The Hidden Legacy of COVID-19

- I'm going to be talking about long COVID. And the reason that I want to talk about long COVID is because we have all spent a number of years, well, two, three years, and now I'm thinking about COVID, but life's moving on. And when life's moving on, we sometimes forget what has actually happened. And we forget the ongoing suffering, we forget the ongoing inequalities, we forget the ongoing impact that it has on people. So I just wanted to start by asking a question first, which is, how many people have had long COVID or think they have long COVID? Okay, so I would actually argue that each one of us is suffering from long COVID. There is a medical terminology of long COVID, but actually long COVID in itself means that we are living through COVID. And I don't think any of us have ever been untouched by COVID in some dimension or the other. So somebody said to me, you can call it long COVID or you can call it the long pandemic, but literally everyone has been touched in one way. And that's why I chose the title, the short title's long COVID, and I was like, I think I know what people are going to think I'm going to talk about, but actually it's Opening Pandora's Box the hidden legacy of COVID-19, because that's what we've got ahead of us, and that's the war really and the battle that we're going to have to face. To get us into thinking about this, because again, like I said, you know, people have started thinking, okay, COVID's over, is it over? Yes, we're going to have the next set of vaccines, do we have them, don't we have them? We could debate that all evening. We don't have the answers and I'm not going to stand up here and say, I know what the answer is for you, I can give you a direct answer. And I don't think anybody can actually, because all the information is still coming out, we are still learning, and we learn every day something new about this illness. And I wanted to start with thinking, just taking us back a little bit, just so that we could ground ourselves in what I'm going to talk about and get into the sort of mood, maybe somber mood, but what was it like living through the devastation that was happening? And I remember I was myself in India at the time, COVID hit, had to get on a plane, had to come over here and get out of India very quickly. But then you heard about all the people dying in England and all the people dying overseas as well. And sitting at home, you sometimes think, well, what's going on in my brain, what is actually happening? So I wrote a poem, and I'm not a poet, so if there's any poets in the audience, please do not criticize me, because I am not a poet at all. But it was something that just moved me at the time and I wanted to really talk about it. So here it is."I hear the voices of those that die, the souls trapped deep inside. They live to be released to God, not thrown and left aside. They believed and prayed all through their lives, so what did they do wrong? They went to pray once more for life and left us all to cry. Oh God, did they deserve this? What did they do so wrong, but to be poor or through their lives, then left alone to die. Let's pray for all who left us during this distressing time. Please give their souls some peace tonight, whilst we say our goodbyes." And I think that was something that I could see all around me of what was going on with people and what they were feeling at the time. You can just take a moment to read it for yourselves. So what was happening with COVID? Well, like I said, you've come to talk here about long COVID, but you can't really talk about long COVID without spending some time talking about COVID and what happened and where we are today. So if we just look at this at the moment, how did COVID spread? Well, we know that COVID, it was a global phenomenal, it was a regional phenomenal, but it was also something that was happening within our families and within our communities, and it was hitting all of us at very different levels. And we know that as of September 7th, 2002, there've been a huge number, as you can see there, of individuals and confirmed cases of COVID-19. And they may not be all the numbers, because not everybody is tested and not all the numbers are available to us. But that's a huge number of people who have been affected worldwide with this devastating illness. And that's why we are going to have an aftermath of this and we are not known going to know how we're going to deal with it, and we can't hide our heads really away. So if you just look at this diagram here, it sort of gives you a visual picture of where the different deaths were. And again, the challenge with this is some countries were able to test for COVID, some places were not able to test for COVID. So there's a difference in the numbers, and we don't know the exact numbers, and I don't think we'll ever know the exact numbers, but it was a very, very large number of individuals throughout Europe, Americas, Western Africa, and even Eastern Mediterranean Africa. We talk about it having less numbers of COVID, but did it, did it not, you know, there's a debate that goes on about that. But it really hit communities in many, many different ways, and that's what really my passion is, is how did COVID hit communities and what actually happened to individual people living within those communities? So you will all live within a community, some of you will have lived with your families, some of you will have actually moved away and had to live alone and had to segregate yourselves off from loved ones to really protect yourselves. But take yourself back, how did that make you feel and how does it make you feel today? What did you lose? We talk a lot about loss. What happened with you for loss? Did anybody feel they lost anything? Did anybody feel that they gained anything? But loss was a huge thing, was it bereavement of losing individuals? Was it lost through losing, you know, your job? We don't really talk about loss very much and we don't really talk about bereavement very much, it's something that we're strong about and we move on. So 90% of countries are still reporting one or more disruptions to health services. And this means that individuals are not getting the services we need. I'm a pediatrician, and I know that children today can still not get the services they need. There's still a backlog of services for children with down syndrome, services for speech and language therapy, services for physiotherapy. So most of the world cannot be seen by the people they should be seen by, which means that you're going to have a knock on effect on all our health. So you have the COVID, and then the double whammy of COVID, plus the other illnesses, which is going to affect all our lives going forward. And in the Philippines, we know that about 76% of all small and medium sized businesses were forced to close. And we now have the second problem of the crisis that we're in at the moment. And if we're in a crisis of illness, and an economic crisis, and poverty crisis, we have all of that to contend with at the same time. The UK did try and have a retention screen, as we know, and employers were paid and there was some money going into that. But how long can that pot of money retain and how long will people be remaining in their jobs before they lose them? So things were put in place, but things are now being taken away, and that has an impact on our mental health and our physical health as well. And I'll come to talk a little bit about mental health, because mental health is a big, big factor for us all, which again, we are not really talking a lot about. But just some studies in Africa actually showed us that girls particularly found it very, very hard during COVID, and subsequently to get the emotional support that they needed. They felt very left alone, very just set aside, were becoming carers, taking over caring roles more than, probably the males in their families, and really felt they weren't able to be educated either. And this is not just in Africa or Asia, but actually here in the UK, we've got some data on that as well. So we are trying to do something about it. We have set up long COVID clinic, there are long COVID clinics in the UK, but this isn't reaching everybody. And of course the long COVID clinics, our challenge will be for people who've been diagnosed with long COVID and who have medical reasons. But what about all of you out here who didn't put your hand on up and who didn't think you had long COVID, but actually you probably have suffered in some sort of way? So this is where we talk about long COVID and the inequalities. And as I say, inequalities are something that I've been looking at for a very long time, different lenses, different places, different parts of the world. What do we mean by inequalities? We can't all be equal in the world, we can't, we never will ever be equal, you know, we'll be always challenged on that, there will always be inequalities in this world. But COVID really did split us apart. It really did mean that there were some people who were suffering much more than other people. For some of us, we had a nice garden, we were able to go out, we were able to keep physically healthy. For other people, you were in tiny little homes, you were not able to move around. And that physical impact on you, that health impact on you, again, will not be undone because we have the cost of living crisis as we know. But there's certain groups that we can consider, and when we're talking about inequalities, we need to think about which different groups are we talking about. But there's a lot, I mean, it's not just one group, there's a lot of groups here who are in this inequalities discussion. We have the elderly. The elderly who really were isolated very much from their families and very much not engaging in activities, and the fear of, what's going to happen to me? We have frontline health workers, we have frontline workers generally, many of you may work in areas where you were actually at the frontline having to face the public and risking your lives. And many people still continue to get ill, be off work, continue to risk themselves, and that's having knock on effect on their families and their income as well. And we'll come to the ethnic differences as well, there's a lot of data about the ethnic differences that long COVID has had an impact on, and we'll discuss that in a little bit. But also poor housing and hygiene. If you can't wash your hands, if you can't go to the toilet, if you can't actually keep your environment clean and suitable for you, you can't actually tackle the virus itself. And we think that's only abroad, we think it's only in other countries, but actually here in the UK, we know there's numerous, numerous families living in poverty who are sharing bathrooms, who were locked down during COVID, who were waiting in queues to use toilets, and we're not able to actually access different services. So what's our data telling us? Well, this is just some data that we collected and well, colleagues collected, not myself, and we've been utilizing in a project called Co-POWeR. And you can look at just the differences there of the different ethnic groups and who was really affected by COVID the most. And within that, you'll see that there are stark differences in the fact that the Black African and the Bangladeshi communities, much more than anybody else, were really affected by COVID at the time. And this ethnic disparity continues today. And it continues because of all the other, we talk about overcrowding, we talk about the jobs people we're having, we talk about how they were accessing healthcare, and so people actually A, were getting the virus, B, ethnically were at more risk of the virus, and C, were actually had the knock on effects of the virus, and many were losing different ages of family members, from young children to really the elderly as well, and generations were being lost. But again, it's something that we sort of don't talk about, something we don't discuss, how are people coping with the loss and the death of different people in the family? So this was a study which was actually talking about vaccine uptake, and I'm sure a lot of the people will be interested in vaccines, because that's always a hot topic, should we have vaccines, shouldn't we have vaccines? Who should have vaccines, who shouldn't have vaccines? And when we talk about inequalities, there is quite a big inequality in the fact that people who are most at risk were there people who were not getting vaccines the most. And there's a whole debate about the reason for that, was it because people couldn't access the vaccines? Was it because there was a mistrust of the vaccines? And was it because they just, you know, the way the families were set up didn't allow you to access the vaccines. So if you think of it, if you are in an extended family and they're multiple people, and you've been told only one person can go for that vaccine at a time, how do you actually leave your family to go and get that vaccine when everybody else is at home? So the vaccines were not done as families, they were done as individual people, and that restricted people. Also you'll see from the different ethnic diversities, many of those people were people who may be in frontline jobs where they're either in the hospitals, or porters, or taxi drivers, or whatever it is, and they were not able to give up their jobs and the time to go and get their vaccines at all. So again, there's a disparity. But the message that was given out was people didn't want them, which was not quite true. Also, there were more hospital deaths for Black and Caribbean families. And what people are now understanding is that there is a definite difference in the way the virus would attack different ethnic backgrounds and how that would affect them, and even today with long COVID. And we talk about housing. So I dunno, many of us would, like I said, we have the luxury of being in very nice homes, but most people in the world actually lack basic sanitation. They don't have water, they were not able to clean, they were not able to isolate. So you can see in 60 countries identified by UNICEF, they had the highest risk of health and nutrition crisis due to COVID-19, and two out of three people, that's one billion in total, still lack basic hand washing facilities with soap and water at home. So all of these recommendations that we've given out, you should do X, Y, Z, even in this country, actually nearly impossible for many of these families. People living in poor housing conditions and people who are in poor housing conditions, about 50%, they have a high risk of COVID incidents, and 42% high risk of COVID death. So we've got huge numbers of people who actually died, were ill, were in hospital, or lost their jobs, or actually were left behind with their education, who we don't know how people will now catch up and how we're going to deal with it all. The frontline workers, even today we know that some of the nurses and the doctors and the hospitals are still off sick. We have turnover over turnover of frontline staff who actually are getting sick with COVID today, still picking up COVID, despite vaccination, but also then they have to stay off work and getting long COVID as well. And with the long COVID, you get all the symptoms we'll talk about in a minute. But they were not just frontline health workers, as I've mentioned, there were many, many other people. And there was a study in the Pacific region, which showed that people were getting physical exhaustion as well as mental health challenges. So we have a huge workforce who are actually out there on the frontline who are absolutely shattered from the work that they were doing, and have never been given that time to really just regroup, get healthy again, before they're back in the workforce again. And this constant feeling of exhaustion and being like, just trying to get out of being buried under all of this feeling of lack of hope of what's going to happen, means we're losing staff, we're losing doctors, we're losing nurses, we're losing frontline people. So what are the health risks? What are some of the health risks? Well, we know that COVID hits certain people more than it hit other people. So it was seen that the older that you are, the higher risk you were of getting COVID, and that has continued since. The more deprived you are, the more you had risks, such as the comorbidities, such as diabetes, asthma, other medical conditions as well, you are more likely to A, get COVID, but also more likely to die from it as well. It's not surprising, is it, that if you were a smokers, it's something that affected your lungs, it's something affected your breathing, so if you were a smoker, again, you were more likely to have worse outcomes if you were going to get COVID and if you're obese as well, overweight. So all of these things stack up. And if you had any other health conditions as well, such as heart disease, diabetes, many other things at the bottom, you can see, you are also more likely to suffer if you have it. And that goes on with the long COVID as well. So I just wanted to set the scene there a little bit just to remind us, like where have we come from, what has been happening? So that really we can think about, if you've had the illness already, if you've been acutely in hospital, if you've had treatment, what does that mean, depending on what your age is and where you are going from here? So we'll talk a little bit about pregnant women, children under five, children who are now the adolescents and really the future adults of tomorrow, the adults, and then the elderly. So pregnant women, a terrifying time during COVID when you were pregnant. And why is this relevant to long COVID? You're thinking, well, she keeps talking about COVID and the acute COVID, but why is that relevant? Well, if you were having your baby during the time of COVID and you were in hospital where you could not see anybody, you could not have your family around, you could not have anybody there, it really traumatized very many women. And we haven't really interviewed the women very much, there are some studies, but we haven't really talked to women, how does this actually impact on how you are going to have your next baby? Will it impact on the women's fear next time they have a baby? Will they want to have another baby? Or will it be a very positive thing that they're thinking, actually that happened during COVID, actually next time it will be a very different experience? We know that many women did feel traumatized during this experience and actually very, very frightened, and everything they had hoped for through giving birth, pregnancy, was really removed from them. I mean, I think the restrictions were quite severe actually. But the other issue that comes is the baby, is within a mother, it's within a mother's womb, and that baby has to be born, and probably obvious, I suppose, but when that baby's born, that emotional attachment has to occur very early after the baby's born. Some of the mothers have said that they feel very, as though did COVID affect the attachment with their baby? Did they feel they could be a good mother? And some of them, as you can see from the statistics there, you'll see, and the transcripts as well, is that there were earlier delivery, baby was born earlier than they should have been born, higher risk of Cesarean sections, higher risk of pre-labor problems, still born babies increased, and increased risk of babies being admitted to the neonatal intensive unit. So it wasn't just the pregnancy issues, we have quite a large number of babies who've been born, who now are going to be at risk for their own health problems as they go forward. And again, nobody's really talking about the legacy of COVID for these young little babies that have been born. There was another, as you can see, a review that was done where they did look at 95 studies of pregnant women and mothers who were not found to be at high risk of COVID infection, and that means they weren't at higher risk, but if they got COVID infection, then the problems that really ensued, and they had the adverse outcomes at the end. So we've talked about trauma and now more and more people are being trained in trauma informed care. But I think we're going to have quite a number of women who actually have mental health problems, emotional problems, anxiety, and depression due to their experiences of going through COVID when they were pregnant, losing that lack of support, losing that lack of community support that they thought they were going to get. So what about children? Well, COVID has hit our children globally. It's hit children in the UK, and again, not high on the agenda at all. And it's not surprising that I'm advocating here a lot for children and young people, because I think that's my job to do that. But we had a huge problem with COVID, the problem was numbers overall were very small from actually children dying. Not many children died of COVID, and people were very focused on the number of children were dying. So understandably, you're going to think about, how many people actually died? But when you think about how many children suffered during COVID, well then it is a very, very different story. And that's why the repeated thing about long COVID comes in. So we have about six to seven million children under five were wasted, malnourished, couldn't get good food, were not cared for in the same way they would normally, they were really hidden from society, and they're still hidden from society, even here in the UK. Due to COVID-19 measures, 18 million children under the age of 1 in at least 68 countries actually didn't have vaccines that they should have had, these are their normal vaccines. And we know currently in the UK as well, we have this continuing problem where we have not picked up all the children who should have had their vaccines. So many missed opportunities. People are focusing on the COVID vaccines and yet the normal routine vaccines have actually been missed. Now what that means, some of you may have heard polio is sort of coming back again in the UK. Nobody would've ever thought of that. And if we can't get those children immunized, we are going to have a problem with polio in this country again. So, you know, COVID isn't as simple as we think, because if you drew a map, you could really just say it affects every moment of our life in every different way for everybody, from pre-birth to the elderly. So what about in the UK? Well, in the UK for children, we've seen that children and more and more people are going into poverty. And we know that this affects children a lot. Once you go into poverty, I'll show your slide in a minute, but once you move into poverty, you cannot have access to the same healthy food, you're not going to be able to run around, you cannot have access to open spaces, and really your health and wellbeing is damaged. There was a rising risk of domestic abuse cases during COVID, and we are still seeing the aftermath of that today. Because once you have an increase in domestic abuse, that is again, I'll keep talking about trauma, and we could do another lecture on trauma itself, but children have been traumatized by the environment they were in if they were in a household where there was domestic abuse. That will stay with them, that will not be removed, and there's no undoing of that, and we don't have the support services to actually counsel the children who went through that, and they can't speak for themselves. Children didn't play, they were isolated, they were not meeting friends, they didn't learn how to play with other children. And so again, we've got children who can't even take risks. They were so scared during COVID that they actually don't know how to take risks anymore, they don't know how to play, and they don't know how to interact with other children. Schools were closed, so many children who would normally get food in schools were not getting food. And that we know will affect them with vitamin D, they'll get rickets, they'll get other physical problems going forwards. They weren't playing, as I said, no peer support, and lack of education. Education, I always talk to people and I always say, I have this acronym, HEE, Health, Education, Environment. You can't detach any of those things, because particularly for children, if you're unhealthy, it affects your education. If your environment's poor, it affects your health. They're all interrelated. And many children, many children fell far behind during COVID and still cannot catch up with their education. So we talk about life chances, we talk about the future of our population, who is going to look after us when we're older? Who is going to be actually the people who are going to be able to take care of us if people aren't physically well, mentally well, and haven't got the life chances to be in jobs that they can fulfill their lives with? So that's where I come to this, this is a slide I put together from a project that I was doing called the CHAMPIONS project. And the CHAMPIONS project is all about homelessness. So we've talked about poverty, but if you go a little bit further, people who in temporary accommodation and people are homeless. You don't think to yourself, children are homeless. I mean, most people will go, okay. I understand people are rough sleeping, people are out there, and there's a lot of talk about rough sleepers during COVID, but nobody really talked about children in temporary accommodation. These young little children who really locked up in these rooms, 13 meter squared, or in bed and breakfast, or hotels, or sofa surfing at the time, and they were not able to see the outside worlds. People have forgotten about that and what the impact is. They're the ones who are going to live through this legacy of COVID as we go forward. And that's why I talk about this, I always like to talk about things in threes, as you've sort of gathered, I think, but see, smell, hear. That's who we are, all of us, all of you, you're seeing me, you're seeing your environment, you're hearing the noises, you're hearing the voices, and hopefully the smell's not too bad in here and you can cope with the smell. But three things impact on our brains, and any of those are disruptive, it affects the way your brain development and your brain actually reacts to everything that you are doing. So if you've had a stressful experience during COVID, everybody's hyper alert, everybody's frightened, lots of negative messages, parents haven't got jobs, people are shouting around you, you don't know what's going on around you. It's creating a brain that is actually hyper alert for your future, and that means that when you go to school, you are going to react in a very different way when you encounter other people or whether you encounter fear. So we've got this whole set of little kids who we don't know how their brains have reacted, and how they will respond when they actually go into school or when they interact with us. Nobody's doing any studies, so people are not funding this research, people are not taking it seriously. Lots and lots of money going into other areas, nobody seems to want to do any work on the children of the future. There's some quotes from this. So if you look at the side of the slide, you'll see the cycle, and that's what I was talking about, the cycle of trauma. And I really do think that COVID and long COVID is trauma. If you're living through long COVID, whether it's through the economic crisis, whether it's through the health crisis, or your own emotional crisis, it is trauma. And that produces the cycle of lack of security and routine. You then have broken friendships, your broken links with your wider family, feeling and being unsafe, we feel unsafe, we felt unsafe in COVID, people still feel very unsafe. There's a bit like, hmm, can I go and talk to them, can't I go and talk to them? How they're going to react to me? Constant need to catch up, you're behind in your education, you're behind in your job, you're behind in everything else. Parents are stressed or they're not even there. And then people turn to other ways of trying to just stay stable, really, and then you go through that cycle all over again. So you'll see these quotes really from one of our workshops, which was, "My child is actually quite naughty now. I don't know why, I think it's because of the other kids in here as well, like they're all on top of each other." Because the rooms were closed, people were living in one tiny space. I have a children and I can tell you, I have a big house, and it was really hard with us all together."He's not bonding with other children", how do you bond? How do you learn to bond if you've never been around other children?"He's not learning from other children, he's just playing by himself all day." That's one parent, and we're seeing lots, and lots, and lots of stories of children who feel detached, isolated. The next one, "My child wouldn't touch any food, even after washing, first to wash and then give to the kids. They're really scared at that time, five families and we're using one bathroom." And that's what they were doing. This is continuing, this isn't going away. So here we are, just to take you through some of this, this is what I was talking about the diagram. And I think this is for all of us, so how has the pandemic really affected us? It's affected children in this way, but it's affected all of us in this room in this way, to some extent or the other. Our lifestyle, some of us became more active because we were able to go out, some of us became less active, and some of us have gained weight. And now that weight gain will have a knock on effect with diabetes and heart disease for us later on. But it affected the children, who many of them became obese, many of them either lost, became malnourished, or obese, it went both ways. Vitamin deficiency. We don't really talk about vitamin deficiency, but actually vitamin D, lack of sunlight is a real problem for all of us. And many of you, I don't how many of you have been tested, are vitamin D deficient, aren't you? How brittle will our bones be in the future? Poor mental health, we'll come to that. Children and adults were in environments where you are closed down, where you might have been amongst vermin, you might have been around mold, which will have respiratory problems, asthma, problems with animals and vermin carrying infections around you. And then we know that if you were ill and if you still are ill, you can't really catch up because you can't get health services as you need to. So let's move on just to children who are 16 to 18, and you can see here just some of the facts of what's happening. This is really the next age group. So think of yourself as, what were you doing? I don't know what we were all doing when we were 16 to 18, most of us would've been thinking about what's happening in my education, am I getting my exams? Am I going to go the next party? Can I go meet my friends? Can I stay out at night? And some may have been thinking, I'm going to really risk my life a little bit and see what happens. That age group is so important for providing the foundations of who you are when you're older. And if you don't have your brain's not developing, learning to be an adolescent, actually we don't know now what that's going to, again, do to this group of children. They're the ones who feel let down, they feel no hope, will they have a job, won't they have a job? Many of them are getting health problems from long COVID. I know a number of young children who have heart problems, breathing problems, who are really suffering from chronic fatigue syndrome. And they're like, I have that on top of trying to get a life for myself, on top of everything that else is going on, and some of them are just losing hope. How do we give them hope? So we know from the data that increased hot lines, I mean, this is not just in India, but we had an increased use of hot lines here in the UK as well. Children feeling depressed, anxious, and many of them still continue to have social anxiety. Not really feeling comfortable to go out, not really feeling comfortable, and we have a very hyperactive state around us at the moment, which we are not providing the mental health services for. And I think this is something we can debate, how do we, with the economy we're in, provide the services that all of you need and all of our younger generation needs as well? We know that wearing face masks really caused a problem. We needed to wear face masks, and I'm not saying we didn't need, and we can debate that as well, but the young people found that very difficult, because if you are wearing face masks, you can't see anybody and you become quite distrusting of people. And we don't understand, we don't know why that indirect distrust of people has happened. So yes, they're fearful of getting an infection, but on top of that, they didn't really know all the time who they were talking to or what was happening behind that mask, and how do you read people's faces, and that's caused some problems as well. And we also have number of studies, so Terence Stephenson, we mentioned who was my mentor and taught me a lot of what I know has done a very big study, called the CLoCk study, and it's ongoing, following up young people through the long COVID period. And we know that children are worried, sad, and happy, and that's irrespective of whether they had a diagnosis of COVID or whether they didn't have a diagnosis of COVID. So you had COVID, you didn't have COVID, still an increase in feeling unhappy and sad, and these children are living with that as we go on. So this is some more data that's being collected, and as I said, these are small studies, well, I mean, not small studies in that way, I mean a few studies, we don't have enough studies, the funding isn't going into young people. These are just a few studies that are going on. The CLoCk study is probably one of the biggest longitudinal studies, and when I mean longitudinal, this means the children are followed up. There's lots and lots of studies, as I've been told, that are just looking at one point, a survey today, or a survey tomorrow, and actually we need to be following children up into the future, what happens tomorrow, what happens in six months, what's happens in a year? And we don't have those studies, enough funding for those studies that are going on. So what we did find from this study, the CLoCk study by Stephenson at al was that children was having these sort of symptoms in long COVID. So they have headache, they have lost smell and taste, they have dizziness, shortness of breath, unusual tiredness. So they're having to catch up with their work at school, they're having to try and be with their friends, and yet they're having these health problems as well. So physical and mental health problems, but the mental health problems, like I said, are both whether you had the illness or you didn't, you seem to be getting this mental health problems. Other symptoms from other studies, learning difficulties, sore throats, sore eyes. These studies that are on children who do not have a disability in any sort of way. Very, very few studies being done on children who have any disability, and if you've noticed that I haven't talked about that yet, that could be another whole lecture. Children with down syndrome, who I particularly work with, children with autism, children with ADHD, all of these children were also in the lockdown, they were also living through the pandemic, and they are now having the aftermath of that as well. But we're not really talking about how that impacted on their lives or will continue and what health problems they had. Mainly because children didn't get as ill. We know from the data,'cause I led one of the studies on the impact on children with down syndrome in COVID, of course not many children got sick with COVID, not many children were in hospital and died with COVID, but they were still living through it, and they were still locked down at home from it. But there's still some predictors of long COVID for children. So as you can see their age, the old you are, well, you're going to be more risk. Your sex, if you're female, actually in children, you are at more risk of long COVID. Ethnicity, again, south Asians, and what you were like before COVID was there, your health before COVID. So we have a big pub public health message to keep yourself healthy if you want to not be healthy in the future, we've always known that, but you can see from all of this data, it's very clear that you are going to be sicker if you are not well to begin with. Not rocket science, I suppose. So this is again from Stephenson at al's slide that my colleagues have kindly shared me. So have to say, you know, I have utilized the slides of my colleagues and friends, and they have given me permission to do that. But so this is one about, well, how is it that children are getting long COVID? how is it affecting them? What's the hypothesis? We don't know, we actually dunno, so I cannot give you the answer. So if you ask me a question later on go, is it X, Y, Z? I can tell you now, I don't know. People are still theorizing a it. So some people feel it's a persistent viral infection. So the infection sits within you and then it erupts, the infection sits there and it keeps erupting, and that's why you have it. Some people say it's like an autoimmune disease, you know, you're fighting your own body, it's hitting your own body. Some think, well, because of the inflammation that you had from COVID, there's a long term effect. And then some people will say, well, you have these symptoms, because it's like chronic fatigue syndrome, we don't really know what's happening, but you have this long term effect. And this is really hard for all of you who've got long COVID, the medical long COVID, because some people are feeling like people don't believe them, and you've gone through COVID, you've had the illness, and then you go and you say, I'm tired, I'm exhausted, I can't do X, Y, Z, I've got brain fog and people are, yeah, you're just making it up. And people aren't making it up, there's good data that you're not making it up. But people are feeling left alone. So this is another study that we've been doing, which has been looking at particularly Black and minority ethnic communities. And I've been leading the work package on young people, and that's because we've been talking about the double whammy, really, the emotional and physical impact of COVID, which we've already talked about, and also there was a quite big racial inequality that went on during COVID as well. We talked some of it about housing, overcrowding, there were some positive things, people looked after each other, people looked after their elderly, but there was also some issues around policing, people being over policed if you were from a Black or Asian community. And that's a whole big study, which I'm only touching on here, but it's actually a study in itself on what happened during COVID and how it affected people's lives. So this is just one of the areas, I mean, I'm just touching on the family relationships, but people lost their income. There were workplace issues, people felt left behind really. They felt that they didn't know if their parents were going to come back home if their parents went out, went to work, they didn't know if they were going to end up in hospital and they were going to be dead at the end of the day. And I'm not exaggerating, in my own area where I live in Leicester, there were intergenerational families who were losing people one by one. We've never really addressed it, we've never really talked about it. People felt that they had their savings, their money depleted, whatever money they had. And I'm sure we've all saved money, and bit by bit it was depleted because you had to try or you didn't have a job, you had to care for people. And some of it they had kept for their families overseas and were not able to send it back to families overseas. So it wasn't just people here that were suffering, but people had families back in their country of origin as well that they were having to connect with or lose connection with. And sharing devices, this has come up a lot, and I haven't really touched on this, and again, we could talk about the technology and was it helpful or not helpful, but we live in a world of technology, we have lived in a world of technology, and we are so dependent on it. So children we're not able to often have access to computers, iPads, phones to do their work, to connect socially with people, people sharing one phone between people. I mean, I think that was the case for many of the elderly as well, and I'm sure many of us could talk about that, is that, how did you connect socially with people if suddenly you had nobody to help you with your Zoom calls or internet, and how did that make you feel? So here just as well, the impact on relationships, there's just some quotes."As time's gone on, I've been feeling a bit anxious about my dad going to work." This is the legacy of the long COVID, people are still scared, you don't believe that it's safe, you don't believe your family will be okay."So I think it has brought some positives." So there's positives."Like, because now I have more close relationships with my siblings." So I don't want everybody to think there's negatives, there's positives as well when people have lived through COVID and continue to do so."I think that was the most worried thing. I was, like, obviously for like my grandparents, because they're vulnerable people." People didn't see their grandparents for ages, and these were the people that they felt very, very close to. So there's feelings of disappointment, there's feelings of being left behind, there's feelings of not being able to actually catch up with school work as well. So education was a big issue we looked at. And it was interesting how the combination of COVID, plus feeling that you were in some ways not integrating into your school very well, and because you didn't have access to resources, felt you were being attacked from all sides. And we haven't really addressed this at the moment. People felt quite isolated, they felt quite stressed, and they didn't feel that other people understood what they were going through. So if you were from a community where you were losing people more, or the press was talking more negatively about you, or that you weren't having vaccines, people didn't feel like other people would understand them. So this sort of divide has actually increased between people, and that's actually very, very sad, and we haven't addressed that at all. So coming to adults, well, we know that COVID is like a multisystem disorder. We know that it affects sort of every part of you, whether it's your brain, whether it's your lungs, whether it's your heart, and that actually puts us all at risk of strokes, myocardial infarction, which is heart attacks, arrhythmia, when your heart really just changes a rhythm, clots in your body, and it's due to the inflammation, really, not to scare any of you out here, but you know, it is an infection that really hits every bit of you. And that's why we were all so surprised, we were like trying to catch a train constantly, and this train keeps running away from you, because every time you think you solve the problem, you find another problem, and another problem, and another problem. And that's the same with long COVID now, every time we think we've done a little bit of research that may give us an answer, there's another problem, and another problem, and we don't think we're going to find the answer to treating long COVID for quite some time. Because if you think of it, any research, you have to follow people up for a few years. So if you feel that you are feeling tired today, you've got a breathing problem today, actually, for us to do the studies to give you the answers could take two, three years. So how long are you going to wait to actually have the answers? So the question is not what the treatments are today, but what can we do for ourselves today? I think that's the thing, how can we keep ourselves as well as we can when the treatments are coming through? I mean, not saying that we, you know, there has been a lot of fast tracking of science and you'll know that results have been shared very, very fast compared to what they would normally, so that we could actually keep on top of things. So coming to the adults then, well, some people would say it's going to take them three years to get back to where they were before the pandemic, because of the economic impact. Because not just of the healthy impact, if you're unhealthy, then you haven't got a job, you can't get in your job, you keep taking time off, how do you actually break that cycle? And that's how we're going to have an increased number of short people, adults in poverty as well. Just as with the children, family relationships were broken and family members sometimes got on better with each other, sometimes didn't get on better with each other, and this has strained a lot of relationships. We think that, you know, we have a definition of what long COVID is, and you have the symptoms after four weeks, basically continuing symptoms. And NICE did bring out a definition so that we could start labeling what is long COVID. But again, we don't really know how long this goes on for, will this go on for three months, will it go on for longer, will it going for even longer than that? We don't know because we're still watching what goes on. And as I said, you know, the people who actually have had more challenges with COVID and will continue to have more challenges are going to be individuals who have comorbidities, who have health problems, who are on chemotherapy, who have heart problems, lung problems, who have disabilities as well. So this diagram here is again from one of my colleagues, Kamlesh Khunti kindly sent it, just so that you can see how interrelated long COVID is. So you have the anxiety and depression, and then you've got the cardiac disease. You have the abnormal exercise physiology, you have disordered breathing, meaning, when I say disorder breathing, your breathing pattern isn't quite right, it just doesn't feel right, but you can't explain it to somebody, but you actually don't know what is right. People are getting chest pain, tiredness, and as I say, brain fog is one thing that keeps coming up. I've just got this brain fog, I just can't quite concentrate properly. So it's a very complicated picture when we start thinking about how it's affecting each of us. And each one of you won't be the same, so I can say, these are my symptoms, and you can say, those are your symptoms, and you can say, those are your symptoms, but we're not going to be the same. And that makes it really hard to treat. So if you have a disease where you have a heart attack, that's a heart attack, you know, specialists come in and they treat your heart. Yeah, we can do the science, we can do the research, we can say, that's what we're going to do. When you have something that's all over the place, all over your body, who's going to treat you? Are you going to go to me, or not me,'cause I'm a pediatrician, are you going to go to a cardiologist? Are you going to go to a respiratory pediatrician? Who are you going to seek for help? We're not used to working in that way, that's not the norm of how we always work, we become ologists in this country. We're going to have to change the way we do things. So it has a multi-system impact on people. So a quarter of people who have had the virus experience symptoms that continue for at least a month, but 1/10 are still unwell after 12 weeks, that's what I was saying about the long term effects of the COVID. Overlapping symptoms, as I showed you, they all overlap, there's not just one symptoms, there's not another, they get this combination of everything that's going on. Women and healthcare workers seem to be at greater risk, and that's probably why with the next vaccine, the next booster, health workers are still being asked to have the booster because your risk because of where you are and you are amongst people where you're going to pick it up, and they don't want us to be off work either. Long COVID has a serious impact on people's ability to go back to work, but also social life. So I mean, you know, people are still not getting back to really going out with each other, socializing with each other, things that really are important for our mental health and our wellbeing. So risk predictors of long COVID, if you're over 40, I'm afraid you're at high risk. If you're frail, you're high risk. If you've had admissions to A&E and hospital admissions, and you've had COVID-19 symptoms, you're going to be at high risk. So a number of things that we know are high risk categories, so we have to think of individuals who are quite vulnerable as well. Diabetes, so there is research going on in trying to work out whether because of long COVID, we are going to have an increased number of people who are diabetic after long COVID. And we know that with diabetes itself, it comes with a whole range of problems. Again, it comes with different problems with the eyes, your lungs, well, your heart, there are multiple problems diabetes comes with. So if we're going to have long COVID and then we're going to get more people with diabetes, then we're going to get a knock on effect of that. We're going to, again, have another problem with who's going to have these long term morbidity problems later on? So there is this register and we are trying to look at that and see what's going on, not me, but my colleagues. So as I've said, some of the things we've talked about, some of the big things, you know, strokes, and other inflammatory disorders, and fatigue, but also, we know that there's other symptoms that people are getting as well. Hair loss, it's funny, it's hair loss is something that, you know, of course it's not on the not high risk of diseases, but actually it's something that really has an impact on you emotionally. So I'm sitting talking anecdotally to lots of friends who go, I've lost my hair after COVID, and actually emotionally it does affect them quite a bit, and we don't realize how much it does. But you can see a number of other factors there as well of how it's affected people's lives. So coming just to the elderly. We tried very hard during COVID to protect our elder, really, really hard, but obviously we don't know what emotional and psychological impact that had on people. We know people felt very isolated, we know they had reduced activities and some relationships broke down as well, but there is a high risk and we can't get away from that. If you are over 80, you have 20 times the increased risk compared to somebody who's 50 or 59. So it's there, it's a fact, older people are at high risk, but older people were also very lonely during COVID as well. And it's balancing that, and it's always a balance that we don't know if we'll get it right or if we got it right. Families, the elderly also, you know, eHealthcare came in huge amount, everything's not face to face, everything was online. A, you know, I'm useless at using my technology, absolutely useless at using technology. But if you don't really use technology much before, how did you access the health care services, did you miss out on that? And what are we now doing to address that? I still think we haven't quite caught up, there are still many online appointments that are happening. But I don't want to be totally, totally negative about things. There were positives and there were positive relationships where people felt they were at home, and people now are feeling that they've had more time with their children, or more time with their husbands, or wives, or partners. Mental health problems. Some positive mental health problems as well, some people felt they had time out to rethink their lives, they changed their jobs, they stopped the things they didn't want to do, they reframed their lives and they came back in a positive way. So some very positive things. And for some children actually, homeschooling was a great thing for them. Some children felt they were being bullied at school, they couldn't get on school, they didn't like the environments at school, and actually being at home with school, where they could take themselves away, was actually a very positive thing. And that was seen particularly for children with conditions such as autism, where sometimes being at school can be quite challenging. But they're also obviously lost out in other ways as well. So more quality time with their partner. Spend more time doing enjoyable things, more time in nature and outdoors, high levels of positive things going on. And some children slept more, I don't think all children actually slept more, and were healthier than they were before. So just to throw it in there before we go back to the negatives. Okay, so vaccinations, I'm sure this is something that many of people want to talk about. Do you have a vaccine or don't you have a vaccine for long COVID? Does it affect you or doesn't it affect you? Well, we could debate that more and more, couldn't we? Vaccinations are what saved us, and I'm somebody who feels that, I know some of you may not agree with me on that, but vaccinations had a big, big role in actually protecting us and enabling us all to sit here today in one room, I really strongly feel that. The question was is that we had more vaccines than people in the rest of the world did, and we have had more boosters than people in the rest of the world, another debate we could have, how many do we keep having and how much do we share that around the world? I'm not going to give an answer to that, that's for something for us to discuss. And then there's the boosters. So we know that when you have a vaccine, it wanes. You have a vaccine and then the sort of it wears off a bit, and that's why we had to have the boosters, to just keep on top of it. And at the same time, the variants were coming as well. But we do know, and I think there is good data on the fact that if you had the vaccine, your symptoms were not as bad if you got COVID. So then your symptoms of long COVID would be less. So there is this positive protective sort of way of thinking, well, if you've had the vaccine, then actually you're not going to be as sick, and I'm not saying that if you've had the vaccine, you'll never get long COVID, I'm not saying that at all, like, I can't say that. But there was a feeling that if were going to get COVID, it was not going to be as bad or isn't as bad as if you didn't have the vaccine, and that's quite important, I think. And so it is protective in that sort of way. And so you know, I did have my vaccines and I did feel that I needed to to protect myself. The question is, how many do we have? And do we do, I'm not on the vaccination committee, so this will be a debate that people will have, is do we give the vaccines to people who are more vulnerable in the future or high risk in individuals as we go forward, or what's going to happen? And we don't know, we're still looking at the science of what's helpful and what's not helpful. So you can see here for yourselves and you can read later, there's been lots and lots of different studies on vaccination. They will continue, and they will continue, and they will continue, and you'll read one that says one thing, and you'll read one that said says another thing. But if you combine the studies, the bottom line is the vaccinations did help us. And bottom line is we are here today because as a population we were protected. And like I said, it has been shown that it is somewhat protective against long COVID as well from some of the studies that we've seen. I don't want to go into the detail of vaccines and what type of vaccine is what, that's not my specialty area, and you probably need somebody else to talk about that. So I'm, as you can see, I'm more about long COVID, and physical symptoms, and emotional symptoms, and you and our lives, and how we live our lives going forward, and I'd love to discuss that more. But we do have vaccines, and there are different types of vaccines, and there are many, many studies that you can read about if you're interested in the different types of vaccines that are coming out, what will happen in the future. Manufacturers are always going to be trying to battle the next version of the virus and trying to think which ones should be used for what. But it's interesting, the new data that's coming out, they are exploring oral vaccines, skin patches, intranasal, because what's been thought about is if the viruses gets into your lungs and that's where it's affects you most, would it be better to have a vaccine that actually hit your lungs more? So people looking at different research projects to find out the answers to a lot of this. So emergent treatments. Well, again, I can't give you an answer to this, I'm afraid. We haven't got a definite treatment that I could say, well, if you've got long COVID, you can have this treatment, we don't have those answers yet, basically because of the story I've just given you, you know, how does it affect your body? How do you have so many problems in different ways for different people? So really what is the treatment going to be? And that's why we're all battling with it. Do you have an antiviral? Is it a virus? Are you going to give yourself a viral? And there are some studies that are shown that antivirals are working and it stops the virus from growing and spreading, and especially the virus that sat within you, if it is sitting within you, keeps erupting, the antivirals may help that. So there's quite a lot of studies looking at that, and they will continue. Different ways of supporting you when you are ill. So instead of having to go on ventilator, if you're very sick, are there other respiratory supports that will actually be more effective for you? So there's the support for you and then there's the treatments for you as well. But we don't have a clear answer. And I know some of you will be disappointed that you came today and that's what you wanted to hear, and I don't have the answer. And we've talked about, there's other treatments about using antibodies and they can manage symptoms and also prevent you from becoming very, very sick. And so when you're early in the disease, should you have monoclonal antibodies, should you have antibody therapy so that you don't get all of these after effects? And again, some studies looking at who should get that? But it's again, weighing up who the high risk individuals are, and who should get it and who shouldn't get it? So we talked about antivirals, we talked about antibodies, and then it's steroids, those sort of three things that people are really looking about at, antibodies, steroids, and antivirals. If you've just sort of remember those in your head when you're reading your papers in the future, those are the sort of three simple groups of treatments that people are thinking about. Steroids we know have been treating people for a long time for asthma and other inflammatory disorders as well. So if you have a problem with your lung, often you'll be given a steroid by your doctors. So it's like, could that be used for treating individuals with long COVID as well? And there's been some discussion about plasma antibodies, and you can see, there are some studies that people keep trying and everything, but I don't think this has really taken on so much, and there's always going to be side effects with every treatment. So again, weighing the risks and we have to follow people up to know what the risks are when we start new treatments. Just to throw in there, some other things which are people have done some work on treating infections from parasitic worms, head lice, and skin conditions, as well as in some different treatments that have been used for those parasitic worms that they've been trying. These are just a few others to throw in there that people are trying to talk about. But they haven't taken off so much, but the trials will be there. So there's lots and lots of little trials going on at the moment, but we don't have the answer, as I say. And this is all in your transcript, so if you want to know all the references and read the detail of the different papers, you'll be able to go into the detail of the different publications that are out there. Now, home remedies. Well, this is something I wanted to bring in here because we always talk about medical remedies, but we all do use home remedies. We use yoga, we use meditation, we use mindfulness when we feeling stressed, and we also use acupuncture, and I don't think we should forget all of that. So I'm a person who thinks science is important and it's really important we think of science, but we also have to consider the other therapies as well. Saying that though, I just wanted to throw this in, these are not trials, this is not anything that was trialed out with treatment, but people are trying all sorts during COVID, and we know they were trying all sorts. Some maybe felt that they were working because they make you feel like something's working, some may have worked, but we have no trials, and some may have been dangerous. So we have those three buckets to throw everything into. And this was really just to A, make us not forget that there are other supportive alternative treatments out there, that again, we could have another lecture on, and people were trying desperately lots and lots of different things as well. But could any of these things be useful in the future? We need some studies maybe to look at that. We know that turmeric, interestingly enough, you know, is something that's being promoted, and yet before it was just sort to be something you put in new food. Yoga, something that was thought was just a nice thing to do. But now is in the NICE guidelines as well. So some of these things may have a place, not all of them, but some of them may. So we've been going out into different places around the world, and this was a really a story from Rajasthan as well where people were looking at miracle water and people were thinking, well, if they had this miracle water that that might be treated. That may not be the case, and probably the water didn't do anything, but maybe it helped them psychologically, maybe it helped give them hope, and sometimes you have to give people hope, even if you can't give them a treatment. So people, all of us, have a place somehow or other supporting each other through this journey ahead of us. Just to come and round up with policy and recommendations, because I can talk to you for ages and ages, but actually if nothing's going to change out there in policy and in the government, we really can't do much can we, apart from us helping each other, which actually I think is the most important thing. We have to come together with our specialists, with multidisciplinary specialists, supporting our healthcare. We have to do what's in front of us to make our local areas healthier and our communities healthier. But we do also have to go to policy as well. And that's what we do a lot of is campaigning with policy. We have a lot of policy recommendations from all of this work, a lot, and I've just stripped them away from some of these slides, but again, you'll have them in the transcripts. We know that we need to leverage healthcare systems. How do we continue to get multidisciplinary care to support people? How do we make sure there's investment in that when we still have a backlog of everything that we have to do? So we need multidisciplinary approaches, multispecialty teams, but we can't forget all the other illnesses that we all need to take care of. We need to think about sick pay, people being off sick, that's really affecting people, people's financial, the economic crisis, how we're going to get through that with everything that I've said. And we need more studies, we need more funding for more studies. We have to follow people up, we can't forget that we need to keep following people up if we're ever going to get treatments. Health inequalities, I've talked a lot about this, so I won't chirp about this anymore, but I do feel that for young people, doesn't matter where you're from, doesn't matter your background you're from, young people have really, really suffered and youth services have been stripped away. So we really need many more investment for youth services if we're going to have young people who are not going to be marginalized, disenfranchised, feeling that they don't have a place in society going forward. And that's just a nice drawing. We did a policy workshop where we actually had somebody who drew while we were doing the workshop, because we decided that how many people actually read a whole document of policy recognitions? Not very many, but you have this diagram as well. And this was a policy workshop around homelessness and people in temporary accommodation, and what we could do and how we could work with legislation to make a difference for individuals. But I thought this was quite effective way to actually communicate the information to yourselves. So just to finish with another poem, as you can tell, I spent a lot of time writing poetry during that period. It's a bit of a sad poem again, but again, it's just to ground us as we end to say, thank you for all coming here, thank you for listening to me. We have a tough, tough ride ahead of us. I think if we don't have a dialogue, a debate, we don't remember that this is not something that's going to go away, this is long COVID, it's long pandemic, we will be doing ourselves a disservice and the disservice to our children as well. So I'll just finish with this."I cry and cry all through the night for those who've gone away to meet the rest of those that died, and then were washed away. The tears just keep falling. My heart it breaks apart. To think of those whose lives were lost and families torn apart. They tried to feed their children and had to go to work. Why could they not protect themselves from the terrors of this world? I pray for you, my darlings. It's dark and I'm alone. There's silence all around me. But your stories must still be told." Thank you very much.(audience applauding)- Thank you very much, Monica. I mean, I had lots of interesting and very challenging questions online, which I'll start with before opening it up to the floor. And they form a kind of pattern,'cause what you've described is a big overlap between politics, economics, social system, and the abstract word, policy, which derives from those. And as medics, how can we get into that to do anything? And especially, I think very searching question is, what is the medical definition of long COVID that would allow us to lead into that debate? So let's start with a definition and then consider- Yeah.- those relationships between policy and strategy.- Well I think the definition is something that's already been set. I mean, there has been a definition that's been set by NICE, which is the definition of, if you have symptoms after four weeks and they continue, that's the definition of long COVID. The difficulty is, what's the symptoms? So the problem is that you have symptoms that keep emerging and the studies that we do keep finding more and more symptoms. So will we have a checklist of all the different symptoms that if you say you have these different symptoms, then you have long COVID? I know that from the CLoCk study, what Terence Stephenson has done and his team have done is they actually had a Delphi consensus process. And what Delphi consensus is when you all as experts really think about this together and start thinking about, well, what should those symptoms be? What shouldn't they be? You send the questions around and then you slowly come up with a consensus of what the definition is. That's what they're doing for research definition, but maybe we have to also do that for a clinical definition as well. But I have to be very honest, I think it's a really hard thing to say what is long COVID, because of all the reasons I've said. So I'm sort of somebody who's sort of challenging that in a way is to me, is can we say what long COVID is? And how are you going to say to somebody who has a different symptom, well, that's not long COVID then? It's so difficult to tease this out.- I mean, you've described very well that things are different in different communities, with different economic backgrounds.- Yeah.- And different social, different racial, all sorts of differences. And yet we've now entering a situation where the politics are dictating maybe an even worse distribution of income simply than we had when this broke out few years ago. Are we going to enter a phase where health is going to deteriorate because the politics are leading to adverse indicators of the way that health works?- So I think we have a very big challenge ahead of us. I am really, really worried that the politics is not helping the situation, and I suppose that's why I'm here today. So what I try and do is as a medic, I try and advocate for individuals by meeting colleagues, not just in health, but sitting with colleagues in housing, environment, trying to work together in education and say, we have a problem here, how we're going to tackle it? We have to advocate, I think, as medics, we know the science, we know the problems. We have to work together with public health specialists. I think that's the other thing is not just the medical specialists who know the disease and what's happening in front of them, but I think the people who understand the disease need to work with public health as well, because of all the different factors I've talked about. And then we have to start thinking of legislation and policy. And I think our role is, partly, which is what I try and do is do the science, do the research, be the clinician, be a one man band in a way, but all come together and start lobbying and saying, this is the problem, and go, we're going to face a big problem. Those inequalities are going to make the health problems worse with this background of COVID ahead of us. But I don't feel that it's in dialogue much at the moment.- Even as medics, we have a bad reputation for not believing that, for example, ME existed or many groups,- Yeah.- or chronic fatigue syndrome. How do you think that we are going to get both medics and employers, for example, to believe that this phrase of long COVID, whatever it comprises, exists and is potentially solvable?- I always think sometimes in life, some people will never believe things, and you'll always have people that you can never get past. But then I think it's important to work with people who do believe it, and I think when you then try and get a momentum, you try and make it visible. I always talk about, you know, giving the unheard a voice, and that's always been what I try and do is, how do we get the lived experiences of individuals who are living with COVID and the challenges they have, to have that voice along with the science? So you need science, the data, the actual academic data, the quantitative data, but you also need the lived experiences of people. And then you do need advocates and champions, nothing happens without champions. So you need the data and then you need the people to be able to narrate that in front of others. But there will always be some people who won't believe it, it's just the way of the world.- Ladies and gentlemen, I'm sorry, we've run well over our time. So I'm afraid I going to have to call it a day. But I'd like you all again to thank Monica very much for her lecture this evening.(audience applauding)