 All right, so good afternoon, everyone, hope it started. So I'd like to begin by acknowledging that we are gathered today in ancestral and secluded territory of the MacMaw people and to give thanks for the opportunity to be here. My name is Joanna Ergman, and I am the Associate Director of the Health Law Institute at Dalhousie University. And it is my pleasure to welcome you to our second seminar of this semester in our Health Law and Policy series. And if you're joining us for the first time or you're joining us not for the first time, I would like to come back. We'd like to see you. So please jump on our website to check out our two remaining seminars for this semester. This year, we're celebrating the interdisciplinary nature of our field, looking at the different theories and methods that inform our study of health law and policy, but also the challenging. And so our presenters this year come from the many fields of health law and policy and the many disciplines of its practice. And today it's my great pleasure to welcome my friend and leading and inspiring researcher in the field, Professor Pascal Alate. She's the Director of the United Nations University International Institute for Global Health. And indeed, you could say that Pascal embodies the very theme of that series itself insofar as her research is informed by a multidisciplinary background in clinical health sciences, anthropology, and epidemiology. She focuses on health equity, human rights, gender, and the social determinants of health in forced migration and marginalization, sexual and reproductive health, and infectious and non-communicable diseases. And so her competencies and her range are truly remarkable. And I have witnessed their impact firsthand. Pascal and I first met while serving on the World Health Organization's Gender and Rights Advisory Panel. And I can say of that experience that rather than talk across our disciplines in the true promise of such an engagement, we talked with and through them. So we use the methods and insights of each of our different disciplines, mine singular and hers many, to create something new. And so today we can all share in the benefit of that experience as Pascal shares with us some new ideas in her talk, A Matter of Survival Health Rights from the bottom up. So please welcome Pascal. Hi, good afternoon everyone. I am truly humbled to be listed with some of the amazing people. When Joanna first talked to me about the series, I sort of looked on the website to see what it was about and so on. Yes, so it is humbling to be on this stage with people who have gone before me. It's been in the planning for a while and I'd have been thrilled, except for the weather. Having flown in here from Malaysia. But thank you for having me. This is an amazing time to be working in global health and human rights. Sometimes frustrating, sometimes exhilarating, sometimes depressing, but never ever boring. So I want to kick off. So I've taken on this position as director of UNUIIGH just in, I think this is about my fourth month in the position. And I'm just working through now the area of focus for the Institute. So a lot of these ideas are kind of consolidating work that I've done over the last few years. I've been based mainly in Malaysia over the last eight and a half years, about from that doing global health work. So this is trying to consolidate some of the research projects that I've been working on, but also using this as an opportunity. You're the first I'm trying these ideas on. As an opportunity to open up a bit of dialogue about where I see one of the areas of focus for the Institute. So first of all, disclaimer, I am not a lawyer. I don't know whether I need to apologize for that. But I'm also not a traditional academic. I think, as Joanna mentioned, I've sort of done a bit in epidemiology and anthropology and so on. But I find when I present particularly to the anthropologists that they say that what I do is not anthropology. It's very much applied. And for me, it really is about understanding what each of the disciplines can bring to help me to answer a global public health problem. So ultimately for me, it is about what the outcome is and the excitement is about the range of different ideas that I can bring to bear to help me to work in these areas. So what I'm going to talk about is a little bit of a stream of consciousness as I try and bring these different ideas together. I will start off by talking a little bit about the importance of the bottom up approach within global health. Essentially what I'm talking about is community engagement and bringing community's voice into the work that we do. And there's some of the challenges in doing this, many of which you'll be familiar with. But I was asked to undertake a systematic review for and if I I'd like to make this a little bit interactive because I need some input from you as well. So if I use public health terminology that doesn't make sense, please tell me to stop. So the big direction now is universal health coverage from WHO and there was a big meeting in Tokyo in December last year on one of the themes that I had to produce a background paper for was on genuinely how do we bring community's voice into the work that we do. So I did a bit of a systematic review on that and I'll talk about some of the lessons from that. But what I really want to focus on through this is the challenge of working in different contexts and how important that is to bring into the global public health debate. And the real the use of trying to bring together in terms of policy, the full range of policy instruments including the law through national, international, traditional and the religious courts in law and regulation. I'm also particularly interested where so with the paper that I had to produce for this last meeting, one of the things that I had to talk about was what catalyzes community engagement. So in some instances people can give quick examples of ways in which they've worked with community but for the same example it may not work in different places and it's not necessarily about context. So what is it that catalyzes communities to engage actively in their health? So I'll talk a little bit about that as well. I think a critical example or a popular example now is the hashtag me too movement. And none of the issues that are raised are recent. These are things that I've been going. So what is it about now that has made it really key and how do we draw on those lessons to create social movements, to engage communities in their health. And then obviously finishing off with a little bit about so what, how are we doing all of this? Now I think to make it a little more concrete I want to start off with an example and I will come back to the example of this particular community. So this is a research project that was done primarily with the UNFPA in Malaysia. And they're called Baju, the community is called it's actually quite a derogatory term in Malaya that translates as CGYPSEs. But essentially it's this community that is in the northeast of Malaysia and they kind of fall between the gaps of indigeneity and statelessness because they fish and live predominantly on the sea rather than on the land. They don't have access to citizenship within Malaysia. It's a population of about 400,000 as it says here there's stateless or undocumented. The majority of the girls in that community were married by age 12. Very poor education outcomes and the number of children per woman was between five and 18, up to 18 kids per woman. And they live in the island waters in that geographical area that is between the Philippines, Malaysia and Indonesia. Because they're not tied to the land, the housing structures are pretty rudimentary. So this is really just describing multiple forms of marginalization of these particular communities. So very poor housing. As you can see, water, sanitation, all of those are problems. But where the community are prepared to invest in is the seafaring boats for the to work on the water. So just keep this at the back of your mind as a context for now and contrast it obviously with anybody been to Malaysia? Yep, okay, Malaysian? No, okay, yes. So Malaysia is very easy to live. It's a very easy place to visit. It's described as Asia light and it's very easy to visit as a tourist and just think it's wonderful and it is wonderful. I have lived there for eight and a half years, but, but so we'll come to that. So as I go talk about my stream of consciousness, let me go back to the importance of community engagement. So in 1978 was the Amartya Declaration, which was a very strong focus on the importance of health for the people, acceptable, accessible, affordable, all of those things that were wonderful. And the critical thing there was that communities needed to play a critical role. Now part of the reason that the Amartya Declaration and primary healthcare at the time did not succeed was that it was seen as something that was relevant to developing countries that developed countries had to pay for. And quite similar to the MDGs, the funders needed to know what it was they were buying and the community stuff was too warm and fuzzy. You can't measure that. You can't claim any part of it and so on. So it didn't, the comprehensive primary healthcare model never really materialized and it kind of deteriorated into deteriorated, kind of separated out into very specific programs. So you then had a very good focus on immunization because that is something that you can do and you can measure and you can get outcomes. There are problems about what do communities know about their health we own, we as healthcare providers know what they need and we can give health to them. But all through there has been this sense, even if it's tokenistic about the importance of community participation in some form, it's not something that one needs to, I mean, within global health, we've even gone through periods where we've had to produce systematic reviews to measure whether you get better outcomes if you have community participating. I mean, how this is even a research question, I don't know, I don't think it's a sensible research question. Obviously if you want people to be healthy, they need to be a part of the equation. Anyway, someone's invested or people have invested in actually doing studies that look at whether communities participating help. Now it is, if we go through waves of it, there is a real sense that this is an important thing that needs to be done. And but the problem is that it's a great ideology, the how to do it is problematic. So again, within the literature, whether it's development, whether it's in global health and so on, there have been various ways in which the nature of community participation has been analyzed and the best known one is the Einstein's ladder where they talk about different levels. So if you're just consulting, is that community participation? If you're engaging with them, if you're involving them in the research, is that participation and so on. So these different levels, whether they're helpful or not can be argued. And there's another model that talks about about the form and the function of community participation. So for instance, you want to consult if it's important for a political process. So a government needs to be able to tick the box that at least they've told the community about it or that it's not an intervention that requires the community to participate beyond knowing what the intervention is so that they're well informed about it. And you go through to a full spectrum where the interventions are actually generated by the community, for the community and so on. But again, it depends specifically on what it is you want. So when I was doing the review, it was very clear, for instance, that you can, almost everybody could give an example of where a community has participated in some way. We went and met the community elders or we employed health workers from the community or we had a town hall meeting and so on. Which, and it's not necessarily, what I've been trying to argue is that it's not necessarily good or bad. It depends on the outcome that you're trying to achieve to get a certain level. But within the universal health coverage framework, what we needed to be able to find or what we needed to understand, to be able to promote is how as a, not just on a project by project basis, but how at a system wide level or at a state level, you can create the structures that allow communities to be genuinely a part of any changes within their health systems to be able to help to support it. Now the challenges in this obviously go to things like health skills and this is a very, this is a big problem with the medical professions. Any doctors here before I'm too rude? No, okay. That it is, and this goes, again, is in the primary healthcare literature that one of the biggest oppositions to the idea of community participation was very much that the medical fraternity, the nursing fraternity, the health professionals did not feel that the communities knew what health was and that this was something that was very much in their domain. And then there's the, where there is a preparedness for communities to participate, how do you facilitate this? There's the issues of defining, well, what's community? How do you define what the community is that you want to engage with? But for me, I think one of the things that was really interesting was the nature of the democratic process within the different countries. So this was a review, that was a global health review. So just trying to understand what is it about the society and the democratic process that actually enables communities to be a part of the debate. And then it becomes clear that in lots of places where communities were a genuine part of it, they actually had to fight for it. And some of the strongest processes are where communities find that their rights are being violated or they don't have access and therefore they come together to demand the right that they need. And so the, again, just trying to analyze what it is that makes it different in different places and what works is this really critical issue about the importance of context and the enabling environment because without it all you have are individual projects that might work but not necessarily something that within the health systems framework you can actually draw on. So again then looking at the details of the different projects, this goes to, again, another example within Malaysia of working with the indigenous communities. So this was a project, again, with health professionals wanting to go and work with the community and feeling very proud of themselves that they had actually engaged. We know better but we still talk to them and this was clearly very much a kind of a tokenistic model of being able to say that they had worked with, they had consulted and so on. Interestingly, this is actually based on a project where the person who was telling me about this was talking about the fact that they really know the community and they had to trek several, a day and a half to get to this particular community and because they know what the community's value sacks of, rice, oil and sugar as gifts. So they're taking these gifts to the community so that the community see that they care about them and so on. At the same time, one of the things they were looking for was the risk factors for non-communicable diseases. So you're taking high carbohydrate sugar and oil and going to measure non-communicable disease risk. When you're introducing things into the community's diet that will increase their risk. So and it is this real sense of not understanding the technology, not really understanding what it is that they're trying to achieve with it. And again, this is another, I thought another really good example of again with the indigenous community where there is, the health services are taking development to the indigenous community and the way that it's approached has been a number of, they, sorry, the maternal mortality, morbidity and mortality rates are higher in the indigenous community than they are in the rest of Malaysia. And so the way that this was addressed was the establishment of kind of halfway houses. So they have to move from the rural communities closer to the hospitals within the last six, four to six weeks of pregnancy so that they can have the birth in the hospital. But the conditions that, the conditions within the houses were very poor. Most of the indigenous, the Aurangasli women did not want to leave their families and come and stay in these places. But if the child is not born in a health facility, then the child is not, they're not registered. And if you're not registered, you don't get access to a whole range of things because everything in Malaysia requires that you produce an ID card that is tied to where you were born and registered and so on. So there's a real backwards and forwards negotiation about what the health services need have to do to these people in order to provide them, improve their access to services and so on. And so there is a resistance and there is this general sense from the healthcare provider's perspective that this is a resistant population and it's very difficult to work with them. Because they see health workers coming and they run and so on. So there's no real meeting about how they can work together. So going then back to, again, to this example of the CGIPC's community, this, as I said, it was a research project that was undertaken by UNICEF and UNFPA because they were interested in the issue of child marriages. UNICEF's interest was in child marriages. UNFPA's interest was in family planning that the number of children the women were having and so on. But there was, again, very much, I think somebody described it as a forensic approach. This is the problem here is this is what we do about it. Again, without any real negotiation about what it means. So, but for the community's perspective, if you're not, those were not their priorities. So without an understanding of what it is they required, again, there wasn't a meeting of mine so they don't turn up when the health services kind of fly in to help them. There was no attempt to try and address the structural issues. And the challenge and difficulty of working with the community as well is that because they're not registered and they're not citizens, there is no government-related support. So it is an absolute challenge and I totally recognize it. That it is a challenge for an international organization to try and fly in and help without integrating all of this within the national system or with some sort of national support. But then it means that the intervention is not solely about those agencies but that they have to bring in and talk to the immigration services. They have to bring, you know, talk to all the different areas that are involved in making sure that the structural issues are addressed. And taking a human rights lens to trying to address the issues in the community provide us with those tools to be able to look at all the different areas where human rights were not being protected or violated to then be able to say, okay, it's not, we can't address these issues solely from a health perspective and that we do need to bring in a whole range of others as well. It's not enough to talk about the convention on the rights of the child alone because there's a whole lot more embodied within that than what is provided within individual silos. Now, again, going back to the issue of child marriages again. So Malaysia is a federation. Law is made at both the national and state levels. There's a dual justice system, the statutory system passed by parliament and so on, but there is also Islamic Sharia law that applies technically to about 65% of the population, the ethnic Malays, but they are the Muslim majority and as a result Malaysia is considered an Islamic country. And according to the constitution, federal law prevails over Sharia law if there are any inconsistencies. However, the issue with that regardless of what the law says is that religion is such an important part of people's identity and particularly within the Islamic context as well. So there is no way you're going to tell somebody that somebody who is a devout practicing Muslim that given the conflicts in these two, whatever the religious law says is subservient to the federal law. It's just not gonna happen. That's not the way that it works in practice. So in terms of the sexual and reproductive health and rights, it's dealt with under federal law, it's dealt with under the penal code and under Sharia law it's about behavior, religious, what is acceptable moral behavior and is much more strict within that. And this doesn't apply to Malaysia alone, it applies in neighboring countries like Indonesia for instance as well. So while there is an acceptable age up marriage under the judicial law, within the Sharia law you can get dispensation from the Imam if you want your child to be married at a younger age. And this is possible, one of the things that we're still trying to do now in terms of the research is try and see if we can actually interview some of the judges from the Islamic court to find out what the parameter, what their criteria are for deciding which way it is. The quick answer that we get from the data that we have so far, it is the reasons are reasons that anybody who's working in childhood marriages know which is it's a way of protecting the girls, it's a financial issue for the family, what's the third reason? It stops promiscuity and so on. So it is seen as an acceptable, it is any parent that you say they're being, it just wouldn't occur to them that they were being deliberately harmful to their daughter by marrying her off at 10 or at 12 or whatever it is. So the particular provision here on the close proximity to the opposite sex one is one that has been particularly problematic largely in Indonesia. And so this is a recent, fairly recent case where a girl was standing too close to her boyfriend so was camed and so on. These are still acceptable culturally forms of social engagement. There's some states in Malaysia that are, the religious states where you go to a supermarket, you're not allowed, men and women are not allowed to go in the same queue at the supermarket because of the risk of standing too close. They're parts of the cinema that the woman's part and the men's part and so on. And these are actually used as ways of explaining or supporting any reports women have about sexual harassment and so on. So if there are separate areas, and now if there are women only buses, the trains have women only carriages, if you as a woman don't use them and you get felt up, the government has done what it has, what can be done to try and support you and you don't take it out. So there these, I guess the point is the complexity of trying to understand the context in which violations may or may not happen depending on how you look at them and how you define, we had a workshop discussion this morning, but how we define the nature of harm within all of this when you're from a context where the protectors can actually provide justification for what it is they're doing to support you. And if you don't take it and you're violated, then well, we've done our bit, but what it actually does do is entrench the gender inequalities within the society. So in terms of how we address this, how we try and think through it, for instance, is trying to shift the way that the policy directions are within these issues that can be quite polarizing. And we can't do this without making communities a genuine part of it. There is, we can talk about the frameworks and how it is we support things for the majority of the population, but there will be these different contextual areas that don't fall within the norm. So without really trying to engage communities in part of the discussion, it makes it really difficult for us to be able to find the right ways to address them. When you're talking about a context where to challenge the authority, it's sedition, you totally close off any doors, any opportunity to be able to move the debate any further if you take a hard line. So how do we actually work through this? And it may be, I mean, I can say I've lived in Malaysia for however long, so I have a sense of understanding the culture. I never will because I am not, I don't identify. And so any solutions have to be developed. So the challenge for us is really trying to find those mechanisms to actually engage communities in a realistic way to be able to address some of these survival issues. So the catalyst for just trying to look at, and therefore how do we get communities to actually be a part of some of these social movements and work through and stand up for themselves. I was just looking at this, the Me Too movement, for instance, because I thought, oh, this is something that has certainly caught on. And then as you go through, and it may be great in Twitter or whatever, and you look at, you can do a Twitter analysis to see where all the hits are coming from, predominantly in North America and Europe. A little bit in India, but Southeast Asia is almost totally absent from that sort of debate. I'm from Ghana originally, and in Ghana as well, it's a major issue to be able to talk about issues of sexual violence. But people find a way around them. I will move and talk about Ghana. So this is a recent study that was undertaken in Ghana on sexual violence. And I was then trying to have a discussion with some of my friends and colleagues in Ghana, and this is middle-class women who are educated, and you think, yeah, these are people who I would expect to be a part of such a social movement. And it is still an absolute taboo to talk about these sorts of issues, because what is important is you don't want to shame your friends and family, because we know that a lot of the people who perpetrate in the hashtag me too movement are people that we know. It's the bosses at work, it's the uncles, people within our social circles, and it is more important to retain the family and the social piece than it is to make waves, which is a clear problem, and people can be ostracized from the social groups if they seem to be, but these are people we grow up with. Why on earth do you want to create problems and so on? And it is a major problem, and it is, even though I am from Ghana as well, it is one that I would really like to try and tackle and challenge, but I have no idea, maybe because it's much closer to me, I have no idea how I can get the debate going without being, I kind of fly into Ghana to visit my family and they think, oh, Pascal's coming, nobody's going to see her, we don't want to see her, she's just going to come, of course, trouble. So, and then this one's an example of going to the abortion debate, for instance, where as a ground level up movement, that women can find, people do find ways of working within the system or across the system to be able to protect or to get the services that they want. So, what is allowed within Islam in terms of contraception is menstrual regulation. When women have to, when women are going to Omrah for the Muslim pilgrimage, they're parts of the ceremony that they can't be part of if they're menstruating. So, it's okay if they regulate their menstruation and it is the same tablets, the same treatments that can also be used for termination of pregnancy, for instance. So, they're ways in which women find creative reasons to be able to access the services that they want if those services are not available under normal means because of the religious regulation. So, the question of, so what now? The critical thing is obviously working with communities to identify what matters to people, specifically. Even if there is a research agenda, even if there are things that we want to work, particular areas that we want to work in, being able to integrate what the communities want themselves, what matters to them is a really nice way, a really good way of bringing that in. I have some specific examples, but in the interest of time, if there are questions, I can bring those up. I'm looking at, one of the things I want to look at is also trying to interrogate this notion of what is the best evidence or what are the best interventions. At the moment, we rely within epidemiology on very specific methodologies for deciding what the best intervention is for the population. And the argument that I'm making and the work stream that I want to open up is looking at this notion of what is best. Are there different ways in which we can by involving communities think about ways of identifying or bringing the community voice into what works for them? A very specific example, for instance, is under the epidemiological model, you can have a treatment that is effective under clinical conditions. So we know that a particular drug will treat malaria 97% of the time. So we know that that is a good drug for malaria. But when you then try to provide it to people in the community, under the implementation chain, you go from, yes, I know this is a wonderful drug to, okay, I need to distribute it to the population. In distributing it, there are a whole range of people who don't get access, so it reduces within the population the effectiveness reduces to, I don't know, 60% or something. And then if you're able to get it to the population, whether the doctor prescribes it, then reduces effectiveness in the population further to 40%. And then having given it to the patient, you reduce the effectiveness to 20% because the person doesn't take the drug properly and so on. So this whole notion of what is the best evidence, the best intervention changes when you're actually having to release it into the population. How do we think about those sorts of issues of effectiveness in a different way from what is this, perhaps, not perhaps, definitely scientifically rigorous paradigm to one that in terms of implementation actually makes sense because we have to also bring that community bit into the whole implementation process. We need to provide accessible information in accessible formats. And again, I have a specific example of that from some of the research that we've done where in trying to negotiate with communities and negotiate to make sure that their voices are part of the work that we do, how do we make them integrate them really as part of the research process? How do we make sure communities are a part of the, generally a part of the policy discussion? And some of it is we don't speak the right language and we can only get that right language if the communities are a part of understanding and generating and so on, the work that we do. And it is possible. And if we don't do it, we're doing ourselves as a service and we're certainly doing the communities as a service. We need to work through some of the enabling processes for participation. Dialogue is a two-way communication. Very often dialogue, as it's described, tends to be us talking to them, but how do we make sure that we have the processes to get the information up from them as well? And I will end it there. This is just an example of one of the strategies that we have used in our community-based projects. So we bring kids in for coloring competitions and once the kids are there, mom's there, grandma's there, and that then also provides us with an opportunity to try and engage. So what we're actually looking at is as a research project, also looking at what works and trying it out as a, so it's not just something that we do as an event. It is, yes, it's an event and it's lovely to bring people together, but how do we effectively use those sorts of mechanisms as well to see how we can improve the whole notion of community engagement? Thank you. I just have something else to say, but a good amount of time for questions. I'm happy to go first. So I think most people would think about law's relationship to this work in the way that you described it as an upstream determinant factor for people, a community's capacity to adopt new behaviors or to change the way they live to affect their health. But I was more interested in in law and its relationship to participation and the concept of community participation in these two ways. One is that the right to participate has been now recognized within a health and human rights framework. And I wondered if you thought that was a good or bad thing because I think making it a right potentially institutionalized the set of practices, some of which are better and some of which are worse in participation and pretended like they are all the same in some ways. Like it really ratified the concept as more important than how it's practiced or it's outcomes. And so I would be curious as to your thoughts on that. And the second question is law as an enabling structure of participation and how much that came into your work. So you named it at least in two ways, right? ID and registration. That people can't participate if they are not recorded as people in law some way. And often that's on the basis of having a legal residence. That's a primary exclusionary factor in community based work is that if we don't have a legal residence for you we cannot know you as a legal person. And therefore you quote, don't count. And of course with many of communities that are migratory or living in informal settlements this is a problem. The other piece that you named was immigration states for example. And so again your formal or legal status to be in a certain place and the risks that you encounter in terms of participation and so what role could law serve in that respect? So I think it's a different, law is a determinant of participation which I think is a really fascinating area of research in itself. Okay so I think one of the, and you'll recall this from a lot of the WHO meetings. One of the interesting things for me working in Malaysia is that it, I don't want to say extreme, it provokes the nature of the society, provokes ideas about things like this. The difficulty sometimes when I listen to the rights questions is that there are a whole range of countries where you mention rights and the door is just banged in your face. So it is, the right to participate is not something that would worry anyone, any authorities at all because you're not allowed to congregate, five or more people are not allowed to congregate without police permission. And it's up to the discretion of whoever, however you apply or whoever happens to be there at the time, whether you get the permission or not. So the idea of the right to participate is not an issue. So if I were, or the way that I have worked with communities is rather than use the rights language for it is try and get them to understand, this is something that we're trying to do. If we don't allow your, whoever it is, your grandmother to be a part of this discussion, we might not be able to sort out what the issues are or address some of the issues for the elderly and so on. So it is about trying to, knowing that it is, that there is a right, how do you support people to fulfill it without necessarily using the rights language to do it? And it's absolutely the same sort of the issues that I've raised around the migration pieces as well. Again, Malaysia is particularly, in fact, not just Malaysia, that there is, the statelessness is a major issue across, or undocumented migrants and so on, are a major issue within the region. One of the interesting examples, for instance, is, sorry, let me go back, and in addition to that, one of the challenges is where the health services can be complicit in the violations. So there was a period, for instance, when the immigration, in fact, this is not just Malaysia. There was something on the news in the UK, the doctors in the UK were providing people's immigration status to immigration. Yeah, so it's that sort of thing, where there was an immigration van outside the maternity ward. Migrant workers are not supposed to have sex when they come to Malaysia. It's in their contract. There, as a domestic worker, you're not there with your family, you're there to work. So if you get pregnant, you're in breach of your contract anyway. So immigration rates outside the maternity unit, picks women up from the postnatal ward, to detention, and then you go off. I think this now, this now may just apply to men, but when you're in breach of your immigration visa or you overstay, there's, I think, five lashes or something, you're caned before you get sent off. I mean, it is the lack of documentation, the immigration status is still a major issue. And it's not certainly not just an issue within Malaysia and even within the universal health coverage debates and so on, the end within the STG is a lot of the language now is about applies to citizens. And that is the way that states have applied it. Same in the UK. So where you are not a citizen, you fall between the gaps in a whole range of health systems, health services issues. So this is an area that is being picked up within a whole range of, and it's not just about health, it's also about education and so on, that access is denied for non-citizens. I think one of the best examples within the Southeast Asia region is Thailand. Thailand is with kids in particular in education. A child has to be in education regardless of status. That's not an issue. But I think Thailand is probably one of the few in the region that actually does support it. And they have programs for people with different immigration status as well, but not many other countries. There's a comment, another question. I do not know, share your law, Islamic law, inside and out, but what I do know is that there are a lot of grays between what is religiously required and what's become a cultural norm. So there's a lot of things that the religion does not necessarily prescribe but have become a cultural thing. So instead of fighting those systems where it crosses over into abuse and the federal law supersedes is a good thing. However, we do need to build culturally responsive or confident practices. Observing from that community. And it's a good thing. Absolutely. The challenge, another challenge, though, is that being ethnically Malay is in the constitution. Being ethnically Malay means you are Muslim by law. You can't, you can't, they're long drawn out processes if you want to convert out but that's, that is a major issue. So it is, and particularly within the the stricter states in the North, it becomes very difficult to disentangle what is culture and it works both ways. I mean, from the authority's perspective, they can merge the two and so anything that you're saying against Malay, you're saying against Islam. But it is also, it also works the other way around as well. As you say that you can try and use the culture and try and gain cultural support working with communities to be able to address some of those other issues. I just want to turn you to the field, but just, what's the field I guess, of global mental health. So, from something a few years ago and I still sit with this worry and what you're saying speaks to the worry and I'm very sympathetic to this idea engaging with and working with communities and trying to both be responsive to community conceptions of what health is and what rights are and all the rest of it and yet, as you well know, that takes place in the context of these enormous imbalances and in power and also in sort of the strengths of the knowledge systems that are in play. And so in global mental health course, you've got the strong discourse sort of coming out of the global burden of disease or global burden of mental health, the economic hit that that means and then a strong response which has come from sort of biomedical psychiatry and there's this one group that has a lot of sway, the movement for global mental health which I kind of looked into and thought, wow, there's a lot of pharma interest there. So, I'm certainly, many folks have a real worry about the alignment of pharma's interest in expanding these markets with the interest in responding to the global burden of mental health. So that's kind of an obvious point. The way global mental health responds as I understand it is say, well, we're trying to work out these systems at the sites of delivery of kind of responsiveness in conversation. And yet I think that ultimately what's happening is this role of a kind of a way of self understanding, understanding one's love through the lens of diagnosis which we know has become just this incredible wildfire of ways of understanding ourselves. And of course, looking to pharma for response in North America and the rest. So there's that worry but then I'll just have one more worry on which is human rights. So I think that question, looking at the international conventional rights of persons with disabilities and this profound democratic movement expressed through the UN of all places to come up with this incredible socioeconomic plus civil political right stuff. It's just beautiful. And I love that story. And when, you know, many people who just love this story bottom up rights in action and in expression. But there's this one catch that really worries me which is the duty of states and it makes perfect sense to monitor the prevalence of disability in their states, right? Because you have to in order to know where the human rights harms are happening to folks who are disabled. And so my big worry was, wow, at the same time as you've got this role out of global mental health, you've got this bottom up question to human rights to self identify under the, under the perfect of mental disability. Again, there's all this conversation about, no, but we've got to sort of stir up the meaning of mental disability, psychiatric distress and all that stuff. But what's actually happening in my mind is this profound convergence of human rights and global mental health and this kind of imperialist, crazy kind of, you know, role. So anyway, that's my set piece on my worry. And I look to you because you've done all this thinking in all these other contexts and seen examples of those conversations. And that's what I don't have is a good example of how at those sites you can kind of disrupt what seems to me otherwise. I sound like a conspiracy theorist, right? I don't think that's what I'm talking about. So I think it's an area that we're still trying to understand. I mean, even as you talk about the, whether it's the global burden of disease stuff and so on, there's still, within the lower middle income country context, mental health is hugely under understood. Not understood area or poorly understood area. It is, I mean, the communities that I work in, we, and part of what we do is we have to do a regular census, so we do household surveys and so on. And we know because we use community-based data collectors that the houses, the households that we either have households where they know, the data collectors know that we are undercounting because the head of household does not identify people with mental illness in the house as part of the household in the survey. So we know that there's six people in the house, but they'll fill in the form for four because if you say the other two who have mental disabilities are there, there may be some way in which they will be brought out and it's a huge stigma for the family and so on. So it is, I mean, I guess what I'm saying is that the problems are even much more fundamental than you're raising. Yeah, yeah, yeah, yeah, indeed. So it is, it's a huge area that still needs quite a bit of unpicking, but I don't think you should worry about it. I think the fact that is, I think the fact that the debates are possible and that's what I say, it's a magical time to be working in this area because there is so much happening. Hopefully under an SDGs agenda, there will be a little less infighting across the UN agencies as well as with us as academics working in different areas and so on and that there will be much more convergence of some of these conversations with a focus on ensuring that we're doing the best we can for communities. Your focus on the social determinants of health as well, I think it's one way of trying to find a new kind of home aggressive, it's wonderful. Another piece that Sheila's question just made me think about, I mean, I think as this area also gets more sophisticated in its work, I mean, it's already true of moving away from any kind of romantic idea of communities as well, which is a big piece of that, which you realize that it's absolutely, I think I agree with you, critical to understand from the community's own perspective of how they think about their health, the causes of their health and so forth, but whether or not you take that as the end story, it's another question and you recognize that those values, those ideas, those identities can be and are shaped by so many different factors and as a researcher, that's part of your job, is to try to understand that, which people themselves for many reasons may and may not know in any kind of open or conscious way, but I think the idea is to fight against the past in which, as you said, it was sort of people don't know anything about their own health and it's really tried to overcome that bias, but not maybe entirely in the opposite direction, which is people know everything about their own health because as you say, there's lots of reasons why they are kept in the dark quite deliberately for certain ends. And it is also that what, as researchers, what you get if you're trying to bring communities or individuals or whatever within a qualitative paradigm that depending on the question that you ask at any particular point in time, you get a different person. You know, the sorts of questions that I might answer about health service utilization if I was answering the question about what I do with my kids will be totally different from if I was answering a question about my own health, what I would do when it's about me. So it is, and I think the thing that is really exciting is the fact that we are now, it is okay to recognize that complexity and not pretend that the evidence that we generate on one thing has to be the be all and end all to answer everything. And that context, it used to be that there was a real concern about this issue of context. Oh, here are those qualitative researchers talk about context again. And as soon as you talk about context, it means that the evidence you generate is only applicable to that group and therefore I can't do anything with this other group and therefore that data doesn't mean anything and so on. Whereas it is to expect that that sort of data should mean anything, means that you're asking the wrong research question in the first place. And it is now just trying to get people to recognize those different paradigms and ways of knowing and the knowledge, the collecting the knowledge that we need is becoming much more acceptable and you just need to look at the recent, whatever the new PubMed searches might be and you get some real, there's now qualitative evidence, there's now in the Cochrane collaboration or whatever. So it is, we are getting there. Yeah. You can hand me a trick or if you're mind for balancing cultural relativism with universalism when it comes to human rights, February 6th was the international day it was zero tolerance for female genital mutilation and there was a talk on campus on Tuesday and of course this balancing act comes up all the time. So how do you quickly, cognitively, process that given the situation like the Sharia law? I'm not quickly, I'm very thoughtful. Oh, I like to think I am. I think it's a hard one. I mean, so I had done research in the FGM area as part of my PhD. I happened to work in a community, the only community in Ghana where it's practiced. And it was just around the time that the WHO was developing where it gained political priority as a thing and then it became this is a very Western feminist approach to what African women want to do with their bodies and all of those sorts of debates down to, and I think the earlier guidelines from WHO were a little more forgiving and now it's zero tolerance. And there are still the debates about whether it's the right thing or not. It is an issue that is discussed quite a bit in Malaysia as well. And I think while there is, from WHO's perspective, there is a zero tolerance. There are, I think there are communities where there is a bit of a compromise where it has to do has to do with rights of passage for girls and so on. And so whether kind of a pin prick, at least is something. So it's the balancing of the physical health-related harm versus the interpretation. And this is where the problem often arises culturally, the interpretation that the fact that you do anything with women's genitals has to do with the fact that you're that women are, that it is an inequality type issue and that, yeah, with everything that goes with that. And that debate is still, I think still rages. And the difficulty is that we, again, I think it comes from the strict medical paradigm that we can use a single bullet to do a whole range of things. And that is often not the case. And as long as we remain open to the debates about, the causes may be multiple, but the solution is not the opposite of the cause. And that is something that still needs a little bit of thinking. So that is the very, that's the quick response, sorry. Which was it? Well, thank you all for joining us. We're back next week, actually, with another Health Law and Policy Seminar series. We move from the community expert to the medical expert. So Dr. Amy Ornstein will be speaking about the medical expert in Health Law and Policy. And join me in welcoming and thanking Pascal once again. Thank you.