SCR CONNECTions - Capacity Building in Public Health (September 13, 2017)

By: National Network of Libraries of Medicine [NNLM]

Welcome to the SCR CONNECTions September 2017 webinar. It's an honor to introduce our speaker, Jessica Schwind. Her current research interests include disease surveillance, capacity building and risk communication for the prevention and/or early recognition of outbreaks. During this research she focuses on best practices for operationalizing the one health approach and improving global early warning systems for disease, detection and response by bridging the gaps between digital data bases and local health information. Last but not least, I'd be remiss if I didn't mention she's also a faculty members which is taking place this week. So we're especially glad that she was able to join us this morning.

I'm now going to hand over control and let her get started. Hi, everyone. Can you hear me? We can hear you, Jessica. Okay. Great. So I am coming to you from southern Georgia.

Obviously, we have been dealing with a little weather issue lately, so hopefully everything will go smoothly. I will just be sharing the presentation now. So, as Brian mentioned, I am an assistant professor of epidemiology. I'm a huge public health advocate and I just love the opportunities that I get in order to speak about public health and really try to bring people onboard. I'm really excited about talking about capacity building, specifically in public health through strategic partnerships. I will focus on working with health sciences librarians, but I am open to talking about all different types of partnerships as it pertains to public health. And then feel free to ask questions as we proceed. So there are a lot of people joining in from all different types of backgrounds, so I just want to talk about some key issues and bring a little bit about public health, what it is, what we do, as public health professionals so that I can make sure we're all on the same page.

So first what is public health? Health in and of itself is kind of one of those words that's really hard to define. The world health organization says health is not just the mere absence of disease but also the presence of good well-being. Public health is defined by the CDC as the science of protecting and improving the health of people in their communities. This work is achieved by promoting healthy life-styles, researching disease and injury prevention and detecting, preventing and responding to infectious diseases. So that's kind of a pretty big definition, but public health is a pretty big idea, and when it's put to practice, it has a lot of different applications.

SCR CONNECTions - Capacity Building in Public Health (September 13, 2017)

So let's focus on a couple of different things. First when we tend to think of health, we tend to think of the individual. When you go to see a doctor, the doctor is focusing on you as the individual and trying to work out a plan in order to improve your health. Instead in public health we're really focusing on populations. And we're not just focusing on numerous people, but we are looking at the connections between those people. So really thinking of people as a social network, and so you have a lot of individuals and individuals who make individual health decisions, but as a community they also act in a certain way, and so in public health we're trying to focus on the community, on a population level analysis. Now as I'm recruiting students to join in the public health profession, I always say why just help one person when you can help a hole community? And so that's really what public health is all about. Also just like clinical medicine, we do focus on treatment.

We focus on control, especially in outbreak scenarios, but the whole idea of public health really is prevention. So while we tend to respond to outbreaks as soon as we know something's happening, the idea of public health is really to prevent them from ever occurring, and so we do have a focus on treatment and a primary focus on prevention. And so when you think of public health, you probably think of things like immunizations or vans nations as well as healthy programs say at schools or community centers. So we do love to focus on prevention but because of various reasons we sometimes can't take that preemptive approach but rather we're taking a reactionary approach. Public health also focuses on intervention at various points in disease ideology. It's looking at the causes of disease. Now of course let's take an example. Of course we know H.I.V.

Causes AIDS. But when we say the ideology of a disease, we're thinking about all of the different factors that go into disease occurrence. So, yes, we know that H.I.V. Causes AIDS, but what put that person to be in that position to contract H.I.V.

In the first place. So it's really taking a holistic or ecologic approach. With that said we have three forms of prevention, if you will, in public health.

We have primary, secondary and tertiary prevention. It occurs when public health professionals try to intervene before the agent comes in contact with the host. And so, for example, immunizations, we would like them to be immunized against HPV.

Secondary prevention is an early screening in the pre clinical or early clinical stages of disease, and that's why we recommend -- and by we, I mean the public health discipline. We recommend mammograms or colonoscopies at certain stages of life so that we can try to find disease onset as early as possible or in certain disease conditions before that disease actually manifests. And them tertiary prevention is the host and the agent have already interacted, there's a disease, but now let's see if we can improve somebody's quality of life through rehabilitation, for example, in, let's say a stroke patient. So there are a lot of different areas that public health can act on when looking at the natural progression of a disease. And so what that means is public health really has to interact with a ton of different disciplines, whether it's basic scientists, whether it's information scientists or whether it's people out in the community because those are the key stakeholders, those are the people we're trying to help. So a lot of different areas that public health can impact. So what is capacity building? So I wanted to talk briefly about capacity building because capacity building is a topic that I am really fond of and I really view it as a calling. The definition of capacity just in its broad sense is the ability to perform functions, solve problems and achieve objectives.

So when we have the capacity in public health, that means we have the capacity to address issues as they come up. Now that capacity can look completely different depending on your community or your population of interests, but building that capacity is something that is very, very important. And, you know, just highlighting this webinar.

This is capacity building at its finest because we are interacting and we're learning about new concepts, in particular, about building partnerships across disciplines. So let's allowing at the different levels. So when you're talking about capacity building, you have three broad levels.

You have individual, institutional and societal. So individual capacity building, obviously the best application would be education. When somebody is educated about any topic, them that provides them the ability to respond.

Now when you're talking about issues in public health, of people are educated about what's happening in their community, only then can they respond to the issues that are coming up. Institutional, I happen to work in global health, and one of the things -- one of the field sites that I have is actually in Nepal and I'll talk briefly about that later. The institutions that are in Nepal that can address disease emergence are very different from institutions here in the United States. Recognizing these differences, the world health organization actually came up with something called the international health regulations that says we need to have multiple institutions that are able to detect and to respond to public health emergencies, not just in one country but in all countries. And so institutions play a very key role.

Now all of this together such as institutions within a country, individuals who work within that institutions provide an overall societal environment or society that can conducive for an environment to detect and respond to public health emergencies or say disease outbreaks. And obviously any weakness say at the individual level will be seen at the institutional level, and any weaknesses in public health response at the institutional level will be seen at the societal level. And so just understanding how capacity building really has the ability to impact multiple levels is really important. So just talking a little bit about my research and sticking with what I know best is looking at the example of emerging infectious diseases. So emerging infectious diseases are just infections that have newly appeared in a population or have existed but are rapidly increasing in incidents or geographic range.

When we think about emerging infectious diseases just as one area of focus and public health, we can think of things like H.I.V. For example, we didn't really know what we were dealing with when it came on the scene in the .80s. Of course we know it had been circulating for some time for several decades unnoticed, but that's considered an emerging infectious disease of the last century. When you think about reemerging infectious diseases, at one point we thought we were done with tuberculosis. Somebody said, you know, that's an old world disease.

We're not going to have to deal with that, but of course with H.I.V. Coming on to the scene as an emerging infectious disease, tuberculosis has rapidly increased in incidents due to the co-morbidity with TBand H.I.V. And its absolutely devastating impacts on populations. So looking at building capacity in light of emerging infectious diseases, infectious disease capacity is really just the ability to detect and respond to infection shus disease threats at their origin, before they have a chance to spread. And so many of you probably were on high alert.

Remember when the outbreak of Ebola was happening in west Africa? Obviously containment and an understanding of the disease in the local area before it has a chance to go international was a huge concern, and that's simply because any weakness in any one part of the global surveillance network when focusing on emerging infectious Centers for Disease Control is a gap through which it can arise unnoticed. So obviously when from a public health perspective, when we're trying to prevent or predict the next emerging infectious disease, we want to have the capacity locally on the ground where it first arises before it spreads and turns into a global issue. Now capacity building usually runs into difficulties.

And these difficulties typically fall under three categories. Obviously, phenomenon difficulties, that's something that we deal with in the funding climate today. But in some situations, in some countries, they just don't have the money to support public health. So again often times we are trying to put out fires as they occur which is we're trying to treat diseases, and we do not -- we have very little money in order to address things preemptively. And so for that reason public health in some situations tends to be the last pot that gets money.

And so a lot of capacity building issues tend to come up you know from a financial perspective. Secondly political will to build capacity is lacking in some countries. And again I focus on global health, but in the United States and abroad we can see where building capacity is usually not in the forefront until something bad happens. And since 9-11 just came up, there was a huge push obviously for the department of homeland security, you know, and 9-11 and all of the events that happened there. A ton of money came into emergency preparedness at that point.

And so again we tend to be reactionary, but in some countries there's just not a political will to spend the money that they do have on capacity building in public health. And then finally environmental. Using emerging infectious diseases as an example, the inter face between Americans and humans is what we call a prime zone of potentially catastrophic diseases. Now H.I.V. Obviously has a strong primate human link among H.I.V. Many do have a wildlife and animal component. So when it comes to trying to build capacity to address emerging infectious diseases, environmental conditions actually can keep us from learning more about these diseases and building the capacity to detect and respond to diseases.

Now I have worked in Kathmandu valley in Nepal, and it has its own environmental restrictions. I have looked at mental health in post disaster areas in Nepal and reaching these villages so that people can receive mental health treatment has been really hard due to the environmental remoteness. So environmental conditions in countries that do not have a really strong infrastructure can also cause really huge difficulties in capacity building. But I just want to reemphasize that the reach of capacity building goes much larger than we think.

So while there are few of us here in this webinar, ultimately we have the built to be change agents in our organizations. Those organizations can operate at the national level, obviously with NLM, regional levels and then ultimately anything that happens at a great enough point is going to impact the globe. And so when you're thinking about emerging infectious diseases or health conditions or just diseases in general, those that are caused by microorganisms, they don't care where our boundaries are. They don't care where we draw state lines or county lines. Microorganisms are going to spread, do what they do best which is replicate, and they are going to effect all areas of the globe.

And especially we have a lot of drivers in emergency such as globalization, microadaptation that really causes once isolated areas to really play a key role in the public's health from a global perspective. So here are the key players. So one of the reasons why I love public health is because you meet so many different types of people from so many different walks, areas of life, walks of life, and they have different backgrounds. They have a variety of educational degrees. They have a variety of interests.

So public health involves the application of many different disciplines that can include biology, anthropology, public policy, mathematics, engineering, education, computer science, sociology. So many different disciplines come together and work in order to improve the public's health. Now one thing that I do want to point out is a lot of people who practice public health in the United States today do not have a public health degree. Now those numbers are changing, but for the longest time, public health was done by people who had a medical degree or maybe a nursing degree.

But ultimately there was a huge push, especially in the '80s that really said, you know what, we need to build infrastructure for public health, and we really need to improve the public health work force, and so there was a huge push to develop curriculum, offer degrees in public health and so obviously that infrastructure is increasing. But all that to say you don't have to have a degree in public health in order to practice public health. And so when I talk about information science or in particular health sciences, I really want to be very broad and say, you know what, it's not public health professionals, us versus them, but really anybody can work in public health and anybody can make an impact on the community's health. So moving forward, I do want to briefly talk about the core functions of public health, and through this I'm going to highlight the ten essential public health services. Now the ten essential public health services are kind of divided up into general areas, assessment, policy development and assurance and reach is something that links all of these areas. So let's talk briefly about assessment. So what is it a public health professionals from many different disciplines do? Well, the first assessment is they monitor environmental and health status to identify and solve community environmental health problems.

Now when we're talking about environmental health, I don't want you to just think of things like, you know, oil spills in the gulf. I really want you to look at the word environmental and think community health. Okay. So think about all of the different factors that exist in the community that either increases or decreases a person's risk for disease.

Okay. And in the second assessment is diagnose and investigate environmental problems and health hazards in the community. Now a really good example of when this occurred in public health history of the United States was with love canal.

You may have heard of love canal. It's a really interesting and sad story, but basically it was an excellent example of public health professionals coming into a community and making things better. Now it was very reactionary but still they were able to enact change.

So what happened in love canal was many years ago there was a -- and I'm just shortening this story for time, but many years ago there was a company, a chemical company, that basically dumped toxic waste into a former like canal. Then basically the company left the community and they offered up the toxic waste and, you know, put a nice, beautiful grassy lawn on top of it. But they did change link fence around it to try to prevent people from being in that area. Well, eventually the canal started to break down. It was an empty canal, started to break down. I think schools were built on top of the area eventually or near the area.

Neighborhoods of course were built around the area, and the canal is breaking down and toxic waste was leaking. Now this was not really brought to anybody's attention until people started seeing increased rates of cancers, lymphomas and miscarriages in the community. They were like something's not right here, why do we have a concentration of these adverse health outcomes. And so ultimately they traced it back to being in the presence of this area, and this truly was on environmental issue. I went on to establish the first super fund site. Anyway, very, very good public health example of assessment in the community.

So then looking at policy environment. Inform, educate and empower people about environmental health issues. They mobilize community partnerships and actions to identify and solve environmental health problems. And then they develop policies and plans that support individual and community environmental health efforts. Now a good example of policy development and how that needs to action is the development of the smallpox vaccine and the subsequent eradication of smallpox. That is considered one of the biggest public health feats in recent, you know, history and basically we were able through concerted efforts to eliminate smallpox across the globe.

There were a lot of dollars spent in ensuring we could eradicate smallpox. Polio is a little more difficult because there can be a wild type polio found out in nature, and we tend to see polio outbreaks in war-torn or conflict areas, and that's made it really hard to eradicate but smallpox vaccine was an excellent example of how policy can be turned into action on the global level. And then looking at assurance, enforced laws and regulations that protects environmental health and links people to needed health services and ensure provision of these services when otherwise unavailable. A sure, confident, health work force and evaluate accessibility and quality of environmental health services.

Now in public health there's so many different diseases or health conditions that you can study, and there's so many different factors associated with these diseases or health conditions. I am a program evaluator, and it doesn't matter. One day I could be evaluating a program about parolee recidivism and minimizing that in the community, add then the next day I can be looking at a school based healthy weight program and evaluating that. It doesn't really matter the topic. The methodologies are really important, and so every single discipline has its own methodologies, but public health is just so broad that you have programs that have particular areas of focus, but you can apply successes in some cases across the board but in other cases, they really need to be adapted to the community.

And so that's why you have this big emphasis on evaluation and assurance because even though we promote evidence-based practices and public health, the way communities act can be very different. And so what works in one community, may not work in another community. Here's another example of something that was really stopped outside of the United States before it had the potential to impact.

This is an interesting story. It was actually -- this pill was given in order to try to alleviate morning sickness. But the recent that was done on -- this is in like the '50s, '60s, and '70s.

The research that was done was not very thorough. What ended up being uncovered was that prescribing this pill for morning sickness actually led to birth defects and congenital malformations, and so there was a sign activity here in the United States I believe worked for the FDA who said, you know what, we're not going to allow this drug to be given in order to treat morning sickness because the research has not been proven. I cannot say without a shadow of a doubt that this doesn't cause birth defects and so we're not going to use it here. So the impact in the United States was minimized to a except and the largest impact was seen in western Europe. That assurance, sometimes you get to the FDA.

And that's definitely a part of public health as a whole. All of these different factors go in to public health, and at the center of these factors is research. And this is really where ino -- innovative solutions is needed and research has the potential to impact all areas of public health. So that leaves me to strategic partnerships for a truly interdisciplinary approach.

Now before I talk about the partnership between the public health professionals and health sciences librarians, I really want to talk about what I mean when I say interdisciplinary. So sometimes these words can be very confusing. We hear trans disciplinary, multi-discipline area. The way I like to think about it is it spans from the community to the bedside to the bench, the laboratory bench.

It transcends boundaries in order to integrate sciences with humanities. Multi-disciplinary is when you have a bunch of different people from different disciplines that come together but they tend to stick with their own disciplines. So when I think about this in the terms of like a clinical context, let's say, for example, you have somebody who is diagnosed with cancer. Well, that person may go and see their primary care physician, then they may have an oncologist that they go and see and then they may need to see a therapist but all of these meetings happen within the context of their own offices. Okay. But in contrast, interdisciplinary is when you seek to Harmonize between disciplines and really create a coordinated coherent approach to any problem.

So a good example of inter disciplinary in the context of medicine is when a person is diagnosed in the same room, in the same office. You may have a primary care physician and an oncologist sitting with the patient to discuss the plan of action. Okay. And that's interdisciplinary.

And so I really wanted to be very careful when I said interdisciplinary because when working with health sciences librarians or even just working with anybody for the public's health, I tend to prefer an interdisciplinary approach because we all have strengths, and we all can work in public health even if we don't have a public health degree. And we can all have insights into public health simply because it's something that effects us, not just on a professional level in some cases, but also on a personal level, and those insights are very important when addressing public health issues. So there are so many different areas of intervention in public health. I'm not going to say we can intervene here and here but I want to give you kind of a broad look at all of the areas that we could intervene in, whether it was advocacy, whether it was outreach, screening programs and just say to you that these are all opportunities in order to collaborate, in order to work together, in order to improve the public's health.

As I was actually preparing this prep take, I found this from the Texas public health association. You think a couple years ago they actually had and annual meeting. Every state tends to have their own state public health association in addition to the American public health association, but their meeting was entitled public health, optimizing health through partnership. If there's one thing I can say about public health as a whole it's we are all about partnerships. We all recognize public health does not occur in a vacuum. It does not happen in a silo but rather it happens when people start to communicate and collaborate with one another, and so looking at how these different approaches can look like in the field, I just wanted to talk about the different things that I do in Nepal so that you can see how that interdisciplinary approach can look.

So we explored resilience and other mental half outcomes after the earthquakes in Nepal, and through that we were able to work with people from different types of disciplines, psychologists, psychiatrists, not only that, we had biomedical scientists working with us. We also had input from community elders, village elders, and we also worked closely with several non-profit organizations national guard to the Na Pali government who cave us permission in order to care out this research. So in order for do this research we actually had to bring in a huge team of people and we all had to understand exactly what our end goal was so that we could then discuss what does this collaboration really look like. Actually I work with health journalists in Nepal in order to see how they disseminate information.

In developing countries, you know, typically the largest source of information, health information, tends to come from the media or families and friends. And so understanding how the media communicates risk is something that I have to bring people in to really understand. So bringing in health journalists, bringing in key stakeholders, people who read these health events articles, and obviously public health professionals in Nepal as well. And then I am a huge one health advocate. One health is the idea that environmental, animal and human health sectors are all related. And you cannot have one area that that is weak without causing weakness in other areas.

So if you have animal health, domestic animal health, such as livestock, that is weak, then that provides an opportunity for infectious diseases to spread. If you have a weak wildlife health sector in the country, then that allows diseases to spread as well. And so this is truly interdisciplinary in that my main collaborators are ecologists and animal health veterinarians in the country, and I am in so way able to tell anybody about, oh, well, this is how you keep these livestock healthy.

This is how you keep the wildlife healthy. This is where interdiscipline air approaches are so important to main taping the public health. With that being said, let's look at the health sciences-health librarians partnership. One of the many ways that we're connected really are through information systems. Now from a public health standpoint, you can access information systems for really two product reasons. So one reason would be for research, your own research, from like a professional standpoint, and then two, you can access information systems for information to disseminate out to the community.

Okay. And because I'm an epidemiologist, when people ask me what I do for a living, I just sit in front of my computer and crunch data and yell at statistical software programs all day. Because I'm an epidemiologist, I tend to access these systems in order to draw the data out and to look for associations or connections between certain exposures or certain outcomes, but I am just one small part of public health professional work force in that many public health professionals access these information systems in order to get a good grasp of what's happening in their community, and then figure out how to disseminate this information to their community in the most helpful way possible.

And so I can spend hours and hours talking about surveillance systems and public health and why they are done and what context we use them. But I'm not going to do that. I did just want to briefly point out some of the key information systems we do use in public health which is the vital statistics systems that looks at births, deaths, fetal deaths are included, also morbidity data, so sickness data.

The national health statistics gives a ton of information. We have information systems that focus on risky behavior. Behavioral risk factor surveillance system also looks at risk factor as well.

And them we have systems that tend to focus on environmental issue and in knowledge based systems as at CDC wonderer and PubMed which I know you're all familiar with. CDC wonder is great in that it is an information system with a great user interface that tries to tie in a bunch of different systems so that it's more accessible to people. So it's kind of like a system of system, if you will. Public health information systems is really tends to be something that public health professionals and health sciences librarians tend to have in common. Now I was briefly looking at the medical librarian competencies and then I was looking also at public health competencies and I just wanted to mention how we have several areas of overlap in competencies.

Public health is moving away from competency based education and doing more of a learning objective or learning outcomes approach, if you will, but I did want to point out that anybody graduating with an accredited public health degree in this country has to have some foundation in communication infomattics. You can probably look at these and say, yeah, well, I had to do the same thing too, I had to prove competent in the same area as well. You can see where you may even consider yourself a public health professional simply because you're like, yeah, I do these things every day. I gather data, I organize data, I manage data, I disseminate information to different channels every single day, and so I think it's a great opportunity to point out what we have in common. Now I just want to kind of take the talk into looking at, well, where do we go from here, since we have a lot in common and we're all focused on improving the health of communities, which of course will then have a trickle down effect to the individual, how do we use these partnerships in order to do that? Obviously gaining information access is going to be a huge need. Public health professionals, whether you're in the field, working for a public health department, they were always in need for the latest information. That helps them to provide real time changes for their approaches and interventions in the community. That allows them to really achieve that evidence-based practice that we're always trying to do.

But not only access to the information. I think another huge need is access to quality information. I really believe that we are in information overload. I can really see students just in the classroom feeling very burdened by the amount of information that they get and not only do they need to read all of this information but they need to sort through it in order to say, okay, well, which ones do I need to listen to, how can I critically analyze this situation in order to apply it to my situation. And so it's not just access to any information but it's access to quality information.

And then another area that I think needs to be focused on is really outreach and dissemination. So I'm going to briefly talk about my interactions and my collaborative projects with health sciences librarians, but I can really see that there is a huge need for improving overall user experience. Whether that user is in the community, and I don't necessarily mean in front of a computer, but whether that user is in the community soaking up information or whether it's somebody in a library, whether it's somebody in a hospital that improving the overall user experience will actually improve the ability to succeed in outreach so that people come back for more information so that people can make evidence-based decisions, and so those are a lot of really broad recommendations, but that's really what I see moving forward. So with that being said, I want to talk about my past experiences working with health sciences librarians. So in the bottom right of your screen, I would like to introduce you to code blue. This is my team. We're a team of five people.

Kathy, the lady on the left in the pink, she is the health sciences librarian who I worked with, and the five of us developed an on-line immersive training course in epidemiology, he is instructional designer and Aaron in the front is a web and graphic designer, and Kathy is a librarian, and the five of us came together and we said how can we improve the on-line learning experience of students, and we have a lot of resources. We have a lot of disciplines represented here. How can we bring in the strengths of our discipline in order to address the weaknesses across the board in on-line learning. And so we actually developed a course where we immersed a student into a pandemic situation, and so they learned epidemiology which is a core class in a public health degree in the United States.

They learned epidemiology in the context of a pandemic, and so there was a lot of multi media. We had an outbreak scenario. We said, you know, you're in this training program, you're a student, there's a pandemic occurring right now, get out in the field. And so it was a lot of fun. Kathy in particular, her contribution to the course was amazing because she contributed to this immersive experience by providing a ton of resources that the students can use in order to improve their assignments. So, for example, I had a little leadership on risk communication.

They needed not only to relay the pandemic information to professional audiences but they needed to relay the information to the media. Understanding risk communication from that perspective, canalie was able to provide resources that said here's how you interact with the media in these scenarios of public health emergency. So that was just one example. Another example, I taught at the medical college of Georgia for a couple years and we worked so closely with the libraryions in order to teach evidence-based medicine. So typically in courses we have one course director. Well, in evidence-based medicine there was like I think twelve of us.

There were a lot of people. In working together we were able to really bring in library systems and we were able to really merge the disciplines in the context of really providing treatment and help individuals and in particular medical student here. Risk communication, I briefly talked about, but working with librarians to view them as communication partners. There's really and opportunity for developing, designing, innovative product because really communication is such an important key. So scientists, we can know everything there is no know, but, if we don't know how to communicate that to the general public who are the stakeholders in public health, then we're not going to succeed no matter how much we work and how much research we do. And so providing services from that perspective would be super, super helpful.

And so those were just some of my past experiences working with librarians in the context of public health but also have a personal level. I was thinking not too long ago, my first job when I went to college was actually in the library. I spent so much time in there, they offered me a job when I was a student, and I just loved working with librarians and I really view them as, and depending on the context, especially like public libraries, I really view them as the frontline workers for all matters of public health because people tend to go to them for advice. Recently we had this eclipse that came through South Carolina not too far from here and we were able to go to the library to do the health thing to get glasses so we don't ruin our eyes. At that point that was a really big opportunity for librarians participate in public health. But it provides an interesting perspective that we don't necessarily think about in different scenarios in public health because everybody's so focused on local health departments or hospitals or clinics but I think there's a really huge opportunity for collaboration and capacity building here. I am open to questions and I am happy to answer them to the best of my ability.

Thank you for that wonderful presentation. We'd now like to open it up for any additional questions. We're sort of -- we're running on time here. So if you do have any thoughts or comments after this session, please go ahead and send it to us and we'll forward them on to Dr.Schwinn. I'm so glad you're all able to join us. And I'm glad that there weren't any incidents. I know there's been trouble with the weather over there.

Now now going to actually stop the recording before a few final housekeeping items, so please stay logged on for a little longer. All right. Thank you again, Jessica. We all ask that you stay on for a few more moment as we do our final housekeeping.


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