1 00:00:03,950 --> 00:00:20,160 Like. Good evening, and welcome to this year's Black History Month lecture at the University of Oxford. 2 00:00:20,160 --> 00:00:27,570 I'm Alexandra Gordon, co-chair with Daphne Cunningham, the university's BME staff network. 3 00:00:27,570 --> 00:00:31,560 The network supports BME staff members of the university at all levels, 4 00:00:31,560 --> 00:00:35,940 promoting BME staff representation in the university and serving as a critical 5 00:00:35,940 --> 00:00:43,410 friend to the university as it works to combat racism and to achieve inclusivity. 6 00:00:43,410 --> 00:00:49,290 The BMA staff network supports this annual event in Black History Month by inviting speakers 7 00:00:49,290 --> 00:00:58,160 to present to a community and to the broader community on topics of relevance and concern. 8 00:00:58,160 --> 00:01:04,730 I would invite BME staff members in the University of Oxford who are interested in joining the new stealth network 9 00:01:04,730 --> 00:01:11,870 to look for our contacts and information on the web page of the Universities Equality and Diversity Unit. 10 00:01:11,870 --> 00:01:20,900 That Web page also provides information for those who are not BME, but would like to connect with us as an ally. 11 00:01:20,900 --> 00:01:26,150 This evening's programme will be formally opened by the University Registrar of Selection, 12 00:01:26,150 --> 00:01:31,530 who will make a few remarks and introduce our speaker, Professor Kevin Fenton. 13 00:01:31,530 --> 00:01:36,390 His talk will then be followed by a question and answer session to be moderated 14 00:01:36,390 --> 00:01:41,940 by Mitchell is embedded from the university's equality and diversity unit. 15 00:01:41,940 --> 00:01:47,520 We invite you to send in your questions for the Q&A session to the email address. 16 00:01:47,520 --> 00:01:54,750 Oxford BME Staff Network one vote at Gmail dot com. 17 00:01:54,750 --> 00:02:01,560 And to now, I will hand over to Jill Payton, who will introduce this evening's speaker. 18 00:02:01,560 --> 00:02:05,760 Good evening, everybody. Delighted to be with you. We've. 19 00:02:05,760 --> 00:02:12,660 The university has held a Black History Lecture Month lecture every year since 2008, and it's, of course, 20 00:02:12,660 --> 00:02:22,500 the 34th year since Black History Month has been celebrated in this country, and this has been a particularly important year for for this movement. 21 00:02:22,500 --> 00:02:27,420 We all of us know more than we probably want to know about the events that followed 22 00:02:27,420 --> 00:02:32,190 on from the murder of George Floyd and the BLM protests across the globe. 23 00:02:32,190 --> 00:02:42,000 The university has absolutely engaged in all sorts of ways in which it can address the ways in which these issues affect our own community, 24 00:02:42,000 --> 00:02:54,180 and it makes me particularly delighted to be introducing Professor Kevin Fenton to give this this year's keynote lecture. 25 00:02:54,180 --> 00:03:04,620 He has a wide ranging career, his starting from being a doctor in Jamaica, which created this lifelong interest in public health. 26 00:03:04,620 --> 00:03:14,160 He studied for his doctorate in epidemiology in London and went on to a really eminent career which is still in absolute full flight, 27 00:03:14,160 --> 00:03:22,290 both as an academic lecturing and and as a consultant, epidemiologist and not only holding. 28 00:03:22,290 --> 00:03:26,370 Such Eminence goes on about to tell you about that. 29 00:03:26,370 --> 00:03:31,110 He has been lauded for his his action on the wider stage in this country. 30 00:03:31,110 --> 00:03:37,770 He was lauded twice. I think of this as one of the root 100 black achievers and influences. 31 00:03:37,770 --> 00:03:43,800 And this year was ranked by power list as the second most influential black Briton. 32 00:03:43,800 --> 00:03:47,970 So I rather wonder what you have to do to be the first most influential. 33 00:03:47,970 --> 00:03:54,900 And so Kevin has also been playing a key role in the pandemic, which makes it particularly apt to this year. 34 00:03:54,900 --> 00:03:59,160 Giving tonight's lecture and in particular at his reports, 35 00:03:59,160 --> 00:04:07,230 highlighted health inequalities faced by minority black British people through the pandemic. 36 00:04:07,230 --> 00:04:11,670 And so he's worked in a variety of public health health roles across government 37 00:04:11,670 --> 00:04:17,970 and academia and has been on the Public Health England board since 2020. 38 00:04:17,970 --> 00:04:25,470 He's currently regional director for London of the Office of Health Improvement and Disparities and regional director of Public 39 00:04:25,470 --> 00:04:35,710 Health for NHS London and a statutory health adviser to the Mayor of London and on the Assembly before taking up those roles. 40 00:04:35,710 --> 00:04:36,720 He's eight. 41 00:04:36,720 --> 00:04:49,680 He was the key, the strategic director at the London borough of Southwark and senior adviser there for public health as the the role of Suffolk, 42 00:04:49,680 --> 00:04:51,990 I think is just worth drawing a bit of attention to. 43 00:04:51,990 --> 00:04:57,570 He led the council, the council's planning, regeneration, community engagement and public health portfolios, 44 00:04:57,570 --> 00:05:07,080 and that was driving inclusive regeneration as it based community development and promoting health in all the policies of that council. 45 00:05:07,080 --> 00:05:11,880 As the director of public health, he led the council's public health programmes, 46 00:05:11,880 --> 00:05:16,380 worked across the council and the NHS to promote health in all policies. 47 00:05:16,380 --> 00:05:24,450 All of these key things that we now think of as being absolutely natural and really, really important to do, and he was leading the way in Suffolk. 48 00:05:24,450 --> 00:05:29,820 He has previously been the Public Health England's national director for health and wellbeing. 49 00:05:29,820 --> 00:05:35,970 He led Public Health England's national prevention programmes, including screening for cancer and other conditions. 50 00:05:35,970 --> 00:05:40,920 Health checks, public mental health, sexual and reproductive reproductive health. 51 00:05:40,920 --> 00:05:44,520 And a range of wellbeing programmes for infants. 52 00:05:44,520 --> 00:05:49,440 Use adults everybody. Older adults, too. 53 00:05:49,440 --> 00:05:56,400 He established his health equity portfolio with a range of programmes and activities that focussed on 54 00:05:56,400 --> 00:06:02,490 addressing the social determinants of health and promoting place based approaches to health improvement, 55 00:06:02,490 --> 00:06:14,010 all of which makes him suitably qualified to have written those reports during our pandemic on health inequalities between 2005 and 2012. 56 00:06:14,010 --> 00:06:21,150 Professor Fenton was the director of the National Centre for HIV AIDS, Viral Hepatitis, STD and TB Prevention, 57 00:06:21,150 --> 00:06:31,920 but that organisation has an incredibly long acronym, which I won't repeat, and it was also at the Centres for Disease Control and Prevention. 58 00:06:31,920 --> 00:06:38,550 He was chief of the CDC's national syphilis elimination effort, and he's worked broadly in research, 59 00:06:38,550 --> 00:06:45,570 epidemiology and the prevention of HIV and other sexually transmitted diseases since 1995. 60 00:06:45,570 --> 00:06:54,430 This is just such an amazing career. We're absolutely delighted that you've been able to join us this evening. 61 00:06:54,430 --> 00:06:57,680 Professor Fenton, over to you. 62 00:06:57,680 --> 00:07:09,650 Jillian, thank you so much for the wonderful introduction, and it's very humbling just listening to us and realising just how time has flown, 63 00:07:09,650 --> 00:07:20,660 but also the privilege that I've had of serving in such diverse geographic locations on such interesting programmes. 64 00:07:20,660 --> 00:07:28,790 But most importantly, contributing to improving health and accelerating health impact here at home and around the world. 65 00:07:28,790 --> 00:07:37,610 So thank you for reminding me of that, but also thank you for the invitation to speak this evening. 66 00:07:37,610 --> 00:07:47,900 This is my penultimate Black History Month engagement, and this year I've made it a particular mission to ensure that my voice, 67 00:07:47,900 --> 00:07:50,870 along with the voice of many other black professionals, 68 00:07:50,870 --> 00:07:59,150 are both seen and heard that we celebrate excellence, that we speak about the issues which are relevant to our communities, 69 00:07:59,150 --> 00:08:06,080 that we ensure that we bring allies along with us, but also that we educate and empower. 70 00:08:06,080 --> 00:08:15,260 And we use this month not just as a single moment in time where we have lots of activities and then move on. 71 00:08:15,260 --> 00:08:26,270 But we use this time to reflect, to replenish, to regroup, to strategize and to think about how we can work together to create that more. 72 00:08:26,270 --> 00:08:34,070 Just society that I know we're all committed to society and the privilege of giving this lecture. 73 00:08:34,070 --> 00:08:40,310 And again, my sincere thanks for inviting me to do this lecture. 74 00:08:40,310 --> 00:08:46,610 I'll be reflecting on our experiences of navigating the COVID pandemic to this point. 75 00:08:46,610 --> 00:08:55,610 I'll be highlighting what we have learnt about inequalities. Many of those lessons were well entrenched and well known even before the pandemic, 76 00:08:55,610 --> 00:09:05,630 but the pandemic has allowed us a time to both reacquaint yourselves of the nature of inequalities and why inequalities matter. 77 00:09:05,630 --> 00:09:16,970 And perhaps they have unlocked new perspectives, new imperatives for us to begin thinking about how do we move forward as a legacy of this pandemic, 78 00:09:16,970 --> 00:09:26,810 to strengthen our actions, to strengthen our commitments to truly addressing disparities and addressing those wider determinants of health? 79 00:09:26,810 --> 00:09:34,490 So I'm just going to project my slides now just to get us started, and I'll be covering three key things today. 80 00:09:34,490 --> 00:09:39,590 The first will be a reflection on the pandemic and some of the early work that I was 81 00:09:39,590 --> 00:09:44,810 privileged to do on behalf of the then secretary of State and the chief medical officer, 82 00:09:44,810 --> 00:09:52,670 really understanding disparities and inequalities related to COVID in the first wave of the pandemic. 83 00:09:52,670 --> 00:10:00,920 I then I'm going to extrapolate some of the lessons from that first wave and how that has influenced our response as we've moved through waves too. 84 00:10:00,920 --> 00:10:04,340 And now with three of the pandemic. 85 00:10:04,340 --> 00:10:10,700 And then finally, I'd like to share with you some of the work we're doing in London because we have used these lessons, 86 00:10:10,700 --> 00:10:12,950 we have to use these new insights. 87 00:10:12,950 --> 00:10:24,170 We have used these new imperatives to fundamentally change how we work as a city and how we prioritised tackling health inequalities within our city, 88 00:10:24,170 --> 00:10:33,920 working from the specific actions of equality, diversity and inclusion for all our staff straight through to world leading programmes. 89 00:10:33,920 --> 00:10:39,380 Tackling inequalities, which we're delivering at scale for population health impact. 90 00:10:39,380 --> 00:10:47,870 So and by reflecting a little bit on the journey that we're on in London and ways in which we want to have as a legacy of this pandemic, 91 00:10:47,870 --> 00:10:55,820 both a renewed, empowered and stronger relationship with our communities and engaged, 92 00:10:55,820 --> 00:11:02,210 passionate and focussed staff working across our health care systems, 93 00:11:02,210 --> 00:11:10,910 as well as engaged and empowered partners who understand that together we need to work to address these inequalities. 94 00:11:10,910 --> 00:11:17,590 So I begin by just reflecting a little bit on the nature of the pandemic that we're living through my partner. 95 00:11:17,590 --> 00:11:21,380 I think you've already been introduced to, so I want to reflect on this anymore. 96 00:11:21,380 --> 00:11:26,540 Apart from saying and to Jillian to the point, I made earlier that in a sense, 97 00:11:26,540 --> 00:11:35,780 all of the diverse experiences which I've had throughout my career have in their own way prepared me and us for this moment. 98 00:11:35,780 --> 00:11:41,540 But there's so many lessons that I'm learning now that I will be taking through throughout my career. 99 00:11:41,540 --> 00:11:49,010 And this is, I think, a reflection of just the growth development that we all have as professionals and whatever 100 00:11:49,010 --> 00:11:55,610 walk of life we are in that we are truly on a journey of learning and development. 101 00:11:55,610 --> 00:11:57,050 And this is for me. 102 00:11:57,050 --> 00:12:07,920 Certain parts of that as well, so as many of you are aware, we've had a fairly severe impact of the COVID 19 pandemic in the United Kingdom, 103 00:12:07,920 --> 00:12:16,260 and we know there are millions of people who have become infected, millions who lives have been upturned as a result of this pandemic. 104 00:12:16,260 --> 00:12:26,430 And I think none of us who have either been affected by or infected with COVID or have had our lives touched in some way, 105 00:12:26,430 --> 00:12:33,090 whether it is people who have loved and lost, whether it's convincing a family member to get the vaccine, 106 00:12:33,090 --> 00:12:39,150 whether it is encouraging those who we know and love or we work with to be COVID secure and safe. 107 00:12:39,150 --> 00:12:45,960 This pandemic has touched us in ways which hitherto were unimaginable and which I'm sure 108 00:12:45,960 --> 00:12:51,210 will leave an indelible mark on all of us as we emerge from the pandemic in the months, 109 00:12:51,210 --> 00:13:02,670 weeks and months ahead. So this slide is this is a sense here as a pictorial representation of the past 22 months and recognising the challenges, 110 00:13:02,670 --> 00:13:08,820 the pain, the difficulties, but the scientific discoveries, the new ways of working, 111 00:13:08,820 --> 00:13:16,120 the innovation that have arisen from this pandemic, which I'm hoping that we'll be able to take both sides of this pandemic, 112 00:13:16,120 --> 00:13:21,750 the good and the bad to help us to do better moving forward. 113 00:13:21,750 --> 00:13:28,680 Now, one of the defining characteristics of the COVID pandemic has been inequalities, 114 00:13:28,680 --> 00:13:35,460 and the inequalities have really been manifest as early as the first wave of the pandemic. 115 00:13:35,460 --> 00:13:43,380 And if you take yourselves back to March and April last year, when we began to see images on the news, 116 00:13:43,380 --> 00:13:50,490 whether the BBC or Sky News of people who were affected by the infection who are dying from the disease, 117 00:13:50,490 --> 00:13:58,560 it became very apparent and very clear, very quickly that we began to see more brown and black people represented in the 118 00:13:58,560 --> 00:14:05,070 COVID deaths than you would normally expect given or distribution in the population. 119 00:14:05,070 --> 00:14:12,540 It was also clear from some of those news reports that the people who were dying from the disease or had severe disease were people who 120 00:14:12,540 --> 00:14:22,710 were largely in the health and care sector or people who were in sectors that had them having a high probability of contact with others. 121 00:14:22,710 --> 00:14:26,250 And it was this emerging reality and this real concern, 122 00:14:26,250 --> 00:14:34,710 both from the medical fraternity as well as the wider community that prompted both the chief medical officer and the secretary of state at that time, 123 00:14:34,710 --> 00:14:42,450 Matt Hancock, to ask Public Health England to do an initial rapid review of what was happening in 124 00:14:42,450 --> 00:14:48,450 the first wave and to describe the disparities and risks and outcomes for COVID. 125 00:14:48,450 --> 00:14:55,410 I was privileged to lead this work on behalf of Public Health England and in doing so was able to build upon my 126 00:14:55,410 --> 00:15:02,760 experience as an infectious disease epidemiologist and someone who's worked in HIV for more than two and a half decades. 127 00:15:02,760 --> 00:15:08,190 And I recognised right at the beginning that any enquiry into disparities in 128 00:15:08,190 --> 00:15:13,890 risks and outcomes had to both combine the quantitative or epidemiological data. 129 00:15:13,890 --> 00:15:18,540 So looking at routine clinical data, death and mortality statistics, 130 00:15:18,540 --> 00:15:28,740 ICU statistics and in addition to begin to understand context, to begin to understand the stories, 131 00:15:28,740 --> 00:15:33,120 to begin to understand the voices of communities that were affected by this 132 00:15:33,120 --> 00:15:38,370 condition and to understand their experiences of going through the first wave, 133 00:15:38,370 --> 00:15:47,280 but also their views on what could have been prevented and most importantly, what should be done moving forward. 134 00:15:47,280 --> 00:15:59,070 So this work combined both epidemiological as well as social socio anthropological work we embarked upon over an eight week period. 135 00:15:59,070 --> 00:16:07,740 I went a massive programme of public engagement on the first wave of the pandemic, engaging individuals, 136 00:16:07,740 --> 00:16:16,110 members of the community, politicians, leaders of organisations both within almost every region in the country, 137 00:16:16,110 --> 00:16:22,110 as well as the devolved nations using a variety of methods, including one to one interview, 138 00:16:22,110 --> 00:16:27,150 focus group interviews, as well as large scale town hall events. 139 00:16:27,150 --> 00:16:32,550 By virtue of the fact that we were in lockdown at the time, most of these were done using online formats, 140 00:16:32,550 --> 00:16:40,440 which really facilitated us having large numbers, rapid engagement, as well as meaningful engagement online. 141 00:16:40,440 --> 00:16:47,040 In total, we were able to interview more than 4000 people and engaged more than 4000 people in preparing 142 00:16:47,040 --> 00:16:53,400 these reports and really captured some of those early stories of the first wave of the pandemic. 143 00:16:53,400 --> 00:16:56,740 So the first step to show some of the key findings that were published in. 144 00:16:56,740 --> 00:17:02,670 The report and certainly everything that we found in that those first investigations. 145 00:17:02,670 --> 00:17:07,980 Remember, this is the first report from governments on disparities in risks and outcomes. 146 00:17:07,980 --> 00:17:15,810 All of our findings have been replicated by the OAS. Other researchers that have been worked in, I've been working in this space. 147 00:17:15,810 --> 00:17:21,840 And of course, the lived experiences as we've gone through successive waves of the pandemic. 148 00:17:21,840 --> 00:17:23,550 So again, in the first wave, 149 00:17:23,550 --> 00:17:32,040 it was clear that we were beginning to see differences appearing by age and sex with higher rates of severe disease and death occurring. 150 00:17:32,040 --> 00:17:38,730 If you were older and women had a higher likelihood of being diagnosed with COVID in the first wave, 151 00:17:38,730 --> 00:17:42,480 but men had a higher likelihood of dying from the disease, 152 00:17:42,480 --> 00:17:48,300 the report highlighted the geographic clustering of infection and larger metropolitan areas, 153 00:17:48,300 --> 00:17:56,580 especially those that had significant international connectivity, were particularly hard hit in the first wave of the pandemic. 154 00:17:56,580 --> 00:18:02,730 And that in part explains why London's rates and the impact in wave one was so severe in the city. 155 00:18:02,730 --> 00:18:08,850 But we saw this feature occur in other urban and suburban areas across the country as well. 156 00:18:08,850 --> 00:18:13,230 Perhaps the only exception that we also observed was in the northwest, 157 00:18:13,230 --> 00:18:19,770 where we began to see some of the early signals of the high incidence of disease and persistent 158 00:18:19,770 --> 00:18:26,790 infection in that part of the country or epidemiological data confirm the links of deprivation. 159 00:18:26,790 --> 00:18:35,340 So if you lived in more deprived parts of the country and in cities, you're far more likely to have severe disease and to die from the infection. 160 00:18:35,340 --> 00:18:40,020 And of course, the reports highlighted the increased risks experienced by black, 161 00:18:40,020 --> 00:18:45,270 Asian and minority ethnic individuals, especially Pakistani, Bangladeshi, 162 00:18:45,270 --> 00:18:49,170 Black, African and Caribbean communities in wave one, 163 00:18:49,170 --> 00:18:56,520 which had between a two to three fold increase the risk of death compared to their white counterparts. 164 00:18:56,520 --> 00:18:57,150 So as I mentioned, 165 00:18:57,150 --> 00:19:06,690 we combined the epidemiological data with the socio anthropological work using a variety of techniques to understand narratives and stories, 166 00:19:06,690 --> 00:19:14,640 the lived experiences of people who were either experiencing the pandemic or responding to the pandemic and the qualitative interviews. 167 00:19:14,640 --> 00:19:22,860 We really began to uncover four key areas which were important in determining why we were seeing the patterns that we were seeing. 168 00:19:22,860 --> 00:19:29,010 First, it was clear that longstanding social and economic inequalities that had placed 169 00:19:29,010 --> 00:19:36,030 communities at disadvantage and were actually accelerators of further disadvantage. 170 00:19:36,030 --> 00:19:46,080 Once COVID arrived, and this really was a reflection on the social and living conditions that people had, the impact of income and poverty, 171 00:19:46,080 --> 00:19:50,580 the ability of communities to be engaged and empowered, 172 00:19:50,580 --> 00:19:57,210 and to be active participants in their health and protecting themselves and vulnerabilities in vulnerable groups. 173 00:19:57,210 --> 00:20:00,330 For example, the homeless migrant populations, 174 00:20:00,330 --> 00:20:09,060 undocumented populations which were less likely to engage with national messages less likely to engage with services. 175 00:20:09,060 --> 00:20:16,050 We learnt from the qualitative interviews about the importance of factors which increase risk to exposure to COVID, 176 00:20:16,050 --> 00:20:24,180 especially the Real-World realities of staff who were working in frontline roles not only in the health and care sector, 177 00:20:24,180 --> 00:20:27,690 but in the transportation sector, in the construction industry. 178 00:20:27,690 --> 00:20:36,090 Those who took care of us in the supermarkets while we were all in lockdown, lifting out and working with members of the public. 179 00:20:36,090 --> 00:20:40,980 We also began to understand in those early interviews the importance of overcrowded 180 00:20:40,980 --> 00:20:47,520 housing and multi-generational households and how these factors clustered by deprivation, 181 00:20:47,520 --> 00:20:53,860 by geography, by social and economic, as well as cultural groups as well. 182 00:20:53,860 --> 00:21:04,000 Qualitative work also helps us to understand not only that the risk of developing COVID was a function of being exposed to the virus, 183 00:21:04,000 --> 00:21:07,660 but there were factors that increase the risk of complications and death, 184 00:21:07,660 --> 00:21:18,340 including your ability to navigate the health care system if you are unwell in order to be seen in a hospital for your coverage. 185 00:21:18,340 --> 00:21:24,220 It also had uncovered the stories of people who perhaps were coming into the 186 00:21:24,220 --> 00:21:29,200 pandemic with undiagnosed or poorly managed multiple long term conditions, 187 00:21:29,200 --> 00:21:33,280 and how that had a detrimental impact on severe disease and death. 188 00:21:33,280 --> 00:21:42,010 And we also learnt absolute clarity about the impact on the intersection of poor mental health and people with severe and enduring mental 189 00:21:42,010 --> 00:21:50,860 illness and their experiences of navigating the first wave of the pandemic and the difficulties they had both been diagnosed and being managed, 190 00:21:50,860 --> 00:21:53,620 and to manage those comorbidities. 191 00:21:53,620 --> 00:22:02,890 Finally, the report was the first in from government, which really reflected on some of the wider structural issues that influenced our risk, 192 00:22:02,890 --> 00:22:07,690 including racism, discrimination, stigma, fear and mistrust. 193 00:22:07,690 --> 00:22:16,900 And these were important stories for communities to get across the sense that actually many of the preventive messages, 194 00:22:16,900 --> 00:22:22,870 the early messaging, the images that were used in the first wave of the pandemic didn't really speak to them. 195 00:22:22,870 --> 00:22:27,100 They were only in English. They didn't use the channels that communities would use. 196 00:22:27,100 --> 00:22:32,800 They didn't use the key community leaders who are trusted voices in their own communities 197 00:22:32,800 --> 00:22:38,080 to help people to understand the nature of the threat and what needed to be done. 198 00:22:38,080 --> 00:22:48,070 And we uncovered real issues related to steer stigma of being diagnosed with COVID and how that impacted on local communities and local networks. 199 00:22:48,070 --> 00:22:55,690 And, of course, fear and stigma of going into the hospital with presumed COVID because of fear of death from the disease. 200 00:22:55,690 --> 00:23:01,880 There are a lot of real issues that we're able to uncover using this mixed method approach. 201 00:23:01,880 --> 00:23:04,390 Another report a year ago, more than a year ago, 202 00:23:04,390 --> 00:23:13,270 highlighted seven key areas where we needed to act if we were going to limit the impact of both COVID in its first wave, 203 00:23:13,270 --> 00:23:21,220 as well as subsequent waves of the pandemic. And we were deliberate in identifying seven key areas for action, 204 00:23:21,220 --> 00:23:29,560 in part because of the nature of the speed of response that we needed and we wanted to focus all system leaders, 205 00:23:29,560 --> 00:23:38,200 whether working nationally, regionally, locally in the community on a few things which would be high impact that would be deliverable, 206 00:23:38,200 --> 00:23:44,020 feasible, acceptable and would have impacts if implemented. 207 00:23:44,020 --> 00:23:49,390 So the seven recommendations are highlighted here. I won't go through these in any great detail, 208 00:23:49,390 --> 00:23:54,580 but just to say that they really focus on the importance of strengthening our data collection 209 00:23:54,580 --> 00:24:00,220 and recording so we could better characterise the impacts of COVID on our communities, 210 00:24:00,220 --> 00:24:09,760 not only their clinical characteristics, but capturing more of the social and economic and contextual realities of our communities. 211 00:24:09,760 --> 00:24:18,550 We call for new research, which really had communities at the heart of both asking the questions, framing the issues, 212 00:24:18,550 --> 00:24:26,560 helping with the methodology, disseminating the results and being part of translating that evidence into practise. 213 00:24:26,560 --> 00:24:35,800 We asked for more accountability from health and care providers to ensure that they held themselves to account, to protect their staff, 214 00:24:35,800 --> 00:24:45,070 to engage with communities and to ensure that their programmes and policies were geared towards tackling these inequalities. 215 00:24:45,070 --> 00:24:53,770 We found and really made recommendations on cultural competency, both in terms of risk assessments, the messages that were being given out to COVID, 216 00:24:53,770 --> 00:24:59,140 as well as wider preventative programmes which were dealing with the multiple long term conditions, 217 00:24:59,140 --> 00:25:03,370 as well as other Real-World realities of communities. 218 00:25:03,370 --> 00:25:13,480 And this cultural competence is important because it moves us from a discussion on being culturally sensitive to a more proactive 219 00:25:13,480 --> 00:25:23,170 stance where we are working with and alongside communities to develop and shape and implement and evaluate the work that we're doing, 220 00:25:23,170 --> 00:25:28,960 so that those interventions actually meet the needs of the communities that we're told to serve. 221 00:25:28,960 --> 00:25:33,580 And finally, we ask that as we emerge from the pandemic and we think about recovery, 222 00:25:33,580 --> 00:25:42,910 that we have equity at the forefront of our minds with that with with our work on recovery. 223 00:25:42,910 --> 00:25:46,360 So there have been a lot of things that have happened over the last year, 224 00:25:46,360 --> 00:25:54,970 and we won't have time today to talk about just the range of activities that have taken place in response to not only this report, 225 00:25:54,970 --> 00:26:04,000 but other reports from awareness of the researchers about the nature, scale and profound depth of the inequalities that is being seen. 226 00:26:04,000 --> 00:26:12,100 And some of the interventions are highlighted here from resources that have been delivered by governments 227 00:26:12,100 --> 00:26:18,190 to better engage and to build capacity in communities to build much more culturally competent, 228 00:26:18,190 --> 00:26:22,690 sustained and community engaged responses to the pandemic. 229 00:26:22,690 --> 00:26:29,600 We fundamentally changed communications on COVID, and many of you are aware of the diversity of images of languages, 230 00:26:29,600 --> 00:26:35,020 the channels which are now used to engage with members of our diverse communities. 231 00:26:35,020 --> 00:26:44,140 We have built stronger links with faith communities, with community organisations both on coffee, but more importantly, on wider health issues. 232 00:26:44,140 --> 00:26:53,500 And in London and many regions across the country. Local authorities, the NHS businesses, regional governments have prioritised equity, 233 00:26:53,500 --> 00:27:02,170 have developed new governance to lead on equity and are holding themselves to a higher account for ensuring that the data, 234 00:27:02,170 --> 00:27:09,400 the programmes, the people, the public are engaged in this journey on tackling these inequalities. 235 00:27:09,400 --> 00:27:13,630 And finally, we've seen over the last year where public health bodies, 236 00:27:13,630 --> 00:27:18,760 including the Association of Directors of Public Health and the Faculty of Public Health, 237 00:27:18,760 --> 00:27:26,500 have come out strongly to denounce racism and to think of and encourage us to think of racism as a 238 00:27:26,500 --> 00:27:34,630 public health crisis and to use our skills in public health to bring to bear to addressing these issues. 239 00:27:34,630 --> 00:27:40,270 So again, many interventions that have taken place over the last year, year and a half, 240 00:27:40,270 --> 00:27:48,100 leading us to a much more equitable, much more culturally competent response to the COVID pandemic. 241 00:27:48,100 --> 00:27:55,060 So as I said, as we've gone through the successive waves of the pandemic, we've seen this disproportionality appear. 242 00:27:55,060 --> 00:27:59,860 Now the good news is that the patterns of the disproportionality have changed over time, 243 00:27:59,860 --> 00:28:04,420 in part because communities have adopted new behaviours to protect themselves, 244 00:28:04,420 --> 00:28:12,460 in part because as we've gone through subsequent waves, the nature of exposure to some communities have been differential and that in 245 00:28:12,460 --> 00:28:17,290 turn has an impact on their experience of subsequent waves of the pandemic. 246 00:28:17,290 --> 00:28:20,050 Certainly in London, we know that, for example, 247 00:28:20,050 --> 00:28:26,900 black Caribbean and black African communities were severely and disproportionately affected in wave one and Wave two, 248 00:28:26,900 --> 00:28:35,410 we saw change where our Asian communities in London, South Asian, especially Pakistan and Bangladeshi communities, 249 00:28:35,410 --> 00:28:39,700 bore disproportionate burden of cases and deaths in the second wave. 250 00:28:39,700 --> 00:28:44,200 Whereas in Wave three, which began in the spring summer of this year, 251 00:28:44,200 --> 00:28:55,540 we began to see far more young white British individuals being affected as we moved into and began experiencing the delta waves of infection. 252 00:28:55,540 --> 00:28:58,270 And we see how these have changed over time and again. 253 00:28:58,270 --> 00:29:05,320 This is looking at some of the age standardised death rates for men by ethnic group in waves one compared with two. 254 00:29:05,320 --> 00:29:11,470 And you can see, as I mentioned in Wave one, nearly all of the minority ethnic groups for men, 255 00:29:11,470 --> 00:29:15,430 we saw an increased risk of death as we moved into Wave two. 256 00:29:15,430 --> 00:29:21,190 We saw persistence of that increased risk in Bangladeshi and Pakistani communities, 257 00:29:21,190 --> 00:29:27,190 whereas we saw less or equal to white British, the risks in other ethnic groups. 258 00:29:27,190 --> 00:29:31,090 So we did see the impacts of both our interventions, 259 00:29:31,090 --> 00:29:39,440 as well as how the second wave of the pandemic evolved and how that differentially impacted different communities. 260 00:29:39,440 --> 00:29:48,010 And we looked so much in past year, right? So studies have come which are really highlighted and helped us to understand the nature of 261 00:29:48,010 --> 00:29:55,180 occupational risk and the nature of why in so many of these occupations that were at high risk. 262 00:29:55,180 --> 00:30:00,430 We saw this disproportionate burden amongst black, Asian and minority ethnic communities. 263 00:30:00,430 --> 00:30:10,600 And this slide shows data from the awareness that shows the proportion of men working in the highest death rate occupations who are ethnic minorities. 264 00:30:10,600 --> 00:30:17,710 And you can see more than half of our taxi drivers, cab drivers, drivers and chauffeurs are BAMC. 265 00:30:17,710 --> 00:30:23,000 We see more than a third of people working in catering and chefs, 266 00:30:23,000 --> 00:30:30,460 those who are working in security guards and other related occupations who are black, Asian and minority ethnic communities. 267 00:30:30,460 --> 00:30:33,910 So this increased risk through occupation would in turn, 268 00:30:33,910 --> 00:30:41,660 have had a disproportionate impact on our communities, and that's why we called for better protection in. 269 00:30:41,660 --> 00:30:51,050 In the workplace, that's a focus on risk assessments and ensuring that those who are especially at risk have the protections that they need. 270 00:30:51,050 --> 00:30:58,190 Now this relationship of ethnicity and COVID is a complex one and interacts with deprivation, 271 00:30:58,190 --> 00:31:07,040 and that is really important to understand because not only did it affect who got infected, who had severe disease and who died from the infection. 272 00:31:07,040 --> 00:31:09,260 But as we move through the course of the pandemic, 273 00:31:09,260 --> 00:31:18,800 we've seen this interaction between ethnicity and deprivation play out in the effectiveness of or testing and contact tracing programme, 274 00:31:18,800 --> 00:31:24,530 but also playing out in the uptake and delivery of the vaccine programme as well. 275 00:31:24,530 --> 00:31:31,250 And this slide just shows on the left hand side that as we move towards more deprived parts of the country 276 00:31:31,250 --> 00:31:40,040 that you see far more engagement and far more cases occurring within black Asian minority ethnic individuals. 277 00:31:40,040 --> 00:31:48,110 Whereas as you move to the least deprived parts of the country, then you begin to see a lower impact on these ethnic groups and we see these 278 00:31:48,110 --> 00:31:53,630 patterns operating differently and differentially across different ethnic groups. 279 00:31:53,630 --> 00:32:00,980 And I talk about this interaction because it is pretty it has influenced our vaccine programme and vaccine uptake. 280 00:32:00,980 --> 00:32:10,040 We understood because of our experience in ways, one in waves, two that we, for example, in London, needed to start earlier, 281 00:32:10,040 --> 00:32:16,790 even before the first vaccine was delivered to do work with our communities around vaccine hesitancy, 282 00:32:16,790 --> 00:32:20,750 mobilisation around vaccines and education, around vaccines. 283 00:32:20,750 --> 00:32:25,190 And in fact, we established a vaccine equity group before the vaccine. 284 00:32:25,190 --> 00:32:32,000 The first vaccine was given because we could see these patterns of inequalities playing themselves out over time. 285 00:32:32,000 --> 00:32:39,200 And this slide just highlights where we were at the beginning of the year with levels of hesitancy by ethnic groups. 286 00:32:39,200 --> 00:32:43,040 And this is highlighting the portion of individuals in an ethnic group who 287 00:32:43,040 --> 00:32:48,320 said that they were unlikely or very unlikely to receive their COVID vaccine. 288 00:32:48,320 --> 00:32:53,300 So we began with this huge variation across the different ethnic groups, 289 00:32:53,300 --> 00:32:57,410 and we've been working diligently over the past year to address this and in 290 00:32:57,410 --> 00:33:03,290 this process have continued to learn about or work on tackling inequalities. 291 00:33:03,290 --> 00:33:09,500 A core strategy for us in London has been developing a particular approach in the city that 292 00:33:09,500 --> 00:33:15,560 was both holistic and comprehensive to address vaccine hesitancy in the centre of this slide. 293 00:33:15,560 --> 00:33:22,460 It really shows the logic that we have pursued an understanding that the motivation 294 00:33:22,460 --> 00:33:28,760 to get vaccinated is a function of what people think and feel about the vaccine, 295 00:33:28,760 --> 00:33:36,290 as well as social processes, how they're influenced by wider leadership, who they're speaking to, the networks that they're in. 296 00:33:36,290 --> 00:33:44,630 We need to look at the practical access of vaccination as well, who and where our vaccination sites located. 297 00:33:44,630 --> 00:33:50,150 Are they confident? Are they welcoming? Are they open to different communities? 298 00:33:50,150 --> 00:33:59,390 And to ensure that we're looking at both the practical aspects of vaccination delivery, as well as engaging communities in a comprehensive way? 299 00:33:59,390 --> 00:34:06,470 So over the past year, in all of these demands and coloured boxes, we've worked on working with communities, 300 00:34:06,470 --> 00:34:13,280 for example, thinking about influencing vaccine policy and ensuring that it was again culturally competent, 301 00:34:13,280 --> 00:34:20,720 recognising and working with chances to understand the historical context and why trust in institutions and 302 00:34:20,720 --> 00:34:27,830 government might be low and how we work together to overcome that in order to have the lifesaving vaccine. 303 00:34:27,830 --> 00:34:37,160 We did a lot of work to build health literacy, challenge health beliefs, working with parents and peers and key influencers within our communities. 304 00:34:37,160 --> 00:34:43,430 And we've done so much on access registration and the Phillipson approach in London, 305 00:34:43,430 --> 00:34:53,090 which we call the hyperlocal approach to vaccine delivery, where we used data overlaying the demographic profile incidence of disease, 306 00:34:53,090 --> 00:35:00,860 what we know about vaccine uptake to target where we place for vaccine outreach sites, where we knock on doors, 307 00:35:00,860 --> 00:35:08,360 where we work with local community organisations to mobilise communities in order to get us to a better place again. 308 00:35:08,360 --> 00:35:16,340 Learning and implementing our programmes have been a key part of our work over the past year on vaccines and again, 309 00:35:16,340 --> 00:35:18,170 extracting those lessons are important. 310 00:35:18,170 --> 00:35:25,790 So here we just highlight some of the things that we have done that we're particularly proud of engaging targeted groups, 311 00:35:25,790 --> 00:35:30,500 really focussing on community competence and community appropriate, 312 00:35:30,500 --> 00:35:40,850 acceptable ways of engaging, using different spokesperson Q leaders weather and sharing resources across the city and with other regions. 313 00:35:40,850 --> 00:35:47,220 We've held. Hundreds of vaccine confidence events for Londoners listening to some tough truths, 314 00:35:47,220 --> 00:35:55,980 sometimes being open to criticism and being open to being challenged, but at the same time, sticking to the evidence. 315 00:35:55,980 --> 00:36:03,690 Listening to the facts, sharing the facts and building that confidence through truth, consistency and time. 316 00:36:03,690 --> 00:36:09,990 We've built capacity in communities, developing a bureau of community speakers and public health ambassadors, 317 00:36:09,990 --> 00:36:12,840 people who are not public health trained or health trained, 318 00:36:12,840 --> 00:36:20,820 who understand and can speak to members about the vaccine and engage them in access and addressing fears. 319 00:36:20,820 --> 00:36:26,640 We've developed a network of community champions which have also helped us not just with the vaccine, 320 00:36:26,640 --> 00:36:35,220 but as we've moved through subsequent waves of the pandemic. So again, new assets, new ways of working that we've developed in the city. 321 00:36:35,220 --> 00:36:41,760 Now we're making significant progress and as many of you know, or rates in London are still lower than the rest of the country, 322 00:36:41,760 --> 00:36:46,290 but we know that that's the London characteristic for all vaccination programmes. 323 00:36:46,290 --> 00:36:49,230 London generally has lower vaccination rates. 324 00:36:49,230 --> 00:36:56,550 But I, for one, I'm so pleased and thankful to our communities for the journey that we've been on together over the past year, 325 00:36:56,550 --> 00:37:01,380 where we started with very high rates of hesitancy and poor uptake of the vaccine. 326 00:37:01,380 --> 00:37:09,990 So a point now where in terms of double vaccination and the resilience that we have in the city, a combination of both of our vaccination, 327 00:37:09,990 --> 00:37:17,970 as well as natural exposure to the virus, we know that we have a robust and substantial population immunity to the virus. 328 00:37:17,970 --> 00:37:27,540 So we know that we're on this journey. There's more to go, but this is the kind of work done in partnership with communities as what we're learning. 329 00:37:27,540 --> 00:37:31,240 So again, data there on vaccine hesitancy. 330 00:37:31,240 --> 00:37:38,340 I'm going to move now to the final part of the talk, which is really just extracting some lessons from all of these experiences. 331 00:37:38,340 --> 00:37:45,210 And I look forward to your questions in a few minutes. You know, I've often asked what I've taken away from these experiences as well, 332 00:37:45,210 --> 00:37:50,070 apart from trying to get sleep whenever you can and taking breaks and getting rest. 333 00:37:50,070 --> 00:37:54,420 There are a number of things that I think we're all taking away with us in it. 334 00:37:54,420 --> 00:38:00,720 Nothing prepares you for a once in a generation or multiple generation events such as what we're going through now. 335 00:38:00,720 --> 00:38:09,000 But the practising and the skills and the drills and the capacity and the training that we have as public health professionals, 336 00:38:09,000 --> 00:38:13,680 the exercises that we've been through have prepared us for this moment and it 337 00:38:13,680 --> 00:38:18,060 has been amazing to see how we have been able to step up to the challenges, 338 00:38:18,060 --> 00:38:23,640 but how we have been agile learning almost on a daily basis, partnering differently, 339 00:38:23,640 --> 00:38:28,440 working differently, bringing in new capabilities to help us to get the job done. 340 00:38:28,440 --> 00:38:35,640 And that has been a fantastic legacy and reality of our pandemic response. 341 00:38:35,640 --> 00:38:39,660 It's been complex at any given time or dealing with the infection. 342 00:38:39,660 --> 00:38:45,720 What's happening in the NHS, respecting social care government policy, what's happening from, you know, 343 00:38:45,720 --> 00:38:54,930 local political leaders where communities are pushing back in an environment which continues to change on a regular on a daily basis and 344 00:38:54,930 --> 00:39:03,960 learning to live with that complexity and to find your own individual and organisational resilience within that complexity has been key. 345 00:39:03,960 --> 00:39:10,890 Clearly, a lot of what we've done is working closely with politicians of all stripes, backgrounds at all levels, 346 00:39:10,890 --> 00:39:18,000 from local councillors straight to the prime minister and being able to stand in the truth of the evidence, 347 00:39:18,000 --> 00:39:23,130 but recognise that the evidence is going to be only one of a series of inputs 348 00:39:23,130 --> 00:39:30,180 that politicians are going to use to make decisions and at the same time, 349 00:39:30,180 --> 00:39:36,480 widening the net of partners that we have engaged in this response problems that I think will now be with us for life. 350 00:39:36,480 --> 00:39:44,010 So whether it's the business sector or the faith sector or working with groups which had hitherto been hidden, 351 00:39:44,010 --> 00:39:54,270 which we have brought into our partnerships and continues to create a new and dynamic ecosystem of partnership within our city. 352 00:39:54,270 --> 00:40:00,660 Communication is key. You know, whether it's the No10 briefings, whether it is the town hall events, 353 00:40:00,660 --> 00:40:07,140 whether it is a one on one engagements that we do with people to address issues and concerns around the vaccine. 354 00:40:07,140 --> 00:40:13,290 I don't think that we've done as much communication in as many channels and 355 00:40:13,290 --> 00:40:18,690 forums and in as many ways as I've ever done in my entire public health career. 356 00:40:18,690 --> 00:40:22,290 And for all of us going through this and we've learnt new skills, 357 00:40:22,290 --> 00:40:32,760 but we've also valued the importance not just of transmitting information but of listening as well and becoming active listeners for communities, 358 00:40:32,760 --> 00:40:40,560 for partners, for politicians to understand not only what is being said, but what is being felt as well. 359 00:40:40,560 --> 00:40:45,600 And. Turning that into our response and finally learning to take care of ourselves, 360 00:40:45,600 --> 00:40:54,750 our people have been a really key part of what we've had to do over the past year, and I'd be happy to speak a little bit more on that as well. 361 00:40:54,750 --> 00:40:58,620 Now, you know, we've been taking this through in so many ways. 362 00:40:58,620 --> 00:40:59,310 In London, 363 00:40:59,310 --> 00:41:08,250 I want to end by just giving a sense of how do you make sense of this traumatic experience that we've been through to do things differently, 364 00:41:08,250 --> 00:41:15,990 to have different outcomes? I think it's clear that, you know, not only are we dealing with inequalities from COVID, 365 00:41:15,990 --> 00:41:21,300 but very quickly we're going to have to face the realities of other health inequalities, 366 00:41:21,300 --> 00:41:26,550 which we're going to grapple with, which pre-existing the pandemic, which are already reality today. 367 00:41:26,550 --> 00:41:34,200 And here I've just highlighted from the Race and Health Observatory Observatory some of the data related to other inequalities, 368 00:41:34,200 --> 00:41:38,850 which are longstanding and pervasive and which are persistent. 369 00:41:38,850 --> 00:41:43,890 And as we emerge from this, we need to find both the voice, the advocacy, the evidence, 370 00:41:43,890 --> 00:41:48,960 the programmes to be taking a much more holistic approach to addressing needs. 371 00:41:48,960 --> 00:41:57,870 One of the most poignant bits of feedback that we've got from changes as we've been engaging is you've never engaged us before. 372 00:41:57,870 --> 00:42:04,410 Why are you engaging us now? And if we take this vaccine, are you going to run and leave us? 373 00:42:04,410 --> 00:42:09,870 Or are you going to stay with us to finish this job of helping us to be healthier and 374 00:42:09,870 --> 00:42:15,330 helping us to improve our well-being and tackling these long standing inequalities? 375 00:42:15,330 --> 00:42:21,540 And that, for me, has been a fundamental promise that I've made to the citizens in London that what 376 00:42:21,540 --> 00:42:26,490 we're building today will be a part of the legacy of doing things differently. 377 00:42:26,490 --> 00:42:29,710 And you can see, by the way, the city itself is approaching recovery. 378 00:42:29,710 --> 00:42:34,800 So one of our recommendations was that equity should be at the forefront of recovery. 379 00:42:34,800 --> 00:42:38,490 And clearly, this is not just going to be an economic recovery, 380 00:42:38,490 --> 00:42:46,590 but we have a chance in our recovery efforts to integrate all the other pressures that and realities that we're dealing with now. 381 00:42:46,590 --> 00:42:54,030 So in London, we're looking at London recovery through the grand challenge process of integrating the environment 382 00:42:54,030 --> 00:42:59,070 with a Green New Deal for Londoners thinking about the built environment and high streets for all, 383 00:42:59,070 --> 00:43:04,320 really thinking about supporting our young people who have been so hard hit by this pandemic. 384 00:43:04,320 --> 00:43:08,400 Looking at issues related to our health priorities, mental health, 385 00:43:08,400 --> 00:43:13,850 obesity and ensuring showing that there's digital access for all and using these great 386 00:43:13,850 --> 00:43:18,660 challenges from the city to ensure that we're focussing on building collaboration, 387 00:43:18,660 --> 00:43:26,970 focussing on sustainability, tackling inequalities and ensuring that health and wellbeing is at the centre of everything we're doing. 388 00:43:26,970 --> 00:43:34,500 And the driver here is that not only do we build back economically, but we build back a legacy of a healthier, 389 00:43:34,500 --> 00:43:42,300 engaged workforce and pockets that in turn makes us much more productive as a global city. 390 00:43:42,300 --> 00:43:50,790 And in unpacking this, we're looking at actions, which operates at different levels and which are now governed by new bodies in London, 391 00:43:50,790 --> 00:43:55,500 including a new London health equity group which reports into the London Health Board. 392 00:43:55,500 --> 00:44:04,530 We focus on strengthening system capacity policy response to programmes looking at data key indicators that we're tracking, 393 00:44:04,530 --> 00:44:10,320 but also the ways in which we're polling and engaging Londoners on issues of inequality, 394 00:44:10,320 --> 00:44:16,500 working on the workforce and thinking about how we work with the NHS and local governments, 395 00:44:16,500 --> 00:44:26,190 universities and businesses as anchor institutions in place to help to improve the life chances and life course of our residents. 396 00:44:26,190 --> 00:44:32,100 And of course, as I mentioned earlier, continuing with our efforts to support and engage communities, 397 00:44:32,100 --> 00:44:39,730 building upon the lessons that we've learnt so colleagues, I'm going to bring my reflections to a close. 398 00:44:39,730 --> 00:44:48,780 Now, I've really wanted to just take you through, in a sense, my experience of going through the pandemic and to perhaps share a bit of the story. 399 00:44:48,780 --> 00:44:51,000 And there are many stories of this pandemic. 400 00:44:51,000 --> 00:44:59,340 You all have your own stories, and perhaps this is a glimpse into a part of my story to extrapolate from that story, 401 00:44:59,340 --> 00:45:05,310 the lessons that we've learnt and why addressing inequalities was not just a thing of the first wave, 402 00:45:05,310 --> 00:45:13,980 but it has been with us throughout the course of the pandemic and will continue to be so as we progressed through this new phase. 403 00:45:13,980 --> 00:45:21,890 And then to transition into how do we because we now know better, do better. 404 00:45:21,890 --> 00:45:25,910 Thank you very much. Thank you for that. 405 00:45:25,910 --> 00:45:35,810 But by way of confusion on behalf of the BME staff network, I would like to conclude this evening's event with it with fish tanks. 406 00:45:35,810 --> 00:45:46,440 And we are very grateful to Gillette and the university's equality and diversity unit for their continued support to this, this annual lecture. 407 00:45:46,440 --> 00:45:50,690 And in addition, we express our gratitude to Richard Chinese Ambassador, 408 00:45:50,690 --> 00:45:59,420 the ITU for so ably moderating the Q&A today a little and said Imagine such talks for the logistical and 409 00:45:59,420 --> 00:46:08,800 technical support and to our colleagues and academic colleagues across the university who supported this event. 410 00:46:08,800 --> 00:46:10,000 Most importantly, of course, 411 00:46:10,000 --> 00:46:18,280 we are very grateful to Kevin Fenton for speaking to us this evening and for sharing is particularly timely insights on our experience and racial 412 00:46:18,280 --> 00:46:29,130 disparities and disproportionality arising from the virus pandemic in London in particular and the forward challenges in public health and beyond. 413 00:46:29,130 --> 00:46:35,270 And and finally, may I thank you our audience for your participation this evening. 414 00:46:35,270 --> 00:46:42,220 And I think I speak for all of us in observing that we have all been enriched by this exchange. 415 00:46:42,220 --> 00:46:47,486 Thank you and good evening.