 meantime Now Iこれ or I SLAng and look at the answer There is I sorry and. And on behalf of the concern and help research group, it gives me enormous pleasure to welcome many of you here in person for the first time in over two years, now and. So many people online and remotely from across the world and in the UK, my name is generally I'll share and I'm the lead for research on health intelligence and health security here at the complicated in health research group. Mae'r panel ydy'r cyfnod o'r cyfnod yn ystod ymlaen i'r ysgolwyddiant, gyda'r ysgolwyddon yw'r ffordd ymlaen i'r ffordd o'r cyfnod hefyd, a'r cyfnod o'r cyfnod yw'r cyfnod, wedi'i gwybod, ymgyrch, ymgyrch, ymgyrch o'r cyfnod cyfnod o'r cyfnod cyfnod, ymgyrch o'r cyfnod o'r cyfnod ymgyrch o'r cyfnod cyfnod. Mae'r ysgrifetau o'r Covid wedi'u cyfnod, ister dull cwm dechrau i mid Four 영상을 Cymru, byw i'n unrhyw hon, ond duio i hybridd mewn tuad gyfu. Dyna bobl gweld i chi meddwl sydd wedi'u methu, ond mae'r gyfnod, différents a was防 clân.îr cy有 cysty theaters, ydych chi'n bwysig o'r ffordd gyda i'r cyfrannu oherwydd ar y pandemi, yw'r cyfrannu o'r bairau'r hwn, ychydig o'r oed a'r newydd. Mae'r rhagorau ar y emanar oedd dechreu â ddod, ac mae'n gwneud yn 60 ymnyddio ddechrau'r ddechrau o'r ddweud, ar y LL. Mae'r ddechrau a'r ddechrau ddechrau yn 1962, bod yn ymgymru, sy'n Michael Howard, ymgymru ein cyfnod o'i siwr araf, mae'r ddechrau oedd eich ddweud yn y ddweud, a yw y Cymru Llywodraeth, o ddigon ni'r dweud hwnnw, y cwmwyl, yn dweud a'r dweud. So, Michael yw'r dweud yn awdur, efallai mae'r dweud hwnnw, o'r dweud o hynny'n cydweithiau dyfodol yn cael ei cyfnogi ddysgu o'r ymddangos o'r ffair hynny, y dweud o'r cael y rôl o'r dweud hwnnw, yn ychydig, o hynny o'r oed yn cael eu cyfnodydd a'r byddau cyfnodydd. Of course our celebration here tonight here in London comes under the shadow of war once more again in Europe. The Russian invasion of Ukraine less than two weeks ago painfully underpins the rationale for the work we do here. The conflict and health research group led by Professors Richard Sullivan and Professor Priti Patel has a unique focus on the convergence of health and warfare. Our work engages across health security, humanitarian and directly clinical spheres supported by our team spanning practitioners, international relations scholars, clinicians, anthropologists, CBRN and other kinds of weapons experts, all with a common ethos to support the health needs of populations affected by conflict and complex emergencies. Our unique research collaboration is characterized by this laser focus on connecting rigorous scholarship with effective policy and practice across global settings experiencing and at risk of the damaging consequences of war and insecurity. 60 years on from the establishment of the Department of War Studies so Michael's founding ethos remained alive and well here at the conflict and health research group. In that spirit, it gives me great pleasure to introduce tonight's esteemed panel. Our first speaker tonight will be Professor Laura Connelly, the Professor of Global Health and Development at the National University of Ireland Ballway. Professor Connelly worked at the WHO from 1995 to 2012, where she was the lead advisor to the WHO's assistant director general for health security and the lead focal point for pandemic preparedness. Prior to that she was the WHO's coordinator for disease control and emergencies. She's worked on WHO response teams in over 20 countries, including Afghanistan, Kosovo, Iraq, Iran, Gaza, East Timor, Uganda and most recently Jordan as part of the WHO's Syrian crisis response. We also have Dame Jenny Harris, a public health physician and since April 2021, of course, the chief executive of the UK Health Security Agency. Prior to taking up her post at the UK Health Security Agency, Dame Jenny was the deputy chief medical officer for England. She holds a number of other roles, including membership of the Joint Committee on Vaccination and Immunisation, and is a part of the expert advisory group on the NHS Constitution. She's worked in policy, evaluation and clinical roles in a number of countries, including Pakistan, Albania, India and New Zealand. Finally tonight we have Professor Richard Sullivan, who's co-director of the Conflict and Health Research Group and director of the Institute of Cancer Policy here at KCL. Professor Sullivan is the UK representative on the WHO's Noncommunicable Disease Research Innovation Advisory Group. Prior to joining Kings, he was the clinical director of Cancer Research UK and from 1999 to 2008. As a former member of the British Army Intelligence and Security Group, he's also had many years of experience working on biosecurity and counter-proliferation issues, including recent deployments to boiler outbreaks in West Africa, PRC and most recently, of course, the COVID-19 pandemic. One speaker is missing tonight, that's Professor Claire Wenham, who from the LSE, unfortunately has had to pull out for personal reasons, but we will miss her tonight, but nevertheless we will have a stimulating conversation. So first, may I welcome Professor Mora Connolly, who's going to present her thoughts and reflections on the future of health security, after which I'll invite Dame Jenny and Professor Sullivan to reflect and respond to those queries. We will, of course, have public questions and questions on Zoom, which I will facilitate afterwards. Thank you very much. Okay, good evening. It's a pleasure to be here. I want to thank Gemma and Richard for the opportunity. The area of health security is an area I started working in 1995 at a time when the majority of those working in the clinical domain felt that this was something that wasn't particularly relevant or pertinent. What we've experienced in the last two years showing how important health security is and how the biological world threatens human beings despite our advances in technology and healthcare delivery. So I think today it also shows the impact of war in Europe on health security and how the current situation there has global implications beyond the devastation of the population in Ukraine itself. Let me just see. Okay. Okay, so I'm going to speak about definitions. I think again it's an area that we've had many public health emergencies, public health events of international importance, pandemics, epidemics, a lot of these words, health emergency are used interchangeably. So I'm going to go through a number of the definitions that we're currently using in this domain. I'm also going to look at the current context where we are in March 2022. It's a very different world to what we were doing two years ago, the very beginning of the outside of the pandemic. I'm going to talk about the threats to health security as we face them now, the impact of war on global health security in addition to the affected population, and then a number of lessons from the COVID-19 response in the area of health security. So in terms of the definition of health security so it's been defined as activities required to minimize the danger and impact of acute public health events that endanger health across geographical regions and international boundaries. The definition of an epidemic, and this is what we used in WHO, an increase often sudden in the number of cases of a disease above what is normally expected in that population in that area. And then a pandemic is an epidemic that has spread across numerous countries, continents or worldwide affecting a large number of people. I think we all know that epidemics and pandemics have shaped our history from the Middle Ages, from plague outbreaks of various diseases over the years. Influenza particularly, any of you working on the history of emerging diseases will know the impact of the 1918 pandemic. And we're over 50 million people were estimated to have died in this. And then we had subsequently three other pandemics, and I suppose 2009 was quite a mild pandemic, and it led to, I suppose at the time I was working in WHO in Geneva. And at the time there was a lot of criticism that perhaps WHO had overegded or overemphasized the potential threat posed by influenza. And I think what we've seen now is, is again the potential threat posed by biological agents. And this shows, this shows the transmission of influenza across the US. And again, this is the time before airlines and before the level of transport and trade that we have at the moment, but it's still managed to get across the states within a very short length of time. This, this, this photo shows the outbreaks that WHO in Geneva to the Global Outbreak Alert and Response Network were involved in over the last 20 years. And you'll see how they range across all parts of the globe, but many of them in low and middle-income countries. So we're talking about diseases like Ebola, antivirus, lasso fever, monkeypox, nip and hendra, drift valley fever. And obviously COVID-19, the SARS-CoV-2 virus, the latest challenge to affect the world in terms of health security. So where are we today in March 2022? So the pandemic is still ongoing. We certainly are with the Omicron variant dealing with the disease of much lower virulence with lower rates of hospitalizations, but we're not out of the woods yet. We've now reached about 6 million deaths and over an almost 500 million cases reported globally, but this is likely to be a significant underestimate. And the social economic implications are we're still dealing with the consequence of them. I think we can agree that this disruption is at a scale that has not been seen since the 1918 influenza pandemic. And I do recall working with David Nabarro and David Heyman in Geneva when we did a number of scenarios based on influenza, pandemic influenza. And I don't think at any point did we envisage the level of disruption that we've experienced in the last two years. We've seen health systems faltering, and as I mentioned, significant social and economic upheaval in terms of schooling, in terms of education, in terms of employment, in terms of people's economic wellbeing. And again, it's very important that we continue to measure the impact. And beyond that is the issue of long COVID and what the long term health implications will be, and those who did not get health care during that time were delayed access to health care during the time of the pandemic. Gemma mentioned climate crisis, the climate change issue and that changing terms of temperature and the transmission of the transport of vectors, the issue of multi drug resistance, biosecurity issues in BSL, level three and four labs, working on high impact pathogens. Gemma mentioned the risk of deliberate use or dual use. Again, it's something that we have to keep a very close eye on as the risks are increasing every year with the number of labs working on high impact pathogens with poor international regulatory mechanisms. And finally, the events of the last two weeks I think has shocked Europe to its core, even though there have been significant warnings of it, I think actually seeing what we're witnessing on our television screens at the moment is harrowing and has obviously an impact on health and health security. So where will the next pandemic come from, and I know we're not out of this one yet, but our role as academics and our role as physicians and microbiologists, our role is to look at where is the next threat coming from. And in the analysis, obviously Southeast Asia where there's a lot of contact with animals and humans, that is really where a lot of the increased risk is. For a pandemic to occur, a novel pathogen must emerge to which the general population has little or no immunity, and it must be able to replicate in humans and be efficiently transmitted from one human to another causing global spread of disease. And what we saw with SARS-1 was this ability to transmit efficiently between humans, but thankfully with SARS-1, you were sick with the disease for a week before you were able to transmit it. And that one factor in 2003 allowed us to control SARS-1 to 10,000 cases and 800 deaths, primarily in healthcare workers. So the concept of planetary health is one that a lot of academics are looking at in terms of Earth as an entity. So I think we can all agree that the human population is healthier than ever before. We see life expectancy increasing, poverty levels reducing and infant mortality, child mortality reducing. But these gains have come at a high price to planetary health, and you'll see in the lower graphs there increase in carbon dioxide emissions and also ocean acidification energies. And a number of these changes have directly increased the risk of emerging diseases, the loss of tropical rainforest and fertiliser use. So I think we can safely say that from a scientific point of view, the risk of emergence of novel pathogens with pandemic potential is higher now than in any other point in human history. And this has to do with deforestation, encroachment into virgin forests, intensive farming practices like poultry farms, large poultry farms, wet markets leading to spillover events from wild animals, which is what we saw in Wuhan in late 2019. Population growth, increased urbanisation and high population densities in cities increased the transmission once an emerging disease arrived in a densely populated city. And we've also seen the increase in the frequency and severity of natural disasters associated climate change. We see the impact of conflict and forced displacement. And if there are camps that are going to be set up in the coming weeks amongst the risk of infectious diseases among that population will increase significantly. And finally, the expansion of global travel and trade. And I think we all know the impact of how our world is so interconnected now compared to any other time in history. In terms of deforestation, this is the single largest cause of habitat loss worldwide. And deforestation, it alters the natural circulation of viruses, changes the composition, abundance, behaviour and viral exposure of reservoir species such as bats. The largest outbreak and Richard was involved in that outbreak in 2014. This originated in a remote forest region of Guinea, where about 80% of the surrounding forest area had been destroyed by international mining and timber operations. We saw the same in New York Congo and a number of the outbreaks that occurred in East Africa prior to this very large outbreak in 2014. The initial field investigation by the WHO team in Guinea of the first reported case in an 18 month old child identified an entry in the backyard of the family home which was infested with bats. And this is a photo of a burial being done of an Ebola case in Sierra Leone. So what are the next threats to health security. We've seen a pandemic occurring about every 15 to 30 years. This translates into an annual probability of three to seven percent. The most likely cause of the next pandemic remains in a novel strain of a unit of influenza. An example will be H5N7 and we've seen increasing levels on recent levels of avian influenza in wild birds at the moment in Europe. The WHO is monitoring this carefully because the issue is can it evolve to become a virus that can efficiently transmit from human to human. We fortunately haven't seen this since H1N1. And then finally, we are looking at in Europe the resurgence of known epidemic prone diseases due to global warming. We've seen dengue in parts of Croatia, malaria in Greece, West Nile fever in southern parts of Europe and Chikungunya has been identified in Italy. So we are witnessing now these diseases going into areas that are not historically a problem. So as I mentioned, avian influenza remains the most likely source of the next pandemic. Large livestock farm poultry farms can serve as a source for spillover infections from animal and people. And biosecurity measures, biosafety measures in poultry farms are extremely important, particularly in those high levels of circulating avian influenza strains in wild birds. And every country in Europe is working very closely with poultry farmers to ensure early detection and rapid isolation of affected poultry. The risk then is the transmission from poultry to humans. And that particularly is obviously Southeast Asia is where a lot of the initial spillover events happened with avian influenza. So we'll talk about the Ukrainian crisis and the impact of war on health security. I think we all know about the direct impact in terms of deaths due to war related injuries and attacks and indirect deaths due to population displacement, deteriorating social economic situation and disruption to health services. There's also then injuries and increasing rates of illness in the population that has been displaced. We are seeing the environmental effects of the targeting of water, sewage and chemical plants and the radiological effects and attack on the nuclear plant in the Ukraine. And two weeks into the conflict, Russian forces have seized two of the four nuclear plants in the country, and Zaporizia is the largest nuclear plant in Europe. What we are witnessing in real time is the breakdown of health services disruption to the management of chronic diseases like hypertension, diabetes, cancer treatment, dialysis among the population, both those internally displaced, but those in their own homes but unable to access services and people have been forced to go over the border into neighbouring countries. There's obviously an issue of the lack of emergency hospital services and impact on surgical obstetric and medical care. There's been a disruption to the vaccination programme and one thing that we've noticed in terms of polio is it is one disease that exploits any breakdown in healthcare delivery vaccination programmes. We've seen 20 cases of polio in Ukraine. The first case was in October, a vaccine-related case of acute placid paralysis in a child. There's been a second case of acute placid paralysis and there are 18 cases of children who confirmed polio. The issue of forced population displacement leads to increased risks of respiratory infections, measles, TB and obviously SARS-CoV-2. Unsafe water and forced sanitation leads to increased risk of diarrheal disease outbreaks, motor virus, the ciliary dysentery. This is an impact on the health security of the population. Let us look at the lessons learned from the COVID-19 response. We are, this time two years ago, I remember Cheltenham happened and we were all wondering where are we going. I actually told me to colleagues in WTO in Geneva, they said that the month of January and February was the most stressful, the most difficult, the most challenging because they knew it was like a tsunami was waiting to arrive from China inside East Asia. There was an ambivalence and a kind of disbelief among many member states in other parts of the world that this wouldn't come to Europe or wouldn't come to the US. It was a very difficult time because colleagues in Geneva knew there was a window of time to get prepared and that that window, once the disease was introduced into a country it was going to spread. So what we've seen two years on, significant advances in diagnostics, and I think what's been achieved was achieved in the sequencing and the diagnostic tests that were developed in January within weeks of the first, the virus being diagnosed, but that was unprecedented. We've also seen advances in the area of genomic surveillance and obviously vaccine development with mRNA vaccines. And another area that's usually important is the area of data management, and we've seen big investments by countries across the world and IT systems to manage public health data and laboratory data, and that has strengthened our ability to deal with future threats. We've seen the G20 high level independent panel on financing the global commons for pandemic preparedness response. Cepi met yesterday with Dr Tedros presenting, foreign secretary, and the initiative here is to present 3.5 billion replenishment or investment case to support the development of vaccines against emerging diseases within 100 days of the confirmation of the identification of a new pathogen. We managed for COVID within 300 days, so what we're trying to do with the global communities to make this happen. You can imagine what would have been achieved if we had avoided, if we'd have managed to get an effective vaccine much earlier in the pandemic. But there are a number of, I suppose, weaknesses in our system of health security and global health security have been identified, and I think one of those is the whole area of the international health regulations. There have been delays in state parties reporting public health risks to WHO, not just for this event, but for previous events, a lack of transparency, a lack of regulatory powers and challenges to data sharing. And there are currently revisions to the IHO reform under discussion at the moment. So the international health regulations was revised in 2005 following the SARS outbreak in 2003. And this is a legal framework to prevent, detect and respond to acute public health risks that have the potential to cross borders and threaten people worldwide. They're designed to prevent the international spread of disease while avoiding unnecessary interference with trade and travel and to safeguard human rights. Within the IHO, state parties are obliged to notify WHO within 24 hours of all detected events within the territory which may constitute a public health event of international concern. And this declaration has been employed six times by WHO for polio, SICA, H1N1, Ebola in West Africa, Dear Congo and most recently for COVID-19. And these events are defined as extraordinary events which constitute a public health risk to other states through the international spread of disease and potentially requires a coordinated international response. These events also include environmental threats, chemical threats and radio-nuclear threats. So one of the other lessons we've learned from COVID-19. As I mentioned, while Omicron has led to milder illnesses and fewer hospitalisations, we still must remain vigilant for the emergence of other variants of concern. Particularly in countries where there is, where there are high levels of transmission and high numbers of people on immunosuppressant treatment. For example, that's where you're more likely to get the generation of new variants. But we have seen significant investment in public health and laboratory capacity, which has strengthened pandemic preparedness in most countries. The research on diagnostics and vaccines has increased the availability of countermeasures to respond to future pandemic threats, including therapeutics. We have seen significant advances in data management and IT systems with unprecedented data sharing between countries that can be activated for future pandemics. And I think I'd like to recognise the work of our world and data, which is based in the University of Oxford. It was set up in 2011 by Max Rosner, who is a social historian and an economist. The work that they have done in gathering data across the globe has been hugely valuable to all parties involved in the response. And one of the IT projects I'm working on at the moment is a project on, it's basically to develop an IT system for public health agencies to prepare for future pandemics. We've developed a number of innovations, including geospatial mapping tools, modelling simulators and standardised data collection tools. These predictive tools will be able to monitor the spread of a new pandemic and also predict health service demands and assess the resource needs for a certain given a disease X or for a certain attack rate or certain level mortality. We've seen considerable inequity in the global distribution of vaccines. Much of this is problems with the access to vaccines, despite COVAX and the work that's being done at international level. And Jeremy Farr and the welcome trust here has done incredible work. And obviously the work of the three team and Osprezeneca team in Oxford. But the issue is also healthcare capacity of healthcare systems in low and middle-income countries to absorb and to deliver vaccines. There's the issue of the temporary waiver, the TRIPS agreement to allow COVID-19 vaccines to be reduced in low and middle-income countries. Again, an issue that is a delicate issue and something they'll have to be looked at in the future. But along with that, there would have to be technology transferred by patent holding vaccine manufacturers. But if you are to get global coverage of a new pathogen that causes a pandemic and possibly a more severe pandemic, these issues will have to be addressed in the coming years. So the challenges. So a sudden onset of a large scale pandemic remains a major threat to health. The health, the economic and social consequences of a novel pathogen with higher mortality in younger age groups such as an influenza pandemic in 1918 would have even more devastating consequences than COVID-19. We're seeing greater numbers of BSL level three and four laboratories with varying levels of biosecurity, which is increasing the risk of accidental release. And the advances in biotechnology, genetics and genomics is also increasing the risk of development of new biological weapons possibility of engineering a new superbog. So in conclusion, what is needed to respond to threats to health security from the position we're in now in 2022. I think there is there is room for discussion about the potential for greater regulatory powers by WHR, by WHO using the IHR. Effective pandemic planning and public health and laboratory systems and healthcare services in all countries needs to be strengthened. This should include the testing of national pandemic partners plans with annual scenarios of simulations with cross-border exercises, much as our colleagues in the defence sector do on a regular basis. And we also need to strengthen our early warning and detection and surveillance systems of animal and human diseases with forecasting of emerging threats. And it is possible if it would have been possible if there was early detection and rapid isolation of the initial case in Wuhan in November, December, there's a theoretical chance that the Wuhan strain could have been put back. Once it evolved and became more transmissible than it was on, it was impossible, but there was a theoretical chance of that occurring in 2019. What we need to do is make sure that we are better armed the next time around in terms of early detection, early reporting, early confirmation and early isolation. That includes working with colleagues in the clinical setting for early detection of imported cases. Finally, we need to be looking at wet markets and the unregulated buying and selling of animals like pangolins and other mammals that could present a threat to zoonotic threat to humans. There needs to be a look at the monitoring of biosecurity standards in the barteries, working on high-impact pathogens across the world, investment in the supply and delivery systems for medical countermeasures in low and middle-income countries. And obviously this ongoing R&D and CEPI is promoting this in the welcome trust on vaccines, antivirals, immunomodulators, diagnostics, PPE and IT tools. And finally, I think we need to be looking at conflict resolution and diplomacy in the long term to avoid war. Thanks very much. Thank you very much, Maura, for that very expansive talk about all of the various threats we are looking at and I think it's quite clear how much work there is to do. So I will turn therefore to Dame Jenny Harris to reflect on all of the work that there is to do and her own thoughts on the future of health security. Thank you. Thanks, Gemma. So good evening everybody. I'm absolutely delighted to be here. It's actually nice to be out. I think we're all feeling a bit like that and rather surprised that we're seeing people face to face. I'm a very pragmatic doer and I'd rather answer questions than talk for a long time so I'm going to be quite brief in what I say, not least because of the excellent speech which has just gone beforehand and you would have seen me scribbling rapidly because many of the things of course I would have said have been said already. But so I think what I want to do is just think perhaps turn as I'm now the chief executive of the new UK health security agency. And although I came into post on the first of April last year, it was very much to merge parts of the system together and we might come to that because it's a critical component of responding and being prepared for pandemics. But we actually only really started life on the first of October so I'm just as much in listening mode as I hear as to listen to the ideas that people have so that actually we have a unique opportunity in the UK at the moment to absorb all this learning and feed it into the next structures and systems that we have. Recognising of course that in the microcosm of the UK in the global sense, there are important lessons for global pandemic control, but we sort of do them as well on the UK side in a small way so I'm just going to focus a little bit on that. My team reliably inform me that there have been six major UK health security threats in the 21 years since 9 11. And as I was sitting here I looked down them so two pandemics COVID-19 and swine flu in 2009 Ebola which we didn't grow a case here but we definitely had a response a very significant response. And that show was part of the airport screening progress where I kind of cut my teeth on some of the problems of international health regulations, the impact of borders controls as well which I think are really significant. Then there was a major flooding incident around 2013 to 14 so a climate more of a climate one. There was the Salisbury Novichok event in 2018. And then back in 2006, the Lippinenko poisoning. Now as I looked down these I realised that five of those six I was actually directly involved. So, so I promise you it's not me that's causing the pandemic, but but it does mean that I've got some insight into some of the handling, I hope, and that I think is quite important. This mixture of theory and real life and practical response is absolutely critical. So off those six things the last two were deliberate releases they were direct human intervention CBRN attacks. And there are many threats to health and we as humans are contributing to many of these risks. So I whether directly we can see with those, and we have adverse players and system, or whether it be through other things that we are doing and climate change has been mentioned. And it's sometimes I think it's the indirect associations which people are perhaps not so familiar with so entomology, for example. These is that you've mentioned we have mosquitoes in this country. I think we have 34 native species, but we're now starting to get a whole load of new risks coming through. And the sort of the marshes that we thought we'd got rid of in the Middle Ages are now starting to reappear. We might reappear in a very large tractor tire down a motorway and that causes all sorts of, you know, different environmental conditions for risks around health protection. I think what we've noticed, or what's been described is this issue about the reality of having to move quickly. If you move quickly, you are much more likely to be successful if you are prepared. So the fact that we have emergency planning preparedness and response is not a coincidence. You actually need all of those. And one of the difficulties, I think, and I'll come back to this at the end, is the loss of the reality about the event. I don't know about you as a public health person, I'm getting quite anxious at the moment. So I know, or I'm pretty confident if you ask me on a podium, or to write something down, I would say over the next 12 to 18 months, there is a strong chance we will, it'll be quite unsettled for the current, not past current pandemic. We're very likely, we will see more variants, we're very likely to see another wave of something that we don't quite like the look of. But actually, our media is not telling that. And even as an individual, I'm still trying to get used to, well, am I back to normal? Or am I still wearing a face covering and trying to be very careful? So this issue about memory and the impetus of the risk and lurching backwards and forwards between response and the distant preparedness is an important lesson, I think, for the future. The sorts of things I just wanted to pull out really, we do have in the UK a good public health system. One of the unique features of it actually is that we go right from direct input into government. So as a public health professional, I can present some science, an important feature directly to the sector of state, and yet other parts of my organisation will critically reach right down into every single community through the director of public health, through local authorities, and out to those people who are most likely to be adversely impacted by any particularly infectious disease scenario, but almost any health protection incident. That is actually a gem for the UK, which I think it's only in the last pandemic that we have really got hold of and utilise to best advantage. So there are some key learning points there. If we look at things like our vaccination programme, which is our armory at the moment against the pandemic, we have large numbers of people vaccinated. We are still not reaching many communities who are more hesitant to accept vaccines. And so we can actually at this moment predict where health inequalities will arise in the future. And we also know that those very same communities who then develop more health inequalities are going to be the ones most impacted by the next adverse health protection incident. So inequalities is on my list of three eyes. There is another one. These are rather random thoughts, so bear with me. There's another one. What else have we learnt? If you at the moment want to, you know, I've come today, I have done my lateral flow test because I thought I was likely to take my face covering off, be mixing with people I didn't know. That lateral flow test 12, 15 months ago did not exist. That is an incredible innovation, although there's been a lot of, as I put this academic backwards and forwardness about whether this was a good thing or not. I think we're all broadly moved in the right direction. And actually, I think there would have been a lot less of that if the way the utilization have been articulated at the start of it had been clearer about what the parameters were. So using it in where you're most likely to be infected and most likely to pass infection on is a really good thing. So we have new tools at our disposal. So that's my second eye. The third eye, I've got a whole list of eyes. I do things in letters and pictures. So my third eye and there's only three in each group is intention. So the intention is, and again, I will come back to this. We must always have an intention to do something about this. It doesn't matter whether we think the pandemic has gone away. It has to be on our horizon and we have to be actively doing something. So I'm on seas next. So, well, three capacity issues next, but it that way. So I think laboratories around the world, but actually in the UK. One of the things which came out of the pandemic was a clear observation of the start that we did not have sufficient laboratory capacity to manage pandemic. Now, interestingly now as we go out because we have lateral flow tests, which we can use and most likely will be effective against new variants, the reliance on PCR capacity to some extent has dropped down. We still need it. We need to monitor for the new variants. We need material for genomic sequencing, but that laboratory capacity was not there. And as you pointed out, there is very great laboratory capacity now across Europe, but it is not across the whole of the world. And again, the standards of that laboratory capacity are critical. So something we should hand on to genomics. Every other word in the media seems to be genomics. And I am a super fan, but often what people don't realise is that you need the right samples PCR testing. Secondly, you need a huge data infrastructure sitting behind it to in order to utilise and analyse the results to give meaningful information to feed back into how we manage pandemics. So genomics is something which is even more unevenly distributed across the world than the laboratory capacity itself. So I think going forward, there are some brilliant pieces of work. So I was at the separate event yesterday as well. There is the work WHO are leading on to have an international pathogen surveillance network in the UK to say we also have a new variant assessment platform, which is a mechanism to support those countries which have less genomics capacity to both look at their variants as they arise, which keeps us all safer. But most importantly to provide capacity for training so that countries, other countries themselves have capability. And of course, the brilliant thing about genomics is everybody associates it with COVID, but actually it can be used for all sorts of other infectious disease. And if we look to the future, that's what we're going to be using. We'll be able to track down foodborne outbreaks much more easily. We'll be able to see where they've arisen as we live in this global world. So genomics is my second capacity and data actually is the third one, partly because of the genomics. But actually it is the flow of data, the direction of data and the sharing of data, which is absolutely critical. One of the things that we learned, I think in the UK, so in my past life, I have been a director of public health in several different local authorities. And it is extremely frustrating to know your own community and to not have the data to use for that community. That would apply anywhere in the world. And it is that which is a critical tool for reaching right down to a granular level to manage small incidents, outbreaks, small resurdances so that you can get on top of them and quell them. And we had some brilliant success. So in South, in the South London, South West London, where we had new variants coming in, we had some absolutely fantastic response as well from local communities. And that engagement and a joint effort to try and suppress variants which could otherwise become dangerous was really successful. So so those are my three capacity ones one on laboratory one on genomics and one on data. The last point about data of course is surveillance. And at any point in this we must have good surveillance systems, because we've had so much testing in this country, much of our data has been coming routinely from that. So if we go forward now though we will be we've still got this brilliant backbone of surveillance data for the UK with the OS survey, and that will continue and give us information to go forward. And then I have three, three P's, I think I'm not sure they come out as these partnerships on a PPR that was it so it's like preparedness and resilience. I think this is critical. When I was responding in this country, not in West Africa, but to the West African Ebola outbreak. One of the big criticisms was about sharing so samples were not shared. There's been a huge amount of learning I think to this so despite some of the obvious problems which rose. We have had brilliant sharing in many ways we've really made progress globally I think. So the UK is a great contributor to gives aid it up to upload huge numbers of genomic sequences. But actually, if we look at Omicron, for example, it was a traveler from South Africa. Actually, I think it was Hong Kong that updated the data, and we read it in this country. So that sort of partnership either directly or indirectly is important for us all going forward. Participation so you can have theoretical partnership, but actual participation is important. And I think as we try and put in place the passage and surveillance network real true participation in that is going to be a challenge for all the reasons of data sharing which we already know in this country. And then I've got resilience as the last one. So, I might look to my colleagues on either side, or just out of the audience. We only have to look on an NHS ward, or, or even to Laurie drivers, or to teachers to know or even into every family probably across the UK to know that this pandemic has caused huge impacts on our lives and resilience issues. And as we face the terrible future as people said looking at Ukraine, actually, even through that for them particularly but for us as well to help them, we need somehow to manage resilience going forward and that is a critical component of pandemic response. My last comment would be, I think, going back to the sefi comment, if we have a brilliant system which runs from superb surveillance, whether it be globally, or on the UK borders and across the communities, through to new variant detection, through to brilliant work working with academia and with industry, which is a new endeavor I think through the pandemic to look at the structural biology of these new variants and then translate that directly into new armory and new diagnostics. We actually do have something very positive in the future. And I think that should be our binding mission. And just because pandemic noise has perhaps died down particularly in the UK, our binding mission is to stay on that particular point. Thank you very much. Thank you, danger. That was very, very practical and proactive expansion on the points we've all been discussing. So I turn finally to Professor Sullivan to reflect on all of the themes. I'm not sure there are any left, but hopefully one or two. Great to go last. Bone journey more general. Thank you very much indeed legend and wonderful to see you all. You won't be surprised. I'm going to be a bit more conceptual as a scholar, and I'm going to step back a little bit more. And I'm also going to reflect on some of the marvelous scholarship that's being produced actually by at least I mean three individuals four individuals in the audience here. I guess I'm going to be slightly critical here and I'm going to sort of quote Terry Pratchett that it's better to light a flamethrower than curse the darkness. Mainly because I think one of the things we're trying to do really here is illuminate and understand where we're going to be going with health security and global health security. So let me begin by saying obviously we're talking about conflict and health in this situation, not just dealing with health security in permissive stable countries. We have a really major challenge ahead of us. The nature of conflicts is changing rapidly. They're behaving in different ways and they're creating some really dangerous downstream consequences. What we're seeing whether it's the conflict and complex emergencies within Ukraine, Afghanistan, even I remember in the Narko Wars going on in Mexico. We're seeing completely new ecologies of war and some really radically different therapeutic job geographies, coupled to new ways of waging warfare and conflict. And by new therapeutic geographies I mean patients and people moving across borders. The problem is our systems are Westphalia and still they're still stuck within borders. And I think one of the major challenges more as brought out here is how we even think about moving our systems beyond borders to deal with a new reality. I think there can be a real danger of oversimplification and a myopic strategic intent and what do I mean by this I think we can become very, very obsessed with the next viral pandemic. And if Dame Sally Davis was here right now I know she'd probably be saying AMR, AMR, AMR. We know conflict creates enormously different ecosystems, AMR, toxication, the environment, explosive remnants of war, substandard clinical management, leaving biofilms etc. And so there's a real importance here to step back when we think about health security is what are we trying to talk about what security within health are we really trying to address going forward. But equally there's an equal danger of going too narrow to being too broad. And I'm sure many of you read these marvellous papers out on this often position papers and I'm going to point out the fcdo position paper in December 2021. It's fascinating because it covers just about everything under the sun universal health coverage health system strengthening one health standard public health surveillance measures. The measure it throws in R&D delivery of countermeasures, AMR climate change urbanizations and non-communicable diseases. At that point I was so exhausted I had to go for a bit of a lie down, but there's a real danger in an attempt for these policy documents to be all things to all people. They end up being nothing to anyone. So again, what are we talking about in health security what is the prioritization. How do we make sure we're not missing the wood from the trees. First of a kind of de conflation issue here. We've already talked about I think today by security of global BH3 and BH4 laboratories. We've mentioned bioterrorism spate sponsored programs and of course natural zinotic spillover events. In some way they're interconnected but they're also very separate sub strategies and the players and actors often involved in these are obviously very different from hardcore bioterrorism security services JTAC to what is essentially a much more open ground partnership. And I think there's a question really about how we have these sub strategies and how we address them within global health security. Two other bits I'd like to draw out is what do we mean by the security and global health security. More has already taught very eloquently about emerging infectious diseases. Extraordinary the nature paper that was published relatively recently was actually really quite frightening in terms of the numbers the 6% increase in EIDs majority of these are coming from wildlife and wildlife around the world, not just sub Saharan Africa, Latin America, Southeast Asia, and the reality is we really don't know where the next big spillover event is going to come. It's a really difficult complex picture to get our heads around. There's also an issue here than Gemma's written about this, which is the integration between veterinary intelligence and public health human intelligence. We treat health security as a very anthropocentric issue here we focus on humans humans humans, as though they're only the species that's important. Actually integrating veterinary intelligence, all our expertise within wildlife in this country and sasnet vet compass. How do we actually pull these things together networks that already exists that we can actually bring together integrated intelligence. So when we talk about health security intelligence we're not simply I think talking about human beings here we're talking about health security writ really large. And I guess it comes to this problem of how do you move beyond the classical public health surveillance to see this as a health security intelligence issue. And again, this has been written about very heavily, particularly from KCL, which is rethinking how we address indicators and warnings, how we get ahead of the next pandemic if you like. And again, we've had some near misses. We've had more than near misses quite a few times. I mean, I think you know the Mexico outbreak in 2009 and sorry in 2009 of the novel H1N1. The indicators and the warnings were already out there before CDC and WHO declared by that stage it was too late because it's already got into California, Texas, and New York City. I've probably talked about MERS. I mean it was remarkable really because I know it was picked up from the UK because of a patient transfer for Qatar. But actually in Arabic, the warning was already out there because in the ITU and a man, they'd already spotted this and that was five months before it actually appeared on the radar. So there's a question really about evolving the systems of classic public health bias surveillance to take a more intelligence approach. Really from a case of perspective, we put it forward a lot of work around again, Gemma and Rose here is in the audience on health intelligence frameworks, and also on the cyberbio nexus. And it's not to say securitisation doesn't come with its problems. We've mentioned technology a lot this evening. Rose led on a fantastic piece of work looking at the rise of a participatory signal intelligence, mainly through government surveillance using mobile applications. There is a light and a dark side. There are many countries who are heavily securitised in their approach. There are many countries which have utilised the pandemic to develop very invasive public surveillance of their populations. And unfortunately, technology cuts both ways is not value free how governments use that technology is as important as what the technology in of itself is. And also, I think more broadly thinking about defence health care and engagement and how the security sector come in. I mean, I really recommend a fantastic article in the Roosie Journal this year, published by Simon Horn and Laura McCree, who'd actually discussed the role of strategic health diplomacy. It's a really important area because, as I'll mention in a minute and segue into realism, politics writ large is important. And there have been some really, I think a real lack of understanding about how defence and the security sector are actually involved in health security intelligence. Professor Martin Brickwell here on the end as well, and Dr Chew Yee have done a lot of work looking at this sort of work in understanding security sector involvement in countries and how they contribute positively to global health security. I think that's an aspect of scholarship and discussion that we tend to sort of push to the side and don't talk about. The last bit I want to just touch on very briefly is and it's already mentioned is this realism problem. How to ground everything we're doing in the reality of how the world works. I personally feel incredibly sorry for the WHO at the moment. We've had, what, three independent review panels all complaining and pointing fingers. We've had Oster proposing standalone committee on health emergency, the USA basically trying to kick the international health regulations into touch. I mean, I don't want to say it's political Jenga Jenga Jenga Jenga. Thank you political Jenga at the moment, but it really feels like that. It's incredible about a politic. And this is the worst bit. And I mentioned this only because it is it really important geopolitics matters matters Russia explicitly said during all these debates that it would veto anything that looked like it was undermining the sovereignty of countries and I quote we will reject any proposals that it could used on grounds for interfering in the affairs of nations holding of investigations on the basis of rumour in information unconfirmed by the states themselves. That was the Russian delegate. And of course it was confirmed of course by the Chinese were exactly on the same page. Geopolitics matters and global health security is intimately tied into geopolitics. And I think to the looking forward. We've already talked about the deficits in countries linkage into health system strengthening. I'm going to blunt. I'm a little bit less positive about where we're going in health system strengthening. I would love to think that the data is going in the right direction. Well it's in the WHO paper was published recently and it was just an absolute shocker. It looked at 47 low middle income countries, it said you needed 12 data systems in each country, just to monitor basic SDGs. What they looked at they found between 2015 2020 every single one of those countries had gone backwards basically. In other words, the ability of databases have disappeared and the ability to measure these babies indicates have disappeared. And I think half of the of the 46 countries scored a zero across every single domain. So we have a massive, massive problem with data and surveillance in many countries, and it speaks to the inequalities growing between high income countries with a great surveillance. And many lower middle income countries which are going in diametrically the opposite way. And finally, I've already mentioned, that's Martin Bricknell's work. I'm not convinced the health system strengthening blocks are fit for purpose anymore. I think that may need a bit of an overhaul because there is a conceptual issue I think both with the realism that we approach the political economy of health in countries, and also the realism around who's involved in delivering services and strengthening health systems that may need a really hard relook at that. I'm going to end really by just reflecting on, you know, slightly two big reports one in remember many of you remember law butchers report in 2004 on the intelligence of WND. And in it, they said it needs, we need to constantly challenge by security and health security. And so my review on high impact low probability risks in 2012 also spoke the need for constant external challenge. Have we achieved those up until now, not really. But if anything, our previous two speaks have said very eloquently is the challenges needed more than ever to our global health security systems across a wide range of scholar scholastic and operational areas. So if you're a wake up call COVID-19, I mean put it in medical parlance. It's a sort of global transient ischemic attack isn't it. And if you don't react to it now you're going to be in a lot of trouble downstream. So thank you very much indeed and general back to you. Thank you Richard, and I think after listening to all three of these very detailed and presentations were clear on the hill that is left the climb, which is considerable but this seems like a good starting point. Now I certainly have many questions, but in the interest of time I want to focus on public questions, which will be coming in from zoom and yourselves in the audience. So may I ask microphones to wonder if you are asking a question please could you wait for your microphone please so that the people on zoom can hear your question also. So I think if we can start with any in the room. I also have a list out there's a gentleman up here. So we'll start if the microphone goes to him and I will start with an online one while you travel with it. So we have a question from Kieran atridge on the question is what impact has the widespread practice of shutting borders through the COVID pandemic had on this element of it. Given this is likely the public expectation. How does this measure remain in any revision of it. I'm going to direct this more. That's a difficult question. I think it's, it's again it comes down to the very beginning at the very outset. This pandemic could potentially have been kept within Wuhan if the containment measures that have been that are in place have been implemented. But after a certain level of transmission and travel measures were not as effective. And I think we saw it with Omicron when there was a response by many countries in Europe to to avoid travel from South Africa and really at that point. I think all of us working in in public health thought this is this you know this this we're not going to avoid the introduction of Omicron. So I think it's specific for each disease. We were dealing with the very specific epidemiology of SARS-CoV-2. It's more like influenza than other diseases. And with influenza, we don't implement travel restrictions because of the dynamic and the transmission and the reproduction number and that. So I think, you know, in the very outset, I would have, I think that travel measures, if they have been implemented in time, could potentially have stopped this pandemic. And what we've got to do is look at in the future, how can we more rapidly respond? The cat's out of the bag with this one. And even if we have future variants, we know Omicron, we're not going to stop them by travel restrictions. But there is a role for travel restrictions for future potential pandemic pathogens. And we need to ensure that we don't just use the lessons of this pandemic to take that armory or that weapon away from us as an international community. It needs to remain there. And W.H.O.'s revision of the IHR very clearly states that it is to reduce, to minimise the disruption to trade and travel. So it's only if it's really indicated. So I think, in summary, that's I think at the beginning it could have worked as the pandemic evolved. It became less and less practical and we will, you know, for future variants, the impact of travel restrictions is questionable. Shall I just add to that? So I mean, I think on international regulations. So I think back to Ebola, of course, where borders shut as well, a very, very different disease. And I think that's an important reminder as well. So transmitted in an entirely different way, much easier in some ways from a border control to do something about it. It's not a respiratory erasiles virus. But it's in so IHR regulations absolutely suggest we should not do this. And I think we will recognise that it can be extremely harmful for the countries. And certainly, although I might come back to saying why I think it is OK sometimes, there's definitely a point which says when it is of no value, you immediately lift it. And that is sooner rather than later. The only difference I would suggest is and this is one of Richard's geopolitical areas. I mean, as soon as there is something to do with borders, everybody erupts in all different directions. I think we just need to recognise that. So the question is, does it actually do any good and what is it you're trying to achieve? So you're absolutely right for this sort of virus. It's going to come in anyway. And I think many of us are watching with interest now and perhaps a little sadness and horror at what's happening as you open borders in countries which have been very closed. So China, the most obvious one will be interesting in the future, but places like New Zealand. So and actually there are behavioural analysis as well, because if you have closed your own borders to protect yourselves, there is a perceived. Not a perceived risk. There's a perceived lack of risk, I think around the illness because you haven't seen it. So people are less likely drawn to becoming vaccinated. But in fact, in the Omicron case, it's quite interesting because the time frame, I think this is what it is. This is the time frame to widespread community transmission, which is quite critical. If you look at what happened in the UK, we've actually done a piece of work in the UK HSA, looking at the differential time for if you're monitoring at a border, what you'll do from closing is to affect if you had a very, very tight program. And when you detect a first case of variant, and even though they're probably in the community already, and then when majority of them turn up at hospital front door, by which time you know that you're two or three weeks into an infection and you're going to get a whole load of people coming through, they're all baked in before you get there. And it was roughly, I'd have to go back to the details, so don't quote me on this, but it was roughly about 10 or 11 days. Now interestingly, in the period where the borders were shut before Avocon, actually the UK boosted its vaccination program. And so I think that the real trick here is to say, not that it's good or bad, but to say what is it you're trying to achieve and will that intervention achieve an outcome. In the UK case, it definitely didn't stop on the concoming. It did actually result in huge numbers of people being vaccinated and boosted through that period who may otherwise have ended in hospital. And if you look at our hospitalisation rates, we just got away with that at the top level. So northeast, the hospitals newly tipped, but not quite. Thank you very much. I think our gentleman far up in the sky has been patiently waiting. Yes, so I just had a slight question with regards to. How come that none of you have actually mentioned the HIV epidemic slash pandemic when I believe it was a very, very big influence on the entire society and world. Definitely we started off with the infection being labeled as the gay plague. Then we needed even the Royals and Princess Diana shaking hands with patients to break some of that stigma, which still exists to this day. I don't understand that now with a lot of antiretrovirals and preexposure prophylaxis, we're obviously controlling that. But let's also not forget that there are certain populations and if I'm not wrong, the predictions of infections in, for example, Sub-Saharan Africa, specifically South Africa, go between 19 and 26% of the population being infected. So that's still, in my opinion, a rather large concern. Yet somehow no member of the panel has actually addressed it. So just curious, is there a particular reason. Yes, you're right. We haven't addressed it. I'm going to just reflect and say actually HIV AIDS was one of the first national security events. Richard Holbrooke actually stood up and called it National Security Emergency when it first appeared and started ripping through Sub-Saharan Africa. And that was, you know, there was a paper, I think it was Richard Feacham wrote on this as the HIV AIDS as a national security issue. And it was interesting, a friend of mine Eric Bing was a special adviser to Laura Bush, George Bush's wife. He shared a story about how George Bush was persuaded to actually fund PEPFAL. And it was pointed out that the best way to do it and could get move money very quickly to PEPFAL was to declare it a national security event in order to basically bulldoze the financing through the both of the houses. So it's interesting because you're right now we kind of forget about that we put that to the side we don't talk about HIV AIDS in the sense of being a health security issue. I think in some countries it still is a major major problem. And I think it speaks to the nuances of what is a what do we mean by health security and the context specificity of that definition. In some countries you're absolutely right HIV is a massive health security problem still. So I think you're right to illuminate I'm sorry we missed that out, but it also then speaks to the problem that you know that was yesterday and we're now into the next one, and you forget. I think that's a real problem with health security it's always whatever's in front of you at that moment you're dealing with as an international community. So, you know, great question. I think we have time for one more question so I will apologise to the various people who won't be answered, but I think there's a. Yes. The gentleman here has the microphone. Sorry. My question is on the data you already mentioned the challenges of data capturing. And I think part of the data kept me the challenges of data sharing is data capturing and also data quality as well. And we saw in some countries for example the data is consistent and also not captured properly and inappropriately for our analysis. So, there are many examples under countries where there were cases COVID and other but we were lack of data. So, how can we deal this challenge to overcome this challenge how can we capture data appropriately for future analysis. I would say that I think the UK have the strongest data collection system in terms of surveillance, the epidemiological and laboratory data going back to Collendale in the centre for surveillance and control. So, and what you have is a centralised system in the NHS so you've got hospitals reporting to directors of public health and then the data coming through to Collendale to CDSE. So, I think every, I think the challenge that we found in this pandemic was that the numbers were just, you know, way beyond anything we'd experienced before a lot of the infectious disease reporting systems were dealing with cases of foodborne disease or deferia or tuberculosis or whatever. So the numbers, you know, escalated beyond anything these systems were dealt with, had to deal with. In countries around Europe was basically struggling trying to connect laboratory systems, hospital systems, laboratory systems to public health agencies where, you know, in many cases they existed completely separately. So you would have a public health department activated if there was an outbreak of TB and then there was a link with the hospital services but nothing like the pervasive impact of COVID where you need a data from six or seven sources. I think the UK is probably the best organised and I think you managed to ramp up very effectively with the backup, the genomic capability, the GIZ aid and with, you know, the cloud computing resources that were there. And, you know, there's a small number of countries in Europe that were really at the forefront of that. And a number, you mentioned Hong Kong, a number in Southeast Asia as well. So I think that there's been a huge learning curve and the challenge has been trying to get the data and clean it and make sure that, you know, your bioinformatics pipeline, the information that you're getting is leading to action, and that's been analysed in real time. And that the data, I mean, I think if you see what was presented on, you know, daily updates and COVID cases, I mean, something that we dreamt of 10 years ago in terms of epidemic curves and looking at hospitalisation rate and ICU rate. I mean, it did take, you know, four to six weeks to get up and running but and then the visual analytics and the ability to present this data. I mean, it's, I mean, what I was very fortunate, I was given 10 million euro to design an IT system for pandemics and all of a sudden it's just there. It's just been given these amazing array of dashboards in Finland and Sweden and the UK and actually countries like the US struggled when they were very decentralised. It's like New Zealand struggled where their healthcare system is privatised, is separate from, it's not nationalised so you have individual health units, district based health units. So, you know, I think it's been a data revolution and on many levels, this is a different pandemic that it would have been 10 years ago and public health has come into the 21st century in terms of data management. So I can only get better from here and I think, as you said, for the next pandemic would be in a much better position. But with that requires a lot of what we found in the modelling area. So there were vets and physicists and meteorologists who were going into the public health domain because modelling wasn't done in public health as such. And we saw that in the same computer science where there hadn't been a lot of work on public health data, but all of a sudden, all of this capacity was brought in because it was a governmental priority and because of the whole society approach. And so I think the challenge now is to have ideally a global system that we can all link into in the future. I mean, look what's been done in our world and data. I know it's a small number of indicators, but at the same time there's a principle there of a data source producing global outputs that can help monitor a future pandemic. I think just adding to that. I mean, one of the exciting things to me, the new various assessment platform where you're helping other countries who don't have that capacity to upload data to be handled by others who can support that if the capacity is not available locally. So you get the data quality, the country gets the information it needs. I think the biggest problem of course is it goes back to the geopolitical side of it, which is there has to be really good trust. It's really good for people to engage in that process in the first place. And that is probably the bigger challenge, I think, than the data itself. I think it falls to me to draw our event to a close. I think we could spend the rest of the night talking and the rest. Was there another gentleman? There's one lady who was promised. Okay, one more, go on. Hi. So on the note of data surveillance, and we discussed things like innovation, global collaboration. And I'm wondering, how could that be implemented to address firstly emergency health response and conflict settings for things like non communicable disease in populations. And secondly, in addressing health outside of COVID, but populations that are not currently accessing health services in the future. So things like cancer patients, for example, patients that need surgical care. Do you want to start on that, your area? There are some basic systems in DHSR, DHIS2, for example. And a lot of these systems have been put in on the basis of programs, whether this is GAVI, child and maternal health, and along with that come data capture mechanisms. But the problem is the reality in many countries is those data capture systems are simply not there. So registers in the majority of countries in the world, you know, there are not even decent hospital registers for basic data. And the situation gets even worse when you get to conflict areas. So we're program working in northwestern northeast Syria. There's a health information system which has been run separately in Idlib from the WHO from the E1 system. But it is a tiny fraction of the sort of data you would need to make any form of planning for a health system strengthening, or even to be acting as an early warning system for any emergent disease. I mean, it's not that the will isn't there, it's just the political structures, the access into the private health care, because the private sector doesn't want to give the data across. And the refusal for giving data across even if it's being collected is often one of the biggest barriers and there's a whole range of reasons why that data is not being given across. So it's a massive challenge. It's not technical. It's sociopolitical, it's cultural, and it's the reality of the nature of the conflict often in why that data is not captured. I mean, just a couple of points on that. I mean, just if you go to in non conflict areas, I was just thinking, actually, even with an early warning system with everybody willing, in most cases, you're going to get some sort of zoonotic overflow to a group of cases who will appear in primary care. That's not where you're most likely, it needs an attentive clinician locally to say, hang on, this doesn't look quite right and send the signal up. I think there is a natural challenge. If I turn it the other way and move away from global and back to the UK, for example, though, I mean, one of the things which excites me, you can see how I spend my days, you know, I clearly haven't been out enough, but if we look back sort of 18 months, people were not used to having a little a swab posted through their letter box, picking it up, sticking it up the nose, putting it in a box and sending it back through the post. And actually, it's been amazing. They now do it with a point of care test. There is the opportunity now, I think, that with a public who have been almost moved of necessity to a different way of thinking about things to actually for individuals who are less willing perhaps to go to their GP or into a health setting to send some screening tests, for example, which we do already by post, but actually, I think people have been more accepting of it now in many ways, or we knew some of the other routes that we've learned through, you know, faith leaders, for example, to be doing tests where you don't need sort of heavy handed clinical settings, but you can still ensure that people get the right access. Thank you Catherine for that. Well, it was to me to thank our panel who have, as I said, we could continue talking for a very long time and I think it's both good timing that we at King's are reflecting on these issues in our research group and that top danger Jenny or open and listening to how to take the UK HSA forward. I haven't been able to answer all of the very, very interesting questions in the zoom chat as well, many of which centre on how younger people and students at various levels in various fields can get involved in health security and of course that is so important to our community here at the conflict and health research group. And we can only say that we continue in our ambitions to be the foremost UK and European we hope centre for research education and of course action in health security going forward. So we thank you all very much for being here with us tonight we thank you for your questions and could you please join me in thanking our panel for their fascinating contributions tonight. A drinks reception laid on in the sunset room upstairs on the first floor I believe that's what I'm told Lizzie, and so do go up there and make yourself enjoy the available refreshments and we shall see you up there to take the discussions further thank you.