 Cool. Okay. Yeah, my name is Jake Knight. I work for the Health Systems Collaborative based in Oxford but my work is in Kenya, Tanzania and Vietnam. So yeah, my email's up there. If any of this is of interest and you want to follow up then, please get in touch. Let me just move through this. So I'm going to tell you a little bit about a project that I work on called Cinema. But I want to first give you a little bit of background to that. I think we've covered the fact that AMR threatens everyone. It's a kind of species level problem and that there's a strong desire to create global models of AMR that are informed by data across the whole globe. But unfortunately, it's a fact that there's very little data from African settings and what data is available is mostly collected at private facilities and suggests there's significant resistance, but there are concerns that this isn't necessarily very representative of all the different geographies. And so there's a, in summary then, there's a strong desire to collect more data on the true situation in African settings. There's a desire to create systems that would be able to collect data on an ongoing basis. And then finally, there's also a concern, a desire for better treatments to be given to African patients who are suffering with resistant infections. So the Cinema then is a project based in Kenya that is attempting to link government hospitals, Ministry of Health hospitals with very well equipped laboratories. It's an unfortunate fact that laboratories in the public health system in Kenya are not very good and don't offer microbiology. Many places haven't done blood cultures for more than a couple of years and in many cases it's really irregular when they will be able to do one. And so the idea here is to link these hospitals with very skilled hub laboratories and then ferry the samples from these hospitals to these hubs. The hubs would analyze the blood samples and provide some data back to the hospitals, ideally to the clinicians who have given the samples for them to, for that to inform their choices and about what drugs to prescribe and then equally that the data from this travels upwards to a national team in Kenya who are working with international partners to share the data collected up into this kind of global models of AMR, which would be a very good thing to do and in and of itself a very useful and timely contribution. But this is also then we kind of paint the whole picture, it's important to recognize who else is around this. You've got high income country governments that would very much like to know what the global burden looks like and what types of threat are emerging in different countries. There's new global agencies and old global agencies that now have it in them mandate to look at these things. And then of course there's pharma companies for whom these things represent a market opportunity, but also research opportunities that will eventually end up in new drugs and new things to sell. So yeah, that's the kind of picture as we see it and the work that we're doing with our little team, that our little qualitative research team is mostly in these orange areas. It's around the hospitals and the relationships that they have with the hubs, so how easily they can pass on these samples, how the doctors interpret the results that they get back and the impact of this overall on hospitals. And so in considering this that we look at these arrows and most of this is flowing up the way and there's some kind of missing bits here and of course that's patients and communities. And so in thinking about the meaning of this type of research and taking a step back from it and not just doing the work that's necessary as part of a multidisciplinary team to check this one idea about hubs and spoke systems for collecting data and for analyzing samples, we could just do that one thing, but I think we have a responsibility to step back and think about the system more broadly. And that involves some previous work that we would draw on about what actually drives prescriptions in these types of hospital. And so some of these things are within scope of this new project. So about norms that the doctors follow what their lead clinicians suggest should be the antibiotics they use their own experience in understanding particular symptoms and the role of diagnostics in influencing those mental models that they have of what it is they should be doing. So that's all kind of in scope. But there's a set of other questions that surround this which are really, really crucial and have been picked up by Ben and others on this call. And those are what antibiotics are available in the facility. You know, if the antibiotics aren't there then, you know, to give a prescription for them seems problematic to say the least. Another one which is perhaps less discussed is, will I see the patient again? There's real problems and continuity and doctors are concerned, clinicians are concerned that they won't see a patient again. They want to give them something that will have the effect that they want. They don't want to experiment and watch progress over time and they'd be very nervous about doing that because they might lose the patient. And so instead, there's a strong desire to give them, you know, something that will definitely help. And that results in them going up the kind of chain of of antibiotics. And then finally, and obviously crucially, what can the patient afford? And we were quite surprised to learn in this previous research that doctors make judgments based on this, but they're even really discussing it with patients in some cases. They kind of look at the clothes they're wearing, you know, and make a kind of class based assessment of the patient's ability to pay and then limit, the mentally limit themselves about the types of antibiotics they might prescribe. So this is all relevant because each of these things is rooted in its own set of contextual problems which structure or recreate these issues in the hospital. And so for diagnostics, we're in this project, we're dealing with the issues around that. The hub and spoke system that we're trialing is tries to solve this issue of laboratory effectiveness, which is a known issue. And then that will result in better diagnostics, which is a helpful and useful thing to do. But each of these other issues that I mentioned is also linked in its own background, contextual factors which which create these problems. So norms come from professional networks, from leadership, from guidelines, what the symptoms are telling me how they're understood comes from training and also from guidelines and from personal experience. But then all these other ones about what what antibiotics are available as linked in supply chains, will I see the patient against in continuity of care and what the patient can afford is linked into very complex questions around economics and insurance and pricing. So not a simple system for sure. And so reflecting on all this, I think that into disciplinarity is essential to understanding the hub and spoke system that we're we're analyzing in in this in this project. Because it allows us to understand how clinicians interpret and use diagnostics. So in that area that we're focusing in, we can shed a lot, we can throw a lot of light on those processes and understand what clinicians are thinking and feeling. But we also want to contextualize the outcome of microbiology and form diagnostics diagnosis. So what happens to patients, can they can they afford what the drugs that they're asked to find are the drugs available, you know, to not look at that would be would be errant of us, I believe. And then also can we, you know, do justice to these other issues that they experience and think about the meaning of this hub and spoke system in that larger context. And in so doing, I think there's probably a need to challenge the prevailing narratives that don't really consider all of this. So the idea that the doctors have this huge amount of agency over this and the reason they prescribe is just because, you know, they're lazy or stupid or ignorant. And all they need is better diagnostics to inform that to let them make better choices. That's problematic. And we need to raise up all these other issues to show the complexity of it. But while I say that I don't want to be too cynical about these things, I don't want to be nihilistic and say that nothing will work. Why do we even bother? Look at all this complexity. We've got complex adaptive systems within complex adaptive systems. You have to start somewhere. And so this hub and spoke system does deal with one of these core issues and, you know, is really important for us to work on. So I'm happy to work on it. But I'm also aware that, you know, we need to frame it relative to all the other issues that are at play here.