in order if they are having or facing any type of stressor how can they be uh dealing with that stressor and how they can do the support for them uh so um we are in the e-learning era do we have phones and phones yes we have phones and phones and we have to make use of it till the maximum we are doing it so next please Harris this is a picture from our community practice as you had seen from a ruler area we cannot people cannot be put into out into uh out of business for a prolonged time so based on the situation as you are see we are seeing in the picture the sellers are staying in around blocks where they had been determined and had been told that they have to be distanced within these blocks where there is a space between each seller and another one and also the sellers and the buyers are all um are all wearing masks this is because unemployment rate is high especially in the ruler practice unemployment rate is high especially in the ruler practice and you cannot ask people to stop uh to stop their life uh there had been efforts done by the non-governmental organizations in order to support these peoples uh via monthly payments uh thank you thank you very much Nagua and uh for that insight into into what's happening and I think uh there's been a real revolution in in medical school teaching and postgraduate teaching now Tamayara um is known to you all I'm sure as uh really one of the founders of rural seeds and uh but a great advocate for people in rural areas in Brazil Avadi Amara so good morning from Brazil to you all um I apart uh I think apart the coronavirus is striking all the world and all the rich countries I don't feel that's that equal to how it reach uh Brazil where people cannot quarantine where social that distancing is a huge issue where we have PPI please don't don't change the slides yet the slide before and uh that we are facing a huge crisis uh so political crisis I don't think it strikes equally I think uh who is in in the edge of the world is getting in a in a worse situation because hunger is a thing that we had before and the immune system is getting worse so we also talk about this huge crisis that we are we are facing here and also I use the term of the necropolitics here where we know that some people is getting less access to care than others so saying that before I go further we do have the project of the rural health success stories we have two stories so far about uh what's going on in the world uh the both of them are from Brazil I would like to invite everybody that's watching here to write we have uh some people that can help translating it into English and also publishing in your native language and I think it's really really important for us to have a broad idea of what's going on in Brazil in the world and also in other parts of the world that couldn't have the time to write a full article we are searching for stories and how it's been the experience in the front line so next yeah so just bringing a very quick idea we have done a whatsapp radio program where I work so we have spread it now in Brazil other um health units are doing it we are recording on the consultory room and then recording with uh like these microphones and spreading into the community we have helped another five help help basic health primary health care units to get this uh true and uh I think it's very interesting to see what's the results and the people getting more uh feel the sense of care and having trust in the in the doctor's voice in the nurse's voice and the health primary health team voice which I think it's really interesting with what we are living now uh with our infodemia our fake news uh pandemic pandemic so we need to be aware also and then having these micro politics where we can talk with our communities very interesting so if you need more uh I can I can get another time to talk more about that next well we started here in Brazil we did a quarantine that was a really interesting that we have a virtual camping for indigenous people and we also are doing a lot of telehealth during the quarantine but what I decide to bring today to talk next it's uh just talking a little bit about what's going on I just want to show this map from that had a more more than 150 kilometers from San Gabriel da Cachoeira which is the most indigenous city or region in Brazil we have 90 percent of people there that are indigenous and the distance is three days by river 26 hours by quick bolt and airplane by two hours but the next days they are to have someone transfer to Manaus which is the capital of the state in the middle of the amazon you are taking more than three days to transfer this patient so we cannot and then last week they run it out oxygen and this kind of region and the doctors are more deeply pushed in isolation and mainly the community is suffering a lot they are not reaching the adequate care and the next issue that is in Manaus it's 800 kilometers three days now to transfer the patient and that's what we are living now we have can you go to the next we have already a lot of indigenous people that were dying this is an artist from the design ethnicity and he died by probably by covid probably because we are not testing enough as well we don't have tests enough not just in amazon but all brazil we are testing very low and people are dying please the next that's next yes this one this is just on friday nine two indigenous were killed by coronavirus in brazil so we don't have that much to make this mist wrong and i i think i'm very sad about that and just for you to have an idea also the size of the just one city from amazon is the size of england it's 110 kilometers square and england have 130 so that's how coronavirus had a magnifier blast to what's inequity and what we are living the next and further to do a huge uh to make it worse are aggravating it we're still burning amazon in the last month we have 500 square kilometers burn it of biomass burning in our forest this is for sure something that affects our climate and for sure affects our rural and remote communities and uh i wish we can also discuss this today thank you thanks very much mara and it does highlight the isolation and the sometimes lack of just information about what's happening in rural areas next we go to ji gu from china and ji with gu yuan who's been a long-term member of our working party have been very involved in the primary care response in in china so over to you ji thank you bruce hello everyone it's my honor and pleasure to present in this global webinar same as in other countries there's a shortage of medical stuff and supplies in china's rural areas but beyond that china has some unique characteristics first the awareness of personal protection of rural residents is weak and their personal hygiene habits are cool second rural residents most have a larger social circle they like visiting relatives and gathering with their friends and the third the outbreak coincided with the chinese lunar new year millions of migrants work turned home in rural areas in spring festival which leads to high people level flow in response china has taken a number of supportive measures for example local governments made great efforts on production and supplies to ensure the providing of masks disinfectants and other prevention materials so the construction of online friends form emergency training for rural doctors were intensified to improve their knowledge of covid-19 next slide please the rural doctors in china have large job responsibilities their primary work is routine medical practice but while in the pandemic they extended to conduct epidemiological investigations screen patients with fever follow up close contacts report epidemic information and participate in environment disinfection next slide next slide please most importantly this strengthens health education among people despite the basic knowledge of covid-19 so bulletin boards and leaflets they teach the elderly and the children how to wear masks and wash their hands so as to improve the awareness of infection prevention next slide during the pandemic home order for people to stay at home next next slide please but on the other hand it's greatly promoted the development of internet medical care online medicine has many advantages for example it can overcome overcome the barrier of distance to provide medical care to remote areas and it's a medicaid human resources shortage of medical experts across country and it's also minimized the gathering and physical contact it can provide multiple access you can use emails videos conference and mobile phones and it also promotes interdepartmental and multi-disciplinary care next next slide please in fact online medicine and service have played an important role in the fight against the pandemic in e-hospital we set up a covid-19 dedicated consultation channel to initially screen potential patients we provide online diagnosis and treatments for those patients with stable chronic diseases then drugs will be sent to the patients by express delivery in addition the e-system supports to remotely monitor close contacts for compliance with the rules of medical observation we also leverage online consulting to mitigate the anxiety and panic among the public yeah they hint to online medicine and consultation e-pass form are powerful for other users we just mentioned that the online training for rural doctors the webinars are widely used for extremely meetings both local and international level it's much easier that people than before to discuss prevention and control measures with each other china has established a national wide web web based academic reporting system to collect timely and accurate information in all parts of the country next finally i would like to remind you of the importance of publicity in the fights and this set of pictures titled i am not a doctor call on all industries to do their best to fight the pandemic well that's some information about the rural china thank you thanks g and thanks very much for those insights into how obviously with china it was a very early and initial problem there and and the ability of you guys to get on and treat that was really astounding so over to susan thomas now susan's one of our uh general practice nurses who has been at the front line in in wales and uh we'd like to hear your experience thanks susan thank you bruce and hello everybody um yes i'm i'm speaking from wales here this morning um and um very pleased to be with you all um you can see from my first slide um because i don't think you can see me on screen um my photograph is there i'm on the left so hello to you all i work as a as a nurse within a small team of myself two other nurses and a couple of health care assistants within a practice situation in a place called riska next slide please harris um we have approximately 9 000 patients registered with us and um just to let you know that locally within wales we have seen the highest rates of covid infection um in fact our numbers have been equal to those within london at some point so actually really very worrying for us all um in terms of the numbers of people that we have it worked out so far that we know of that we have about one percent of our um registered patients affected by covid and that's just to give you a little bit of background in terms of the nursing contribution um during this period of time uh just to let you know that probably we've seen the least change to nurses working day uh in usual times than those within the medical team so for example face-to-face patient contact has continued um and continues whilst the medical team did switch to telephone or video consults um sooner i think probably reflecting we've um when the strengths of the nursing team has been that we've maintained business as much as usual as possible for our population's health needs you know we've been really flexible um across the whole board and i'm other my um experiences of our small practice it's very very um similar to um experience across wales um decisions have been made really rapidly in many ways it's been quite liberating that we've been able to make the changes that we've needed um and certainly from the beginning any early changes that we made to our our practice was in order to reduce and control risk of uh infection for patients and for staff but also to prepare for at the time what was unknown but nevertheless we expected an increase in demand from our patients with the increase of covid so some of the things next slide sarin harris um some of the decisions that we made earlier on in order to try and reduce the um can't need for patients who are a bit more vulnerable to have to come to the practice we looked at our patients who have atrial fibrillation for example and along with our specialist um colleagues um made the switch from um warfarin to doak medicines we've looked at making changes to um the 12s and to long acting um contraceptions as you can see on the slide but we've also spent a lot of time um working our way to support our people who have long term or chronic conditions um in switching from face to face to phone or video uh we started by prioritising people with um diabetes who have a high hbo and c people with c o p d who are high users of their inhalers or respiratory medicines we've also encouraged self care for people who perhaps might have wounds um and we've been very proactive in in trying to support people who are more vulnerable who are staying away from the surgery so for example our frail population people who have a dementia diagnosis people who are shielding and shielding is a uk initiative to keep certain groups of people isolated at home people who have cancer who are in a suppressed and have transplants etc and we've worked very closely with our social care and third sector providers to help to achieve that alongside that we've been trying to plan for um people who haven't been admitted to hospital but who are very unwell at home for example people who might need end of life care um support so we've been preparing even though we usually work at the surgery we could prepare to support people within their own homes which just needs uh sort of close working with our community nursing colleagues and palliative care colleagues at the same time um on a national level the national programs for cancer screening have been suspended so we aren't doing any smears or or bowel screening at the moment although the childhood immunization program does continue uh next slide please Harris so that just gives you a flavor of what the nursing team has been doing um I also have another role within the practice which has developed most recently and that is of um being asked to lead and coordinate the practice COVID plan um so I started by looking at um how we could implement infection prevention and control not only to protect patients and staff both clinical and non-clinical and we spent a lot of time in the early days preparing for the worst and we really didn't know what was going to happen so for example the surgery was divided into two we had a COVID wing so that we could um help to um keep people separated those who were suspected or unknown to have COVID or what are the symptoms of and those who didn't um so that that's worked very well and we've had to have constant open communication we put in place I put in place daily early morning briefings updating and sharing on our news as it came along very rapidly as you're all aware and planning us to the next stages really both short medium and long term we did a lot of sharing of skills just in case anybody um became unwell and and couldn't work or even if they weren't unwell but that maybe it members of their family have caused them to isolate so making sure that nobody was was um um seen as as dispensable no indispensable uh PPE was something I had to coordinate uh and in the early days that that was a bit of a daily um uh nightmare but things have settled down now and as other people have said we had to look a lot to the tech to support both onsite and remote working so for example making sure that everybody had access to a laptop so that we could continue to work even if we were isolating at home full access to records and all of that sort of thing and we've done massive learning just as other people have explained um video consultations very lucky that there's a UK um entrepreneur um who has put in place an excellent package so we've had to learn all about that as well as patients of course and we've we've brought some very elderly non-techy patients along with us and we've had some wonderful results uh I could tell you more about that again with more time uh next slide please Harris so planning for the future well our experience to date of the first wave anyway we've actually had low numbers of COVID presentation in in primary care that that would be fair to say across Wales really mainly because people are told to self isolate for seven days if they have suspected COVID so from our point of view it was the occasional care of them with symptoms or maybe through the requirement for antibiotics because people have tended to get sick as you all know very quickly very badly and have bypassed primary care to get direct to hospital for their care so at the moment we're thinking ahead so for example we'll have the flu vaccination season starting in about September and we're going to be doing that during a period of two meter personal distancing and we need to help 1800 people approximately we usually have a very full waiting room of people coming through our flu clinic so to speak so how are we going to do that one that's there those things are in our minds especially in the weather because at the moment we're lucky to have very very pleasant weather for the last um few weeks so we'll be returned to the normal other people have asked that question as well we're taking the opportunity at the moment to take stock to housekeep really um quite enjoying that opportunity in many ways um despite the fact that there are tragedies happening all around us and we are preparing for a new normal whatever that's going to look like and we're certainly learning every day thank you very much thanks to and it certainly brings to us you know what will be the future in in rural practice or indeed general practice more generally over now to Henry Lawson in Ghana and Henry's had particular obviously lots of experience with infectious disease but facing a new challenge Henry and thanks for letting us know how you're going so thank you everybody I am greetings from Accra in Ghana next slide please so I start off my presentation with an empty room that is what happened to us in Ghana we started working with experience from Europe and China and Asia the kinds of cases they were seeing we started screening at the airport using the thermometer and symptoms and signs I will put in a lot of effort into that unfortunately cases kept coming into the country because we were not picking them then we realized that most of our cases were asymptomatic or had mild disease in fact there's a there's a doctor who got the disease and the only symptom she had was loss of smell no temperature no fever no cough no running nose no chest pain no difficulty breathing muscle aches all the case definition signs and symptoms were not found in this patient however she was tested because of um a routine testing that was being done in her facility so we realized that for doctors working in in every practice we needed a very high index of suspicion to be able to pick cases that were COVID posted next slide and so instead of sitting in the hospital and waiting for patients to come in ill and then we check do the COVID test on them to diagnose the disease we started a whole different program program which we called enhanced contact tracing if we find a certain number of people within a particular community having tested positive then a team from the from the Ghana Health Service will go into the whole community and zone them out and test every person within the household and within a short period of time we began to see a trend that the cases were concentrated initially in the urban areas that had well to do people living in there because most of the earlier cases we got came in uh were imported from outside now over time we realized that community spread uh began and so contact tracing individual contact tracing was being done and then this enhanced contact tracing where the communities were being targeted was also being done next slide and so what we had to do was to promote the COVID precautions and number one was hand washing we did have people to wash their hands as often as possible and now we had this contraption developed many years ago by a nurse in Ghana and we call it the verunica bucket and so there was a craze everywhere because the government put out instructions that every facility you enter shop supermarket hospital office should provide something that will help people wash their hands before they enter and this contraption allows everybody to wash their hands with running water the good thing about the device is that the tap is operated like a water dispenser and so once you lift it up the water flows you drop it down the water cuts off the soap is available on the right and then there's a tissue the water runs into the bowl under the tap and then the bucket on the left is used to collect the used tissue paper and so this promoted hand washing among the community every place you go around we have verunica packets to help people keep to their precautions next slide and so the doctors in the community our task was to be able to identify cases or to help the Ghana Health Service identify hot spots go in there and pick the cases there were a few that came into the hospital and our responsibility then was that because most cases were asymptomatic we had to wear protective equipment every nurse every doctor working within primary care had to be well protected because the cases were walking in and they were not showing any symptoms now those that were picked were sent to already designated centers that we call COVID treatment centers and the picture you see is one beautiful hospital if a quaternary hospital that I've been built in Ghana which had not yet been fully operational and they had about six ICU suites and so they were earmarked for training and training and then treatment of cases that tested positive so after quarantine if your test comes back and you're positive you were sent to a treatment center and the good news was that your treatment was free your room and board and there was not no bills to pay and so there was very little resistance in getting patients who tested positive to move into these centers after after treatment at these centers there were vehicles that were designated to take you to your home because we wanted to monitor the where people lived and if test results because the test because they're doing so many tests there were times when test results kept long before they come back so sometimes you have seven days to eight days before your test results come back and because we're using double negative tests before you'll be allowed to leave the isolation center there were times where there was pressure to get patients who who are tested negative to go home because you've tested negative we are waiting for your second negative test you're still in the center blocking the chance for those who were positive and needed a place to be treated in isolation and so this made us change the plan as we went along so we changed our case definition we changed our treatment plan and we changed the when we allowed people to go home so that we're able to cover quite a large number of people and we've seen the statistics from Ghana we've had a lot of a claim from the World Health Organization for the way we have handled the COVID testing next slide so thank you all and have a wonderful Sunday thanks very much Henry um we've had just a plethora a wonderful lot of both presentations and questions we're running really a bit behind time and running out of time I might ask Anna who's been collecting some of the themes and the questions to just summarise some of those and with John's permission I think what we might do John is take this to the Google group please if you if you haven't been on the on the Google group then you can you can get on to that and and John left his email further up in the chat but I think the best way to talk through these issues would be to bring them to the Google group because I think we're rapidly over time or running out of time but Anna if you could just maybe summarise things and then I'll I'll just check in with John to see that that's the right way to go Anna you're on mute you need to unmute Anna you're on mute well Anna's getting the mute situation there John did you want to just make a quick comment about I think this is a wonderful use for the Google group to talk through these topics because there's been I've just been following it as best I can but there's been some great chat John I would agree entirely Bruce there's a huge amount of really rich information and stuff out there can I just give people who are not members of the Google group my email address it's very simple it's John at John WJ so there's no dots it's johnwj.com it's a very easy email address I've already added three people to it this up this morning already so please please if you want to join the Google group we'd like to have you on board with our Google group the Warsaw Google group the European one we've got getting on for 3000 people on it so it's a really good community to join so please please so it's John at John WJ.com sending me the email and I'll add you thanks Bruce thanks John and I think we will go to chat on that I'm just noticing we've lost Anna and unfortunately she's been able unable to unmute I think we might go to the final slides and if we can get Anna back on then that would be good otherwise we'll just conclude with a few closing remarks and over to Donald after that so just back one if we could I think yeah so thanks very much in preparation for DACA we had an international paddle of experts preparing some key workshops and but in this virtual world we're having to switch to these becoming lectures and webinars if you look through that slide there you'll see there are 11 lectures that have replaced our workshops in DACA and they're about really important issues that continue on and in fact sometimes have been enhanced and highlighted by the circumstances we find ourselves with COVID-19 so we've done these in partnership with Towards Unity Health next slide please if we could yep wrong way next one and so the World Rural Health Conference 2020 the 17th Rural Health Conference does continue on as I said these lectures will be available to you in the next little while in addition to the lectures there's an opportunity for all of you particularly those who put abstracts together for the conference to submit those abstracts to World Rural Health Conference that's the WHC 2020 at gmail.com and there's also a chance for you to be able to publish your studies as well in the Social Innovations Journal and we've got some really great opportunities so for you to present at a webinar see the lectures and also present in that journal so I'll hand back over to Donald and thank you very much big thanks to to Wonka for their assistance with this I do know Anna's back so did you want to make any remarks Anna before we hand back to Donald? I don't see her I'm not sure she is online actually Donald Donald let's hand over to Donald for his closing remarks thanks Donald thank you everybody the panelists and all those who have joined us indeed you know a very important subject that we we we dwelled upon tonight and we learned a lot and I agree that we will have opportunities in the group the Google groups and all that now before I say more just want to advertise next Sunday we'll be talking about quality and safety the time is slightly different it's three hours later than tonight and next slide please the aim of the webinar is to identify quality and patient safety issues to improve primary care delivery during the COVID-19 crisis and it will cover a range of topics which includes team organization, safe use of medications, telemedicine, community support and public health issues, giving support to health professions and quality management so please tune in and join us again next Sunday next please so just want to say thank you again and I think you've confirmed the role of family doctors and all members of the primary health team our nurses uh working together that we are the approachable provider of comprehensive and replaceable care to rural communities next slide please next slide please and so we will continue this year as never before to deliver health care to our patients in different sometimes innovative ways as shown tonight by many to meet the demands and restrictions placed on communities for their own safety as ever we are the first in and last out professional group serving our patients as best we can delivering good quality primary health care and we will be celebrating World Family Doctors Day in two days with this theme so do the best you can for your patients next slide please you should stand proud of your contribution to tackling this world crisis our task now is to bring the best of who we are and what we do to a world that is more complex and more confused than any of us would like it to be may we all proceed with wisdom and grace thank you very much thank you very much donald and thanks to all the panelists for some really great presentations the comments and questions will be forwarded to the working party and hopefully they'll be able to reply to at least some of you in slower time so we look forward to you joining us again next week the quality and safety issues will be led by pilar astier the chair of our working party and we'll be welcoming some more distinguished panelists including some colleagues from who so we'll see you next week at the more usual time of 1300 utc i hope you'll join us then and thank you to everybody for taking part today please stay safe we'll see you next week