Dying in childbirth | Delivering solutions for mothers around the globe



this event is the third of a series of biannual public lectures that the School of Public Health has decided to support and we call it art this is public health theories these lectures are to gain information about research so that we can all think critically about public health issues that people are facing locally and globally as you know public health aims to prevent injury and illness protect health and promote wellness for people in all communities it's a multidisciplinary field that includes health social sciences biological sciences and touches every aspect of our lives so today is International Women's Day where we celebrate the social economic cultural and political achievements of women around the globe according to the World Health Organization women in developed countries live 24 years longer than those in developing nations one of the issues facing these women is maternal health we are very proud that one of our school of public health researchers is making an impact in the lives of these women maternal health is public health so I'd like to introduce our speaker dr. Xue via Mumtaz dr. Mumtaz earned her mph specializing in international health at Harvard you at the Harvard University School of Public Health she also earned her PhD from the London School of Hygiene and Tropical Medicine she is an associate professor here in the School of Public Health and her research focuses on the ways that culture and society impact woman's health working largely in South Asia her research focuses on the way that gender and social inequities impact health and her work impacts policies they impact maternal health services and they help us understand how vulnerable women access such services in 2010 dr. mama tells me see if the Alberta innovates Health Solutions population health investigator award and in more recently in 2015 she and a colleague dr. Duncan Saunders were one of 20 research teams funded by the global health research initiative which will help resolve pressing challenges and better meet the primary care needs of mothers newborns and children in sub-saharan African countries please welcome dr. Zoo be a mom tip [Applause] thank you very much fit can you hear me at the back good so welcome and thank you for sure taking time out of so very busy days to come here and celebrate International Women's Day with us I will straight away start my presentation by showing you this beautiful picture of the Taj Mahal I'm sure you all know that this is a symbol of love it is also a very popular tourist destination and a lot of us off to visit this place one day definitely on my bucket list we also know that this beautiful structure made of white marble is actually a tomb it was built by bleach struck Mohan Emperor in memory of his wife and TAS Mahan who died during childbirth it's my namesake by the way but that's about the limit of our relationship so really not that one known that Mumtaz was a maternal mortality and she died giving birth to her 14th child the 14th year of her marriage apparently this was a common occurrence those days 500 years ago the question is as we gather here today to celebrate International Women's Day to celebrate a women's achievements in the political economic as social arena that having made similar progress in saving women's lives globally ah the question is not even today in 2016 and I've estimated 300,000 women will die during childbirth this method numbers think in it translates into about 800 deaths every day which is about a woman dying every two minutes somewhere in the world so let's couple of minutes that I have been standing here in front of you somewhere a woman has died in childbirth that also translates into four jumbo jets crashing every day can you imagine the hysteria if four jumbo jets full of perfectly healthy young women crashed Africa the question arises why does this state of affairs continue to exist to really know a lot but I definitely more than what I appreciation you try several years ago we know what are the causes of maternal death feeding is the biggest killer of women only one-third of women died your proposal pleading eclampsia in which hyper blood high blood pressure is one symptom is another common killer substance and now these conditions are medical mysteries any medical students will tell you how to control bleeding and we have all the antibiotics we need to treat sepsis when we seem to have failed is not been able to translate what our clinical knowledge into health services for all women worldwide it's not that we have not tried in the past 30 to 40 years numerous international policies have been developed with the aim to provide services to women worldwide these included the since the safe motherhood in the 1980s I CPD in the 1990s the Millennium Development Goals in the 2000s and now the sustainable development gold target 3.1 in fact the 17 sustainable development goals that were launched in November last year addressing maternal mortality is just an alone target 3.1 so we have been paying a lot of attention to the matter so why am in fact accord addressing with high maternal mortality was a key element of Stephen Harper's international engagement and at the g8 meeting in Toronto in 2012 2010 he essentially led the leaders who all agreed that reducing global maternal mortality rates was important and they put aside large amounts of money to address this issue and so now it's 2016 and what have you got to show for all this attention actually you haven't done Burnley global maternal mortality rates have systematically and continuously declined over the past 14 years and these numbers by the way are the number of meta maternal deaths per hundred thousand population 100,000 live births sorry and in fact we have made significant progress between 1990 and 2013 we have reduced maternal mortality rate by 44% so while it is really good news I mean I think we need to pass ourselves on the back because clearly I think the rates in 20 shown here are probably some of the lowest in recorded history but before we celebrate and shut the books down it's worth noting that we failed to meet our own target the target that the global community is set for itself in nineteen at the turn of the century in Millennium Development Goal number five the Millennium Development Goals were a set of goals that all the countries in the world signed up at the turn of the century that they hope to achieve by 2015 and one of them and dg5 was a stand alone target and that was that we will between 1990 and 2015 reduce maternal mortality rate by 75% not only did he not achieve of a target only six out of the 75 high burden countries actually match the targets so that is why you have not been least hearing a lot of celebration around this matter had been better with targets there would have been big fireworks so what happened I mean why did we manage to meet our targets it's not that they're not spend money in fact we have spent quite a bit of money in 2013 alone we spend 13 billion dollars on on global health projects addressing maternal mortality maternal health issues in general I don't know whether this number is small or large sufficient or insufficient but it again is obviously just looking at it no small change in fact just over one year from between 2012 and 2013 this was a 34% increase I don't know if many broad broad programs in the world which have this kind of increases honours year to year basis and in 2015 Stephen Harper added to this month amount by declaring contributing another 3.5 billion dollars so money has been spent and but and this is your money I taxpayers this is your money so I guess you in fact that you have a right and a responsibility to question how what have you achieved you know using your money so what happened I argue and I don't think I'm the only one this is now really been quite well recognized then one of the key reasons why we fail to achieve our goal holds that we fail to address the inequities and the inequities exist between at the country levels you know we all know that some countries have much higher rates of maternal deaths than other countries do and these countries are the well known countries the largely in sub-saharan Africa or in South Asia so we have been focusing on these countries but what has been what is really astounding are the inequities that emerge and exist within these countries so for example the dead demographic Health Survey data showed that in Pakistan in 2013 96% of women rich women reported prenatal care compared to just 37% so if you're a rich woman in Pakistan your access to care is as good as any woman in Atlanta so it's really the four women who are getting left behind and this is a cross board I mean all the countries that I listed the – that show up in red here have this problem but what I think what might surprise you – is that even countries that actually don't appear as red and look green on our chart actually has vast inequities within the population and a case in point is the United States of America our neighbor down south hasn't done such a great job in addressing inequity maternal death remain the sixth most common cause of death in women age 20 to 34 in the u.s. today clearly is not a matter of resources it is one of the richest countries in the world it probably the biggest army in the world what it does have is past inequities so what apparently seems to have happened in all this time that we were busy and developing interventions and programs and strategies in at providing services maternal health services in and all the countries especially the high burden countries what we did not realize was that these services were being taken up disproportionately by the wealthier wealthy or the wealthy or relatively wealthy populations when people were working if you sitting in Washington or London or Ottawa and you say that you're working in same Kenya or in Bangladesh you assume you're reaching the poor population and if you are working in Islamabad or in Dhaka or in some other capital Robbie you assume that when you're working in a rural area you're reaching the poor populations this is a very simplistic and what that and that is where we went wrong we were so busy developing interventions that we fail to take into account the inequities that exist and how our interventions then spread into the existing inequities further create inequities and access to mature services so what happened is that this particular group the group that I dropped were socially marginalized vulnerable populations is a group of people that got left behind so in the remainder of my presentation today I will discuss with you why you failed to address this inequity what challenges continue to exist and what somewhat potential solutions to address these these inequities in the interest of time I will only focus on three areas privatization of health services our tendency to focus on magic bullets and to take siloed approaches this is not to say that they only exist these three reason they exist many more reasons but I will only talk about these three reasons so the first one what some reason worldwide there is the creeping agenda to privatize health sir you seem to like the idea of private ranch ah and it's not just in and the world worldwide or in developing countries even in countries like Canada where we have I would like to believe an established public sector system but you know this article came out in the Edmonton Journal just a couple of weeks ago indicating the constant push for privatization of Health Services idea for private health services was aggressively floated by the World Bank in the 1990 1992 there was a World Development Report by the World Bank in which it was very strongly argued that there is in no way that governments and especially governments in poor countries are going to be able to provide services health care and that we need to drop on the private sector but in the recent past this baton has now been taken over by a whole new group of actors the philanthropy activists so while it's a new term the France of capitalism the term does not exist in the dictionary just yet but it refers to a whole new group of actors that have played a very big role in global health and maternal health they include organizations such as the Bill and Melinda Gates Foundation the warfare foundation and now the latest kid on the block the Zuckerberg foundation these foundations this orbitofrontal capitalist have become big players on the scene globally and this slide kind of tells you how big a player they really are so this was the latest data that I could access 2013 and it shows that the Gates Foundation actually spent more money on global maternal health than did Canada and it's worth noting that the Gates Foundation is essentially one individual while there are nearly 33 over more than 33 million of us so you can imagine that they have a huge say in what least what is done and what should be done so you know in principle is nothing wrong with this idea right it's their money and then tourism is great but there's an increasing concern that these organizations are actually not as altruistic as they might appear so according to mark measure were a professor of history at Columbia University the philanthropic vision of the Gates Foundation seems to be largely based on the values of corporate America so what he argues is that these organizations are the other rather than when they focus on material health and all these issues they might end up and in fact they probably are looking after the interests of the multinational corporations they represent at the expense of social and economic justice and this is done in one way is by pushing for privatization of answer if you look at the request for proposals by this but the Gates Foundation Yui and they ask you to develop programs which they would consider funding they use language such as any revenue generating projects and market share and sales revenues in products this is very business language it's all my but I'm not a business major in any way or I don't know anything about business but this looks to me really business so you know if you want to develop a business intervention and the Gates Foundation wants to fund it that's great good for you the question are up the it becomes problematic when they claim to provide services to poor people because my research shows that the poor in Pakistan I cannot just not afford to buy private services they are actually even out of the market so this nice picture reflect the rich people in Pakistan and what I saw in my research in this is a caste based society of South Asian caste based society and at the top of the heap are the Chaudhary's and the Rogers so this group of people have access to land and they are the traditional the land owners and not only that they have access to social capital which enables them to access educational resources employment opportunities they are the group of people that populate the civil service the army the banking sector the industrial sector you name it these are the people who live there who are present there at the bottom of the heap are the low caste coming these are the group of people who are landless and they are in fact born to perform low status no new elimination jobs these occupation normally pay very little but they are actually tied to the land owning class in very traditional bonds social and economic bonds they have to they work all year round in the occupations that they're born to perform and then the paid in kind at the end of the year at the time of the wheat harvest so when you have this woman and you have family working in a brick kiln and they have to manufacture or you know build whatever they do at least 1,000 bricks a day and all the get in return is roof over the head and three meals a day what is the probability that she can save money to buy private in fact this group of people doesn't have cash they are out of the market altogether and I just want to highlight that I was in the field when this picture was taken it was more than 45 degrees heat I couldn't put my finger out there it was like minus 45 degrees in Canada but this woman and her family and a little baby were out there working from sunrise to sunset because they had to build 1,000 bricks so the idea that we can provide private health services to this group of the population is displaced to say the least in fact is the emerging evidence that private health services may actually hurt so this data was presented a couple of weeks ago in New York and I was actually shocked by it what they showed was that in one district in Pakistan a surveillance system found that between 2009 and 2013 the maternal mortality rate actually increased this increase what's particularly shocking because the use of health facilities and maternal health services also increased and seventy percent of the women were using health facilities were delivering in a health facility and yet they were dying it emerged that all the increase in health facilities that has taken place was in the private sector in fact today 80% of health care in Pakistan is in the private sector so you know the only conclusion that you can draw from such data is that you know maybe these women was safer off staying at home rather than going and delivering in a facility in which the bottom line was a dollar rather than 150 and my research shows that private health services tend to convert of what is essentially a public good into a statist Empire and let me show you how that happens this is a Louis Vuitton handbag and these are gucci sunglasses and i will show you how but private health maternal health services have actually become the equivalent of these two items in pakistan or rather my village in which i work Oh I mean I'm gonna give my fieldwork I found some really surprising and I didn't know what to do with him they just were not fitting in the traditional idea that the rich use private sector services and the poor will use public sector services and then I came across the hands model he's moving an economics journal so and has then he developed this model he basically developed it to understand how the population uses luxury items and which group of the population uses what type of luxury item and his objective was to you know provide information to these manufacturers on how you can target different groups of the population so on the x-axis you have the have-nots and a half or the y-axis and on the x-axis you have need for status so these are people who have low neutral stages to people who have a high need for status you understand what status is right it's just signalling Who I am what what has showed in his research was that there are the population can really be divided up into four groups one are the patricians these are the old rich people they are wealthy and they can afford to buy luxury items such as the Louie Vuitton handbag and the nice class sunglasses but you know they know they really don't need to signal their stages at least not to the other three groups the only group that the signal their status to are the other patrician and and and the signaling is very subtle so he hand actually measured the signage of the Louie Vuitton you know this is LV leave it on handbag and there he showed that you know there was no way that at least someone like me would be able to identify that this is a Louie Vuitton handbag I only know that this is a leave it on handbag because I got this picture from the website and of course it's Madonna I was using it right so you know that's what it is Madonna doesn't need to signal who she is the second group of people are the power winners this is the Latin term that refers to people who have arrived so these are the newly rich people and these people are can afford to buy these luxury items but they also have a way I need to signal this status that look yeah all right so they use luxury items but with very loud signage so I don't think you can make out but you can actually see LV on that handbag the third group of people are the poses and the poses refers to the the French term that refers to people who pretend to be what they are not and so these are the people who are not wealthy they cannot afford to buy this luxury items could you just have a high need to demonstrate status and so they are the ones who use the fake items and this bag is supposed to be fake I wouldn't know it's fake but this ad is fake so that's fine with me the math group are the proletarians and this is a term that is used to describe people of low social and economic class and they are the people who cannot afford to buy these luxury items and I guess so they going by Jews whatever it is from superstore and well you know they can't afford it and they either don't know or they couldn't be bothered to demonstrate status what I found was that my complex pattern of Health Services used in my village actually fit in in this two table so at the top of the heat or the Rogers and the Chaudhary's and they tended to use public sector services which was a big surprise to me but I would have thought that they would be the ones who will be using the private sector services but indeed these people had access to some of the best services available out there by either by virtue of their employment benefits or simply by virtue of the social capital it was the upper middle class mistress who actually purchased private healthcare and they could afford to buy it but very importantly they converted it into a citizen so really you know it's up to you to convert whatever you want into a status symbol right Danny did what potable water if I want to I can convert it interested so that's what they did it I didn't understand what it was about this particular woman niggath she was a midwife but using her services work their thing to them the pressure really fell on the be honest the lower middle class they couldn't afford the private sector sandwiches but they felt pressured to use you know the kind of pressure keeping up with the Jones and in fact one woman I shall be be her daughter-in-law Ashford was pregnant and I shall be be recommend wanted how to deliver in this the nearby rural health center which had a physician and I thought was pretty good but of course she wouldn't hear of it and neither would have mother my god her mother was really mad she said is never daughter often did you pick her off the street that she's going to deliver in a public facility so I shall be reborn money and her daughter delivered in a opportunity of her choice and then I shall baby worked secretly as a cleaner pay off her debt that's the kind of pressure that exist and then of course at the bottom of the heap for the the low caste come is they couldn't afford any services and they depended on the on-screen traditional birth attendants so clearly here was an example that if we focus on privatizing health services it's very easy to imagine that they will transform into a statistic can't imagine that happening in Canada you know who will be the people if they were private clinics who are the people who able to afford them the rich and the occasional times that we have seen a clinic sneak up the last time I heard it was in Calgary and you had to pay up ten thousand dollars up front so not many people can afford that those who can it's going to become a statistic can you imagine somebody saying the rest of us who don't feeling small oh sorry so yeah I did even faster huh so the second item that not the second reason I'm going to talk about now that that I believe creates the inequities that continue to exist is about tendency to focus on magic bullets there are no magic bullets out there but for some reason we tend to believe and I I just sometimes wonder it is human nature to believe that if we could find that one single solution that will solve all our problems great belief I can second level its impatient right we really want to solve our problem and any patience is good I really don't have a problem we need to address this problem sooner rather than later but if we continue to focus on looking just for that one solution go to address water otherwise very complex problems we are going to miss the boat here and let me share with you one example of magic bullets some fun that's a businesswoman the latest thing the idea that cell phones the mobile technology that somehow is we managed to provide information to women basic services through cell phones the problem will be solved and foundations whether the Gates Foundation are lining up to fund such interventions yet there is no evidence that they work over 500 mobile health studies have been conducted none of them have shown that cell phone single-handedly I'll be surprised by that not because if you think about it what is it what is a cell phone it's just another tool to which knowledge can be transmitted it used to be that beautiful fall upon the word of the mouth or the or the newspapers to provide health education so this is another example of a health education tool and they all know that just knowing does not let me translate into action we all know we are supposed to eat healthy how many of us actually do it so if health services don't exist if a woman can't afford the health services if she she can't travel to the health facilities knowledge alone is insufficient and yeah and yet we keep on hoping that there is going to be that one magic bullet according to multiple they and he refers to the foundation exaggerate what technology can do ignore the complexities of social and institutional constraints open waste vast sums that would have been better spent more carefully and let me share with you an example on which I actually saw this firsthand I was asked to evaluate a project which plan to provide cell phones actually iPhones to women and then provide them with messaging on when a lady seeks services the idea was to create DeMott thousands of women were given iPhone 4 I told there not many teenagers in the room here but they would have given arm and a limb to receive a free iPhone right what happened was what what a thing happened nothing nothing happened because these women refused to share their cell numbers with the project citing privacy concerns nobody had thought of that but what actually struck me was that he gave them two iPhones but the fact is that they need to have a plan he plays it all cheap they're not cheap here and they're not cheap anyway in the world I don't know about you but I'll I find the plan she's quite expert and so the women that I showed you building blocks do you think she can afford to pay for opera there's no way that she could be able to go to that so again our interventions list addressing the needs of that particular population and we continue to contribute to the inequities and so on the last top the reason I'm going to talk about that leads to the inequities is siloed approaches just to read this pretty powerful this is the title of a paper written by penny hall that was published a few months ago in this paper she says global health has fallen prey to developing conservative simplistic and negligent interventions that remain well short of delivering broad reaching and sustainable kind of unit you know where is she coming from so I'll tell you where she's coming from basically what has happened is that we the global maternal health community has standard focus on developing interventions that are simple silos and vertical and failed to take into account the complexities that actually exist on the ground this slide is not to scare you in any way or try to understand what's going on but just to show you how complex the interventions are and by the way this slide was just focusing on the complexities within our health system we're not talking about factors that lay outside the health system and my research shows that factors that impact service delivery are many so into end 2006 the government of our start this developed midwifery training program they did till the lack of skilled birth death right that's what was understood and so they thought we will take young women good young women from villages provide them with 18 months of training and that's it and then they were let loose they expect you know there's a huge countrywide effort women's of dollars of billions of dollars will probably spend on establishing training programs for these women over in the country nationally rather and over the idea was to train 12,000 midwives in five in five years well after they graduated there were expectation was that they will go back to their home village and be home-based providers so here you have a skin birth attendant who is all based in her village home and that she whenever a woman becomes pregnant in her catchment area she will go and she will provide them with antenatal care prenatal care and when she attended childbirth all in the woman's house that was designed with the idea that women in this context prefer to deliver at home and within the context of seclusion that is the normative idea what I found when I went in about six seven years later for the launch of the program that hardly any of these women were working in fact about 80% of them were not working at all and also 20% of trying to work they were really facing challenges and one of the key challenges they were facing was that they were unable to provide services to what was supposed to be the heat on it these women the midwives were designed to provide services to poor women who were using traditional birth attendants but they were told that you have to charge these poor people for the service you provide remember those poor women cannot afford private sector services so this so they didn't use them instead they continued using the traditional birth attendants whom the paid in kind and the women who the midwives were hoping to provide services to because everybody needs to be paid for the work they do they ended up providing services the rich women wouldn't use them because why would you do that right when you can go and use the well-established physician that's a thing that the landscape wasn't black it wasn't a blank slate they already existed provided just because they had a group of people providing traditional birth attendants you couldn't just fly to the place with the new cadre of providers the third factor that came kicked in was transport the young women these midwives could not travel to these women's houses to provide service this is a contact characterized by seclusion and further and so a young woman of twenty-two cannot just walk in the lanes and go to people's houses she had to be accompanied by at least and all the women during daytime and two men additionally at night these are in secure rural context so a woman who doesn't have reached access to these kind of human resources was unlikely to practice and so this did work however all these complexities are completely ignored but by a funding agencies and our intervention if you look at the list of the projects that have been funded by the various foundations and taxpayer funded organizations like Global Affairs Canada odd US aid each project is a stand alone project so while so there's one program in Ethiopia for training midwives this another program in Kenya that is providing material voucher scheme and there's a third program in Bangladesh that's doing something else each program does one single thing at a time this leads to what penny houses projectif occations that instead of develop addressing the complexities and developing interventions that check out all these issues we end up having in libram a little project which the belief and a hope and a prayer that somehow they will coalesce together in some grand way to reduce maternal mortality it might happen it might not happen sometimes it has worked out and lots of times it has not worked out so at one level I can hear you saying but you know how can you expect someone to do the same thing and see everybody one person one one organizations do one thing at one time at the same time and this makes perfect sense you know to do one intervention at one time these interventions are easy to understand by the funding agencies they are you know easy to implement by the implementing agencies and they are cheap to fund very importantly they lead to the development of simple to measure indicators but micro argument is that if you are failing to reach the women that you're aiming to purporting to provide services to it's meaningless so what are the solutions and how can we address this complexity the first thing I argue is that there is a need knowledge that there exists a group of people the ultra poor socially marginalized and very vulnerable group that for the large number of us are invisible not only are they invisible to people internationally they are invisible to even local providers when I have tried to present the existence of these people I lama bath i have actually experienced quite a pushback first the caste system doesn't exist this is a Muslim country we don't have the cost secondly when I talk about the existence of these people you know it's very easy to talk of poor people and the other we don't see but it's very difficult to realize that these poor people are poor because of you so the bureaucrats kind of you know feel bad become very defensive the first time I presented this findings I was lucky I had Director General Health who was from a village and he bought my ideas and so once the director-general bought everybody kind of you know said yes but it's taken me time to kind of convince that you know you have to address the needs of these people but these realizations needs to be come to us as well the people sitting internationally and to certain extent it has the Sustainable Development Goal number 10 actually aims to address the inequities but now we need to make sure that we walk the talk the second thing that I we need to address is that we need to develop services that are sensitive to the special needs of these group of people and I use the word special needs because I really believe that this group does have special the need to be provided services that are financially sustainable financially enabling for them as well as you need to provide them with respectful care because some of these identities are believed are quite stigmatizing kind of and we need to provide them free care I know this sounds not new for somebody in Canada but it is quite a revolutionary idea if you're sitting in the u.s. what happens is that countries that have achieved success in reducing the material mortality rate have done so by providing free care historically did have in the Western countries Canada Sweden all the Nordic countries and I Jack I told you the u.s. resin is still not there yet it doesn't provide free prayer for in the past 100 years or so 50 years or so Cuba Sri Lanka are the countries that achieved similar success again by providing free clean very recently you know in the last 10-15 years Ronda and Nepal have made remarkable success by providing free so even if you cannot provide free kit everybody there is definitely a need to develop a social safety net for this special group of people and this social safety net needs to be systematic and at the national level developing projects that provide voucher schemes for five years and then once the funding runs out everybody packed the bags and goes home onto the net onto the latest flavor of the month project is not the way we need to go we need to be systematic about it the third thing or the whole thing that we need to do is that we need to start developing complex systems thinking we need to make sure what apparently happens right now is that we like the idea of developing simple singular interventions the easy there the comfortable they are ever any way does but we need to go beyond that there is an emerging literature that is starting to talk of complex techniques and how we need to start addressing these things in a much more complex manner this is where the funders now need to step up because funders really lead the tune if the a lot of implementing agencies write proposals that are required by the funders so if the fungus starts requesting for complex interventions implemented agencies will follow suit but for that to do the fondant need to bring in some serious changes in the plant project currently all projects in at least Global Affairs Canada and I believe US aid are assessed by in-house bureaucrats it really is not fair to expect the small group of bureaucrats to have all the knowledge out there so they need to change the way they fund the way the review projects by drawing upon peer-reviewed expertise so what is some take-home message today for the audience the first one I would say is that we need to continue championing the cause of Greater social justice in matters of maternal health we need to consider talking about this right we need to remain vigilant Lee aware that poor women in some of the poorest countries in the world remain voiceless that you and I are actually their only voice and thirdly we need to hold accountable all the stakeholders in maternal health we need to hold accountable our elected representatives we need to boil accountable the bureaucrats who fund the project with our money you need to hold accountable for like me your researchers what are you doing what I said what is useful research so I guess that's it you take home messages and I would like to thank our sponsors prominent homes for funding this presentation and my graduate students ELISA Ferguson for bearing with me as I brainstormed some of these all these ideas and of course all the people in the communications group who work very hard to make this day happen so thank you very much [Applause] so I want to thank Surya for

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