 All right, everybody, can we sit down? So welcome back. I hope you are refreshed and ready for another session. So after having a good discussion about the various challenges that we face in addressing NCDs in humanitarian settings, we're now gonna look at some of the examples of where we've tried to address those challenges. And so we have a number of speakers who are going to give us some examples from some different sessions. But to start off, we'll have, looking again a bit at the evidence that exists. So we're gonna have Bayard and Pablo who will talk to us about a systematic review that they've done on the effectiveness of NCD interventions, as well as the integration of HIV and NCDs. So Bayard, who you've already met, who's the director of Ecohost and has done a lot of research on settings in fragile and conflict states based on looking at NCDs, mental health and harmful behaviors. And Pablo Perel, who's also a colleague at the London School of Tropical Medicine and Hygiene and a cardiologist, so far. Thank you, Philippa. So me and Pablo are just gonna share this presentation and I should hopefully be fairly quick, partly because there isn't actually much to say on this topic. So this is, so I'm gonna present today the findings from this study that Pablo and I and Carl and others were involved with. And this is looking specifically at NCDs and the effectiveness of interventions for NCDs in humanitarian crises. And this was part of a broader study that I led with Carl Blanchet here that was funded by DFID and the Wellcome Trust looking at the evidence on all public health interventions in humanitarian crises, a fairly thankless task, too. So the NCD one was a bit easier because there wasn't really very much. So the aim of it is given here and we really followed standard systematic review methodology, wide range of bibliographic databases, including great literature. It was quantitative only, humanitarian crisis, so both complex emergencies, complex as well as natural disasters. We only looked at low and middle income countries and we went back as far as 1980 and we did a quality assessment as well. So we retrieved over 6,000 studies specifically in our search for NCDs. We came up with eight. So kind of good news for us, bad news for everyone else. Just to put it in a broader context, these are the results that we found for health interventions for other health topics. So very predictably many more for communicable disease, nutrition, even mental health and psychosocial support. Far less for sexual and reproductive health and water and sanitation. So NCDs is really part firmly in the lower end of that. But overall, actually not that much evidence globally on all these topics. And so what were the study findings? So first of all, there was only, when we're thinking about effectiveness, ideally we would like to have some kind of control trial or at least use of controls. And there was only one randomized control trial that we found, and that was on the use of traditional medicine for Tibetan refugees in India. And then the vast majority were, well, we had a case series, interrupted time series analysis, part of really a cohort. And then the rest were cohort studies, which are really prospective use of surveillance data. And main outcomes of diabetes, heart failure, hypertension and so on. And the vast majority of studies were from the Middle East. But six studies, predictably, given the burden of disease in the region. Importantly, four of these eight studies came from one group of authors, and it was one population. The lead author is here, Dr. Kader. So essentially we should be grateful to you for providing half of the global evidence on the effectiveness of NCD intervention. So thank you for that. And the result, particularly from your work, is that often in terms of clinical outcomes, it's not great, particularly for diabetes, perhaps slightly better for hypertension. And there were problems in terms of just receiving proper checks and screening and so on. So we have problems there. But importantly, what these studies also showed was really the value and the feasibility of being able to do prospective digital surveillance systems and the importance of setting up these kind of systems. And this was with Palestinian refugees in Jordan. And the other, the study, these and other studies amongst these eight also showed the value of disease management protocols and the value of algorithm-based interventions. But there are always buts. So the strength and quality of the evidence was generally limited, particularly on those that some of the other four studies. So the outcome reporting was weak. The sort of diagnostic criteria were not always very clear. There is this reliance on observational study designs rather than more experimental study designs including limited use of control groups. There were a number of biases that were picked up in the quality reporting related to sort of missing data, problems with inadequate patient follow-up and also limited ability to address confounding. And things that none of the studies address were issues around the costs and feasibility of these interventions. And this was brought up in the first session this morning. And I think we know that costs of NCDs can be for treatment for NCDs can be extremely expensive, particularly the complications from NCDs. But we really are lacking in evidence-based to prove what is feasible, what is cost-friendly and even cost-effective. We also didn't find studies on integrating care. For example, with mental health or HIV and TB. And this is certainly a lot of interest in this. And Pablo is gonna be talking about this sort of more globally in the next presentation. And also there were no studies on the effectiveness of health promotion. And this is an issue that was raised this morning. Clearly and very understandably, the focus has been on treatment for many obvious reasons. But it's something I think to pick up. There are obviously a number of limitations with this review. It was descriptive analysis only, but trying to do a meta-analysis on eight studies. We've seen fairly futile, particularly given the varied outcomes and study design. We only went back to 1980. In reality, the first study I think we found was from something like 1997. We only looked at quantitative studies because it was effectiveness. And potentially we did include great literature, but we didn't approach agencies directly for that or seek reports they may hold privately. So there may possibly be added literature on that. And I'm just very briefly gonna go slightly off topic and back into this issue of prevention. In other reviews that we've been involved with, they also show a fairly negligible evidence and so the topic of alcohol was mentioned earlier. There's potential risks for alcohol misuse and harmful alcohol use amongst conflict-specting populations, particularly related to exposure to traumatic events and violence, impoverishment, lack of opportunities, and so on, which could lead to harmful alcohol use. All of those are also known risk factors for a range of mental disorders and there's evidence of strong evidence of comorbidity between mental disorders and harmful alcohol use. And clearly all of these, there's evidence separately of the links with non-communicable disease as well as other key issues in these populations such as gender-based violence. And so I think alcohol is a really critically, for me is a critically neglected issue and it's something that we've tried to sort of raise discussion on, not to much effect really. And there's also no evidence around sort of effectiveness of interventions for alcohol. And these studies, by the way, are not for alcohol and tobacco are not just around effectiveness there for everything. So it's about the burden of harmful alcohol use, access to services and so on. So the evidence is really fairly negligible on alcohol. It does suggest there is some link between conflict exposure and forced displacement with harmful alcohol use. And it's a similar pattern with tobacco and particularly conflict exposure with nicotine dependence. And so while fully appreciating and acknowledging the complexity of addressing NCDs in these settings and the question marks over the feasibility of being able to address prevention activities, it is something I think to bear in mind, particularly given in more stable settings and long-term forced displacement settings where it's whatever the average is now, 17 plus years for refugees. These are potentially situations where more meaningful activities could take place for NCD prevention activities, particularly around alcohol, and the ability to also measure the effectiveness of those interventions. So these are the key messages. Predictably, very few things more irritating than in academics saying we need more data, but I think it is valid. And also the value of looking at electronic surveillance systems need for more studies, better studies, stronger study designs. And this is certainly something that we're gonna explore in the session this afternoon. The potential and the feasibility of these types of study designs in these clearly challenging settings. And I think also more studies on looking at economic methods, cost-effectiveness, and so on. So thank you very much. I'll hand over to Pablo now. Thank you. The question for clarification for Bayard before we move on to Pablo. Anything from the audience? Thank you for presentation. Was very good. My question is, what's the plan for the future then? I mean, there's massive gap in terms of research that's clear, particularly for alcohol, tobacco, possible substance misuse, which is not addressed completely, but it's problem. So what do you think? What will happen in the coming years? Thank you. No idea, really. It's absolutely something that we would like to, when we're actively seeking to do more work on it. And I think as I mentioned earlier, a lot of the work that we're doing with MSF and the thinking behind this symposium today is how we can do more work in improving the evidence-based behind work on NCDs and particularly the effectiveness of interventions. And hopefully that would also extend into prevention activities as well. We'll just stick to questions of clarification for now. If it's that, yes, but otherwise, yeah, please. The microphone. I think we... No, we'll just wait for the microphone. We just have an online audience, so we need to make sure they can hear. Thanks, Andy Seale from UCL. Just wondering if you'd come across any studies on obesity prevention or control in emergency-affected populations, because it's quite... I was a little bit surprised so far that the word obesity hasn't even been come up, my nutrition mentioned once, but of course many populations are affected by the double burdens of malnutrition. Yeah, it's a good point. I mean, I don't... This study wouldn't have picked up on obesity as an outcome because we were looking at NCD outcomes rather than sort of risk factors behind these NCD outcomes. So the systematic review here wouldn't have picked up on it. I mean, maybe a similar story with the presentation given by James this morning in the review we've been working on there, but definitely within that, there have been some studies on obesity and this double burden of disease. So I think it was one from Saharan refugees, and so that it has come up, absolutely, and I think there will be more, but we haven't explicitly looked for that, but I think it's a very valid point. I think more work could be done on that and examining the existing evidence by support, yeah. Thanks. Just a question regarding the environment where the settings, as I mentioned, the systematic review, if I recall, I mean, was bringing together all the intervention and a broad umbrella of humanitarian settings. Like most of the studies of Ali are more in a protected situation of refugee and displaced population, which are more similar to a kind of normal, stable situation rather than really acute emergencies to what extent, at least in the future, we can make that distinction because of course, pulling all together that information. For me, interventions in humanitarian settings, when you have UNRWA interventions, of course, I mean, they are dealing with renewable population. It's not to the same extent of having more acute emergencies where actually the operational model are totally different, the choices that are made also different. Yeah, absolutely, and I mean, in our reviews, we've both won this morning presented by James and these here that I've presented on. I mean, we looked at all settings, both acute, chronic, forced displacement and so on, but predictably the evidence is much more from stable settings because that's really where most of the NCD work is taking place. It also is much easier to do research in those settings and I can't remember if it was brought up this morning or not, but in the review led by James, I think we only found out of the ATR studies that were identified, I think there was one with IDPs internally displaced persons. So that, you know, this is definite bias towards much more stable settings for very understandable reasons. So I think it's a really important issue that you raise, yeah. So we might just move on now. So Pablo, who is going to speak to us.