 very much for the introduction and thanks everyone for joining us. So the default that I'm pursuing is much of a much larger wider piece of work that I thought I'd mentioned given that's a key theme of this whole webinar series about how we we fit into the bigger scheme of things. It's called Fakes Fabrications and Falseds in Global Health. It's a investigator award from the Wellcome Trust that's run by Professor Patricia Kingory as part of the Ethoc Centre and we are a cross-disciplinary team that's looking at the concept of pseudo and global health, fakery, how it manifests in all of its different forms and the ethical implications of that. And my interest, if I can get my slide to progress. There you are. It's in medical products as you won't be surprised to hear as a pharmacist. What I'm going to be talking to you about today isn't the results of the study given that I'm at the design phase. I do discuss these ideas in greater depth in the paper that's shown there on the left, if you're interested in it, which is based on literature and my experience is as the head of pharmacy at various different international and governmental organisations. In terms of design, I am using qualitative research methods because what I'm really interested in is, like Yol mentioned, is understanding the real world implications of what's going on in the world that people inhabit when they're faced with uncertain circumstances in terms of perhaps not being able to trust the quality of medical products that they're using. So I think in circumstances like this it can be easy to forget that while we're talking about big, grand global problems, life is still going on for the individuals who are working in healthcare. They still need to make decisions about how to deliver health, how to provide patient care, despite the fact that they might not be able to rely on the result of rapid diagnostic tests that they've just used, or they might not be sure of the efficacy of their treatment that they're about to provide their patient. And so that can throw out ethical dilemmas for them in terms of, well, what do I do? And I thought I'd describe that a little bit more through means of a scenario and this question of, well, what do I do? So the photographs that you have in front of you is quite a personal one to me. It's one that I received when I was head of pharmacy at a large international and governmental organisation from one of my colleagues in Afghanistan. And it shows the burnt out shell of our regional warehouse in Cunda's province that stored all of the medical supplies for the health programmes at. And the health programme was enormous. It was outsourced from the government for providing all secondary primary healthcare for the entire region. So that's for a population of about one million people. And the question that I asked myself was, what do I do? What do we do? As head of pharmacy, obviously, medicine quality is at the forefront of my mind. And the supplies that were in this warehouse were received from a quality assured source from a Netherlands supplier. And all of our health centres had stock, but as soon as they needed replenishment in a couple of weeks time, there wouldn't be anything to give them. And the stock from another supplier was going to take probably six, nine, perhaps 12 months to get into country because we're facing enormous importation challenges. Lots of bureaucracy and constantly changing requirements. But what I knew is that I did not have the faith of procuring good quality medicines on the national market because of problems of weak regulation, corruption, a rife black market. And so the challenge there is thinking about, well, you know, do I buy or not buy? If we don't buy from the national market, then our patients won't have any medicines to receive that if we do, then potentially we'll be buying medicines of poor quality that could have a substantial public health implications for them and the whole community. And so a really sticky situation. But now I'd like you to think that rather than being the head of pharmacy in that situation, perhaps you're the security officer in Afghanistan, and you'll have a slightly different lens to look at this problem through, that you're responsible for the safety of all staff in Kandah's province. And what you're aware of is that staff have been reporting that they've been receiving threats of assassination from the Taliban who are unhappy with the supply chain problems and the importation issues that I've referred to. And that if there's no medicines in the facility and they can't be treated and their families can't be treated, well, that's really unacceptable. And these threats are very real. So as a security officer, how do you balance up these two problems? The risk of procuring poor quality medicines on the national market and potentially affecting the lives of patients and individuals in the communities that you're serving, how do you balance that against the lives of the staff that you need to protect and the very visible issue of stock outs compared to the relatively invisible problem of substandard or falsified medicines? And let's take another view again. Let's pretend that we're the head of the organization with a CEO. And we hear about this problem, obviously, and we're concerned about being unable to meet our commitments to the Ministry of Health and deliver health care if we don't have any medical products. But on the other hand, we're also very concerned about the fact that we might procure poor quality medical products and distribute them to beneficiaries and the negative reputational impact that might have. And for a charity, really reputation is everything. Reputation dictates the funding that you receive and actually, if there's a large reputational fallout from this, well, perhaps then that might affect funding streams for all of our other programs where we're delivering really essential health care to vulnerable communities. How do we weigh up the lives of those two different populations? And last, and then I'll move on. I think you're getting the point. But let's think of someone outside of the organizational together, perhaps we're a donor, perhaps we're with, say, USAID, the US government aid program. And we're responsible for the responsible distribution of funds to various different programs around the world. And in order to be fiscally responsible and spend public money responsibly, we need to account for where every single dollar goes. We need to do due diligence with various different suppliers. And although we're keen to ensure that aid programs continue, we also can't necessarily risk the problem of giving millions of dollars worth of replacing these medicines into a national market where we're unsure of the suppliers and perhaps what links they have for their standards. And I think so hopefully that shows that we talk about substandard and falsehood medicines perhaps in a slightly binary way, but in the real world that it can have a very complex and nuanced problem that can be seen through a number of different lens, through a number of different responsibilities. And what this question is really pointing to is what do I do? Is that actually who does have the moral authority to decide the answer to that question? Who should determine the quality of medical products that are received from the beneficiary? Clicking up in the front of you on the slides here is an example of a few of the different actors that may have been involved in the delivery of this health program in Afghanistan from policymakers, donors, individuals that design the program, people that audit the the manufacturers and suppliers to ensure that the quality is showed, those that procure the medicines, those that deliver them, regulators to ensure that the medicines that come into the country or are produced in the country of sound quality, the healthcare system who's recruited and and finally the prescribers. And each one of these could feasibly be have some responsibility for quality at their feet, but also I think that the decisions that they make can have an influence on the medical quality that is finally received by the patient, whether or not they necessarily realize it. And ethical challenges and ethical dilemmas can arise at any single point in this very long chain of, I've said this isn't comprehensive, but this long chain of actors who have sort of an accumulative potential effect on the quality that's received by the end user. So for example, it went into the chain of policymakers. And perhaps you're a policymaker with a real agenda for universal health coverage and the challenges for access to medicines across the globe, which is a real problem, obviously. But if you champion a program of universal health coverage without necessarily attending to the importance of quality, if you ask people to do more with the same resources, then something has to give. And an unintended consequence of pushing for greater availability could be the reduction of quality. At the other end of this chain, we've got prescribers. So say you're a prescriber in Kinder's province at that time, and you have a concern about one of the quality of some of the medicines that you're administering to patients. How much should you tell them? It's something that's come up already, that Kellyn mentioned in terms of the risks of vaccine hesitancy in terms of talking about quality issues. Well, how much should you inform your patient in terms of the quality issues? You might scare them, you might reduce their acceptance, but surely you need to inform them of any considered risks due to their autonomy and ensuring an informed consent. The area that I'm interested in with this project, for this piece of research, is procurement right in the middle. I think it's a really interesting decision point where upstream of that, we're thinking of a conceptual project, the product, like we need paracetamol. But at the point of procurement, that product becomes real, it becomes actual. You receive a batch number, you receive an expiry date, and then you have an actual thing in front of you. I think the decisions that go around moving from the conceptual to the actual is a very interesting space. For this project, this is what I'm looking at. I find it very interesting in understanding how different actors could consider the various different dimensions of priorities and bring them to bear in making a procurement decision. If you think back to that burnt-out warehouse that we looked at, obviously cost is going to be an enormous pressure. Flying goods out in itself, the time that this was taken probably cost about $300,000, and the cost of drugs and medical devices may have been the same again. You don't find that on the back of the sofa. In terms of trying to replenish that warehouse as cheap as possible, that would probably be quite a large consideration. But also speed, I've mentioned that we need to replace these medicines as quickly as possible so that healthcare can continue. Who is going to be the supplier that will be able to replenish and supply us as quickly as possible? Or perhaps accessibility is important. We don't have a warehouse anymore. Maybe we'd prefer to use a pharmacist that's down the road to provide medicines directly to healthcare centres on a weekly basis. There we get ourselves up and running with the warehouse again. Or perhaps familiarity. We're not going to be able to provide the medicines that we previously that our staff are familiar with. So rather than buying something in a different language, maybe we want to buy something locally impassioned that we're confident that they can be given safely. Or again, how about payment terms? It's going to take a little while for our cash flow to return to try and replenish these medicines. Maybe we want a supplier that's going to give us quite generous payment terms. They'll give us the goods now, but they'll allow us to pay in three months time. And ever present with equality. And these are just some of the dimensions. Again, it's not comprehensive, but I think you will get a sense of that. It's unlikely that all of these dimensions are going to be achieved for the scenario that I've just presented. So therefore, what to be prioritised and what to be compromised? And that's really what I'm hoping that my research will contribute to trying to answer these kind of really challenging questions, because at the moment there's very little guidance about how to navigate these kind of moral measures. Because every different situation is quite unique. And it's, as you can imagine, there's lots of different agendas and priorities and expectations from a host of different actors. So I'm hoping that the research that I'm conducting in terms of understanding this, and then in future working towards answering these kind of ethical questions will hopefully mean that decision making has done in a more evidence based and ethical manner for the benefit of patient and healthcare general. And thank you for your attention. I look forward to any questions.