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Gavin: Hello, welcome to the Lancer Voice. It's January 2022. I'm Gavin Cleaver. And we're very pleased to be back for another year of this podcast, bringing you health stories and discussion from all over. I'm here as ever with my co host Jessamy Bagunel and we're delighted to also be joined today by Professor Kevin Fenton who's the Regional Director for London in the Office for Health Improvement and Disparities here in the UK.
That's within the Department of Health and Social Care. He's also the Public Health Advisor to the Mayor of London. We're going to be talking to him today about vaccination in London, about Omicron in London, about the last few months because they've been a pretty busy few months, haven't they? It's not been long since we spoke, Jessamy, but a lot has happened.
Jessamy: Yeah. We were, we, on the 29th of November, we sat down with Celine and talked about Omicron, which, was something that we knew was in the uk, but still fairly low. And we were looking to South Africa to see what had happened and what this new variant was. And in such a short space, we've had, an explosion of cases in London, in the uk.
There's been talk about it being milder, but at the same time, the numbers have been so high that there's been enormous pressure in terms of staff absences, but also in terms of it not really being well that us being unsure whether it was hitting a younger population first, not necessarily having the data from the older population, which.
And about this stage, post Christmas mixing, perhaps we might be starting to see fairly soon, so there's still a lot of uncertainty about that.
Gavin: So without further ado then, here's Jess and me and myself, talking with Professor Kevin Fenton.
Jessamy: Kevin, thanks so much for joining us. Gavin and I have had the luxury of being off over Christmas, which I doubt you have. But maybe you could just tell us what's happened in London, because many people are seeing London as a as an example of what's to come in their own region, whether that's in North America or elsewhere.
Kevin: So as we've seen in previous waves of the pandemic, London has been at the vanguard of the Omicron wave in the United Kingdom. And this in part reflects our global connectivity, reflects reflects the size and complexity of our city, the way we mix with each other, the way we move around the city, all of those factors which we know played a part in the city being relatively hard hit in waves one and waves two, we're seeing many of those factors play out.
So very soon after the identification of the variant in South Africa, we began looking for the variant here in the UK, and again, unsurprisingly, given our global connectivity, we found cases of Omicron. So the Omicron was identified at a point where we were already seeing a resurgence of Delta infections.
And very quickly after it became established, we began to monitor and track exponential growth of Omicron. So the first three weeks of December saw that rapid growth of the variant. We tracked its progress through a combination of genotyping of samples of people who've tested positive in the city.
So we're not able to test everybody who's positive, but we take a fairly random sample of our isolates. We send those out for genetic typing, and that gives us a sense of what proportion of our isolates have Omicron. And we were able to confirm that the variant itself was doubling every two to three days in terms of the proportions that we were seeing.
And we observed very rapid spread of the variant in the first three weeks of December. perhaps peaking just before Christmas and over the Christmas New Year period, where we saw rapid escalation of Omicron, substantial increases in our case rates of COVID 19 across the city, replacement with Omicron becoming the dominant variant, replacing Delta, and of course, the net impacts on health and care services.
So the whole process of the establishment, the growth the dominance of Omicron and now the clinical picture that we're now seeing with Omicron being the dominant variant in the city has really taken place over just just over a month. And that in, in COVID times, as we go through this third wave of the pandemic is remarkably fast and remarkably efficient.
So that's been our experience. And as you can imagine, It's touched the lives of so many Londoners because so many people have become infected over the holiday period. It's had a huge impact on health and care systems from everything from staff sickness to infections and outbreaks in care home settings and in hospitals.
And I think it's really also bringing to fore the issues about how we live with this virus moving forward. It was just some of my initial reflections about the journey with Omicron over the past six weeks.
Jessamy: I'd love to pick up on that last issue of how we live with the virus. It's something that we hear a lot in the UK and elsewhere.
People are wondering about how we move to endemicity. What are your thoughts about that at this stage in the pandemic when we have a highly vaccinated population. And we have this, restrictions, things are different, but we at the same time have to consider safety. We have to take precautionary principles.
What are your views on it?
Kevin: So as with all of the waves in this pandemic of the past two years or Feelings and our thoughts on this has to be agile and has to be emergent because none of us have a crystal ball. We don't have the answers in what's going to happen next. But what we can look at are the assets that we now have that allow us to manage the infection and the pandemic better with each phase.
So in wave two, we had a very good sense of what are the preventive measures, what are the things we need to do to protect the most vulnerable from the ravages of the COVID 19 pandemic. In wave three, in addition to that, we now had. The vaccination program. We have new antiviral treatments. We have much better clinical confidence in managing cases of severe disease and all of these things together would enable us to come into this third wave, recognizing the threat of a highly transmissible.
variant. And even if the clinical profile and the clinical severity was less than previous variants, the shared numbers of people who are going to be infected would place a strain on our health and care systems. And that's exactly what we've seen. What it means for us moving forward though is, I think there are three things.
So the first is, as I said, really understanding the assets that we have, that with each successive challenge we're approaching that challenge with new tools in the toolkit. More wisdom, more experience that allows us to make decisions earlier, understand how we use and combine those tools for greatest effects, and how we engage and communicate with the public to bring them along with us.
Second, we need to then understand how do we begin to, is this now going to be the opportunity for us to think about what does living with COVID mean? What of the tools that we've developed over the past few years will allow us to manage levels of infection effectively? minimize harm while allow us to get back to our normal social economic activities within the city and within the country.
And that balance, I think, is going to be a critical one. And you've already seen elements of this. So the commitment to keep schools open, having a plan B measures which do not move into the full lockdown scenario, which allows for significant social and economic activity within our city and within the country.
which allows us to understand what levels of risk we're willing to manage and able to manage and how do we mitigate transmission with this amount of mixing that we have. And then third, it allows us to think about how we really continue to engage the public with us as we move on this journey. So a good example of this is in a post Omicron peak world where so many people have been infected and so many people would have been vaccinated and infected and had mild disease.
How do you then engage people who aren't vaccinated who have been infected about what their preventive measure is? are and what the vaccine role is for people who didn't complete their vaccines, do you then say to them, get your vaccines, please, even though you got Omicron, please ensure that you complete your vaccination course.
And as the conversations on a fourth dose of vaccine are becoming more apparent, how do we prepare the population for that in a population who's not only going to be vaccine experience, but may also be COVID experience as well. So that's going to change, I think, some of the dynamics that we'll deal with.
Gavin: As we're talking about vaccinations, of course, London has quite a significantly lower rate of vaccination as an area than other generalised areas across the UK. But also, it's a nuanced picture, of course. Vaccination rates in other major cities across the UK are similar to that in London. So what are some of the factors of these urban areas where we're seeing such kind of significantly lower vaccination rates?
Kevin: The first thing to remember is that this is not unique to the COVID vaccine. All right. So whether you look at the vaccine uptake rates for all adult vaccinations that we have prior to the COVID pandemic, you look at the uptake of other preventive interventions, such as cancer screening for breast cervical bubble cancer screening, we always have generally lower rates of uptake.
than other regions. And part of that is London's demography, the size, the complexity, the mixing and the diversity that we have with a university that makes us both great, also makes some of these urban health challenges more, more difficult. So coming into the pandemic, I think there are three elements that we have been focused on.
We recognized for London that vaccine uptake and vaccine hesitancy would be a challenge even before the first dose of vaccine was given. So we started work on How would we deal with inequalities? How would we engage Londoners? How do we ensure we have a diversity of channels to give the vaccine?
Because we knew that this would be necessary coming into the vaccination program. So we began planning for all of this in terms of engaging with community organizations, beginning to think through culturally competent ways in which we engage with Londoners and ensure that materials were there, ensuring that we had diversity of channels which were available to our communities.
And that's been a key hallmark of the vaccination program in London, that we not only identify the sort of national mandates for the delivery of the vaccine, but we work hand in glove with our local authority partners, with our community partners to ensure that we're delivering the vaccine in ways that are meaningful, convenient, clear to our communities.
Now there are three sort of groups where we have been particularly challenged and which have required more intensive work over the past year and a bit with the vaccines. The first are people who genuinely had concerns about the vaccine. Is it safe? Is it effective? Can I take it when I'm pregnant? Will it interact with my chronic diseases?
Etc. And for most of those people, as the vaccination program has progressed as millions of people across the country and billions across the world have received their vaccines. And as the data on safety and effectiveness have become more robust, they've been more convinced and they've taken up their vaccines.
And we've seen hesitancy levels fall, uptake increase in some of our most hesitant communities. The second group in London are people who were exposed to the virus before. Remember, London had a very high attack rate in wave one and in wave two, so many Londoners, we estimate about more than 60 percent of Londoners before Omicron had been exposed to the virus.
This means that many people felt like they didn't need the vaccine. Many people felt, okay, I've had the infection. It wasn't that bad, and London's a much younger population than the rest of the country. And that's where we had most infections. So that would have been perhaps more challenging to get people engaged.
And that is reflected in the data that while, whereas you have very high uptake 40, 50 and 60, it's the younger individuals who have been more hesitant and where you have less uptake. So your first group are the people who are absolutely hesitant and need more information. The second group are the people who may have been infected and are vacillating on whether or not they should get the vaccine.
And then you have a smaller group which are the really vaccine resistant people who are listening to and engage with the misinformation and myths online and who are vulnerable to negative messaging. For some of our communities that are connected to other countries where vaccine hesitancy is high, for example, some of our European communities in London, we see patterns of that hesitancy and resistance as well.
And for those, it's about working with community organizations, the channels, being consistent in our engagement, ensuring that we're continuing to provide opportunities there. So in summary, It is so easy to paint everybody who's unvaccinated with the same brush. And what we've learnt in the city is that's not the case.
People are coming to this with different values, different concerns. You need to meet them where they're at and then work with them to get the vaccine. And that's exactly what we're doing.
Jessamy: Can I just ask a follow up question on that Kevin and something which I've been pondering in my head this group of people where you've got a younger population who may already have had the virus and they don't want to get vaccinated for whatever reason and I've spoken to GPs, friends who have had conversations with these people and find it incredibly difficult to be able to persuade them to have it because actually the vaccine often doesn't stop transmission and they've had it and it hasn't been very mild.
At a societal level, how important are these group of people getting them vaccinated? Do we have a clear grasp on that? Or is there some uncertainty there? And is that then reflected in how we're approaching the unvaccinated in general?
Kevin: So it is affecting how we're approaching the unvaccinated in general, because in a sense, we need to segment the population and to find the right strategies to engage that segment.
And the group that you've just mentioned is a really important demographic for us in the city, because we are, as I said earlier, demographically generally younger than the rest of the United Kingdom, and or younger Londoners are far more diverse than anywhere else in the country. So you have both diversity, you have socio economic disadvantage, you have age, and you have multiple other effects happening at the same time.
It is an important demographic for us for our work, for example, with young Black African and Black Caribbean youth. We do fantastic work with community organizations, radio, sports, programs, businesses, et cetera, to really ensure that we're working with recognized community leaders, community channels, developing materials, collateral materials, which speak to those communities and are using images which are relevant and appropriate.
What we've learned, for example, in that same demographic is To understand that people are coming into this with different concerns, right? So we learned from many of our younger Londoners that a sense of, that sense of you've never engaged us before. Why are you engaging us now? Why should we trust you now when you've never given us a reason to trust you before?
And don't give us incentives because if you're giving us an incentive to get a vaccine, that's probably trying to entice us to say, to take something that we really don't want to do. And that's even worse. Those are some of the real world conversations that we have with our communities and our young people, but it's in having those.
Conversations with them and then working through with them their suggestions for what we can do differently that we get solutions, right? So developing, we've heard many of our younger communities would like to see the vaccinators, the teams that are involved in delivering the vaccine look like them and represent their communities.
That's something that we can easily remedy and many of our vaccine teams are far more diverse now, especially in our outreach. People respond well to vaccine buses. People respond well to us taking the vaccines into their communities with health advisors, vaccine champions, or COVID ambassadors who are there to have the conversations with them.
People respond really well to door knocking, having a conversation on the doorstep, asking about whether the whole family is vaccinated, is there anybody we need to speak to. These are more intensive efforts than any final phase of the implementation of any public health program, but certainly vaccination programs.
become more intensive because you're getting to the hardest to engage, hardest to reach, oftentimes hardest to build that trust. They're further, they're less engaged often because they're less, less trustful and engaged with the system. So we're going to see some of that as we move forward with particular demographics.
But you've heard me say, no one will be left behind. As part of this covid vaccination program in London, and this is something that we're all committed to doing. So whether it's keeping our outreach activities, investing in community organizations, making sure we have the vaccine buses, getting community pharmacists on board to deliver vaccines, we're diversifying the channels, we're keeping the opportunities up for everybody to get their first dose of vaccine, and we're continuing to invest in vaccine equity as a key part of what we do because if we.
can solve this, then it opens the door for us to address other health inequality issues, which have been really challenging for the city for many years, right? If we can solve this, we can begin to think about how do we develop our breast screening programs differently to meet with the needs of women from diverse communities.
It can help us to think about our health check program differently. And that's what I'm keen to do. The legacy of this, painful and tough as it is one that will be positive for us moving forward.
Gavin: Kevin, when we spoke to you before we had a profile on you, of course, earlier on The Lancer Voice.
We talked about how you had started in this new role just as the pandemic began, which obviously, is a extremely tough time to take on the role. Is there anything you'd say that you've been really surprised by in the last two years during the pandemic? handling this pandemic and of course all the other public health issues around London.
And would you have any advice for people in other cities in similar roles in your position?
Kevin: I'm not sure if there's anything that really surprised me. I may have said before this isn't my first pandemic because I started my medical career at the beginning of the HIV pandemic. So I had been actively involved from the I was a medical student in the 80s and then as a physician in the 90s and being involved in developing policies, doing research, engaging communities around the HIV response.
Many of those core principles of, an equity based and a human rights based approach to tackling infectious disease epidemics has been part and parcel of what I've done and what we do. I think if there are surprises it's just about how phenomenal it's been working across the health and care partners and in fact all of the London partners for the city to pull together to get through the successive waves of the pandemic and to really engage.
with Londoners. I think the stark nature of the inequalities that we've seen manifest throughout the course of the pandemic has been a real galvanizing call for local government, for the NHS, for social care, for the Greater London Authority, for community organisations. And it has been a rallying call for Londoners and those involved in the response to do things differently to not only control the pandemic but ensure that we do so causing least harm to the some of the most disadvantaged communities that we have.
Jessamy: It's lovely to hear that sort of positive side of some of the outcomes and really interesting to see that your work with the unvaccinated sort of populations in London as possibly a vehicle to dealing with other inequalities. I hadn't thought about that before but of course it makes loads of sense and what a great legacy that would be.
I guess one of the things that I've been uncertain about, and I just wanted to run this by you more than anything, is about the booster doses. And, in this country we've had a real focus on boosters and I wondered what your thoughts were given the sort of numbers in terms of needing to keep people out of hospital of getting unvaccinated people vaccinated versus getting vaccinated people already revaccinated, whether that focus on the boosters was justified?
Or is it just a function almost of public health that we need a big message to get behind and we needed to have that for the country to hold on to? I was wondering what your thoughts were on that.
Kevin: Early on in the Omicron wave, we really need to understand would we have enough protection from the two dose vaccine regimen or were boosters necessary to both reduce transmission as well as reduce symptomatic infection, severe disease and death?
And that was a real question at the beginning because although the Omicron wave in South Africa evolved quickly. It was a very different population to ours. It was a younger population, lower levels of vaccination coverage. So there were many uncertainties about it. So remember, this was all moving very quickly.
Now, as soon as the initial data became available, it was clear that Omicron had vaccine escape capabilities, which meant that the two doses were not going to be enough. And we needed A booster, especially for the most vulnerable in order to reduce transmission as well as symptomatic disease. And that's why the strategy of boosting the most vulnerable first and then moving down the age cohorts as rapidly as possible and bringing forward at the end of the booster program, because remember it was initially end of January, we were able to offer everybody a booster by end December.
That was a huge lift, was the right thing to do. And we know it's the right thing to do because In this wave, even though we're seeing rates in the over 60s, which are six to seven times higher than we've ever seen before, we are seeing some impacts in terms of hospital admissions, but nowhere near what we have seen before.
And that's why we're seeing fewer deaths in this wave than ever before, and fewer ICU admissions. And that wouldn't have happened if we didn't have the booster program, and if we hadn't front loaded the distribution in the most vulnerable. You are right, however, that as we move into this new phase that the messages are more complex and for members of the public there's a real risk that they'll have to juggle pandemic fatigue, mixed messaging, and complex messaging at the same time, right?
You're saying to Londoners, get vaccinated, but people will say I've had infection. Do I need to have the vaccine? And if so, do I need the full course or can I just get away with one or two doses? These are important questions that members of the public are asking or testing policy is changing.
When do you have a PCR test when you not have a PCR test or isolation policy changed? So many things are happening, and there's a real risk at this stage that not only the vaccine, with a vaccine, but other aspects of control of COVID becomes more complex and more confused to the public. And that's one of the reasons why, for London, we're really listening to the questions that Londoners are asking.
We're working with our comms experts, our behavioural insights specialists, and our academics and our community experts to say, what are the things, what messages do we now need to cut through with Londoners on? And how do we work together as we're going through this Omicron wave to say to people, it's okay, it feels complex now, but here are the things we need you to focus on.
And then we will amend those messages as we come out of this wave. But right now, I think the priority is getting some of those messages clear.
Jessamy: That's brilliant, Kevin. Could you give three lessons to people who are about to face an Omicron wave elsewhere in the world?
Kevin: I was speaking to a colleague in the U.
S. last night, and they're a state health official, and they're just at the beginning of their wave, so they want to know all the details, how many deaths, pressures in the hospitals, and so forth. If I had to say three things, number one, the pace and scale of the expansion of the Omicron wave is something that I think I've never experienced at all and I've been working as an infectious disease epidemiologist for a long time and its impacts become very wide reaching very quickly, not only in terms of the numbers of people who are going to be presenting with respiratory tract infections and taking time off, but the material impacts that it has on staff.
vacancies and absences, not just in the healthcare system, although they're in the vanguard, but then in other allied services. So the ambulance service, the police, the fire brigade, all of the essential services, local authority, the people who collect your bins, the people who deliver social care services.
And that rapid increase and that rapid impact is both scary, but in a vaccinated population where people Are well vaccinated and protected. The impact of that rapid increase is minimized. So my first lesson is in preparing for the wave, as much as you're able to do, promote the vaccination program, promote the booster and ensure that you're most vulnerable.
and your essential workers are protected to allow essential services to run. Number two, be absolutely clear on what you want people to do as they go through this phase. We very quickly converted and added to our messages how to manage COVID at home. because we realized that there would be lots of people who would get some amount of respiratory distress or they made us have a mild upper respiratory tract infection.
And the last thing we needed them to do was to begin coming to the emergency departments, calling the emergency lines when actually just good information on managing COVID at home would be helpful. So we switched that on very quickly and we did lots of really good messaging there. on that. So the first is recognizing and planning for the vaccination program.
The second is speaking to the public and preparing them. And the third thing is harm minimization. In other words, recognizing that it is going to move through really quickly. Who are the most vulnerable? in your communities, and how do you ensure that you are vaccinating them, shielding them in terms of policies, for example, care home visiting, or ensuring that you're working with those communities to, to create that wall, whether it's a vaccine wall or a preventive wall to protect them.
So in December, we were doing intensive work with care homes, with care workers. With hospital staff, we identify our homeless population in London as being particularly vulnerable. So we work with local authorities to get our vaccines out to homeless populations and ensuring that we're able to connect with them as we were preparing for this.
In other societies and communities, there are going to be other vulnerable communities. So I think that would be the third thing of harm minimization, ensure you have your vaccine wall, and of course, prepare for its impact on staff continuity and services.
Gavin: Yeah, we really appreciate that. Thanks so much for speaking with us, Kevin.
Kevin: Great. Thank you so much. It's been a real pleasure joining you for this. And, this won't likely be the end of it, but we've gone through this three times now. And I think each time, as I said, we're getting a bit better, getting a bit more confident and we have the tools and the vaccine really have demonstrated the power that they provide in helping us to these waves.
Gavin: I always feel with this pandemic that I'd know less about it as time goes on. I think one of the maxims I knew anyway about science, I don't know many maxims about science going in, were the more certain someone sounds about a complex topic and the more simplistic they make their conclusions on it, the less you should trust them.
And I really think that COVID's been an incredible illustration of that because everyone who's shouting so loudly about their specific conclusion and seems completely unable to change their minds about it, are the people that I've started to listen to less and the people that speak with nuance and interest and show you the data and say this is a complex picture that's changing all the time and we don't particularly know anything about it but these are maybe some conclusions we can draw.
Those are always the people that that turn out to have the most interesting insights on it I think.
Jessamy: Yes I think you're right and I agree that when we look back at the beginning of the pandemic, it was clear we had this incredibly infectious disease that was putting people on ventilators, killing people, we had no idea how to treat it.
We had no idea about any of it. So of course, lockdowns, restrictions, that was. the only thing that we could do. That was the right decision. They were the way forward. Now we're in this position where we know quite a lot more about it. We've got many more tools. And yet we also are uncertain about where it's headed.
And we've had these, these two years that have really altered with our perception of risk. And I think they've raised lots of questions about what we find is an acceptable risk at this stage in the pandemic when everybody's vaccinated.
Gavin: Difficult, isn't it? Because it's a much more visible perception of risk.
Everyone's talking about COVID all the time. We get the death figures every day. We get the hospitalization figures every day. And Everything in life is a balance of risk. Every time you leave the house, you might get hit by a car, whatever. This is such a visible calculation. Now I'm going to this place.
Will I get COVID? I'm going to go and do this. I'm going to go visit a vulnerable relative. How likely am I to put them in harm's way that I've never encountered a situation where. my understanding of what risk involves gets pushed to the front of my brain every time, do you know what I mean?
Jessamy: Yeah, and it's become so central to our lives, it's all we've thought and talked about for most people in the whole country and the whole world, it's all anybody's talked about for the last two years.
And so there's naturally going to be a real difficulty from this stage on in being able to understand how we move forward.
Gavin: And you can understand why people are so overwrought about it by this time, because it is tiring. It's such a huge emotional effort, and neither of us are frontline healthcare workers.
Yeah. The burden that's been placed on them is immeasurable, but it's so tiring and dispiriting for everyone to be going into, essentially, the third year of this pandemic with still so much uncertainty on the table.
Jessamy: And because there's been so much mistrust and ideologically, Governments, particularly in this country, have made decisions based on what they believe to be right, and not necessarily on the data, and so even now, when perhaps not having such harsh restrictions might be the best thing, but there's such a sort of, there's such fractions on either side of pro restrictions, anti restrictions, pro lockdowns, anti lockdowns, that, you can't almost see the wood from the trees, because you're, you've taken your lines of the defense.
You've taken your lines of battle and you have to stick to them.
Gavin: That's what makes it more fraught, isn't it? I often think now about the vaccination rate in Portugal, which I think I'm right in saying had 98 percent of the over 12s vaccinated. And someone asked a senior public health figure in Portugal, how they got so many people vaccinated.
And he said we didn't make it political. We didn't make this a political issue. We just got public health messaging out there. The politicians stayed out of it and people trusted in, in health care and in science and in the institutions. Exactly. And It's difficult to see it way back sometimes in in countries where it's become politicized because now it's such a part of people's personalities, and you can often see it in your big disagreements between families where one person maybe doesn't want to particularly wear a mask in a particular place and everyone else is I think the problem is that people's COVID get projected into these divisions as well.
And it really becomes a very difficult. conversation to have. So much of the nuance gets robbed when people start shouting at each other about these things.
Jessamy: Yeah. And it's interesting because I was having a Twitter conversation with someone the other day and we were talking about trust in science, which is something that we've written about.
And he was saying, it's not trust in science, it's trust in institutions. Brazil has got a political leader who's like misinformation, anti science, and yet they've got really high vaccination rates because they've got institutions in place that people have used their whole lives. They've had all of their immunizations and vaccinations, and this was just the trust and the link between those communities and those institutions.
was far stronger than any kind of overarching political system that was temporarily being placed on top of that. And I think that we often forget that, that side of things.
Gavin: And of course we shouldn't really knock the UK's vaccination rate with 90 percent of over 12s having a first dose now, that's, I often think at the start of a major pandemic, what percentage public health officials would have taken, a bit like before a football match, when you're like, Oh, I'd probably take a draw here.
I think public health officials would have taken 90 percent at the start of the pandemic.
Jessamy: Definitely. I think you're right. But again, all of this goes to changing numbers changing desires and changing needs. And we've said that so many times about these, fast moving situations and you would have thought, we're okay with it by now.
We can understand fast moving situations. But I think on the counter, actually, you also have fatigue. And so people are like, oh, do we really have to change? We really have to think about this more deeply now. Can we not just carry on? In the same mindset that we've been in and, and all of that nuance and that discussion is much more exhausting and much more complex and as Kevin was saying, actually, having those types of messages is more difficult.
Gavin: Thanks so much for listening to this episode of The Lancet Voice. If you're not already subscribed, you can of course find us on the podcast platform of your choice. And we look forward to seeing you again in two weeks time. Thanks for listening.