Hello. So thank you very much for the great honor of being allowed to speak at this meeting. Today I want to talk about critical help early for women in Africa or in shorthand terms. It stands for Tua. And I need to sort of give a big thanks out to Naomi Sangaya, the midwife who runs the critical care unit for women's health in Malawi where I started the program, Sylvia Matango, who's one of her colleagues, and Andrew McWinja. My name is Gloria Sabona and I'm an obstetrician and gynecologist. And currently I have founded and I'm directing the Institute for African Women's Health, which is a multidisciplinary think tank to really bring everybody involved in African women's health together underneath the same umbrella because at the moment it seems like the African woman has been dismembered in terms of her needs. So we have midwives working on one side, doctors on the other, policymakers doing something sometimes completely different. And I felt there was a real need to have an umbrella or platform where everybody can come together to try and improve women's health for the better. So the objectives of this talk are to talk about this critical care program which I started in Malawi and to get people to understand why it's so important. So I want to talk about why critical care. So by critical care I mean the close constant watch of women with life-threatening conditions as a result of pregnancy or other women's health-related conditions by a specially trained person. And I want to be able to hopefully establish why I feel the midwife has to be at the forefront of that. And I want to talk a little bit about how I went about setting it up and then what the outcomes were and what the challenges were that we faced. So I start with why. And for why I usually like to use this term which is mad. And I always say that it's really bad that babies are dying, but it's completely mad that in 2015 mothers are dying in childbirth or from women's health complications. Completely mad because we've known for years how to treat and how to prevent these conditions but women still continue to die. And they die of three main issues based on my experience working for more than 10 years I would say in the African setting.  So the S stands for sepsis, hemorrhage and eclampsia or preeclampsia. And the reason why I set up the critical help program was that I felt greater understanding of those conditions would really, really help to make a big dent in maternal mortality and mobility. I'm really, really passionate about stopping women from getting so advanced just because of simple pregnancy conditions. I always say that it's mad that mothers are dying and there's more than one way to kill mothers. You can kill them physically and we all know about the stats of one woman every minute or 800 women a day. But for me, based on the experience I've had for the past 10 years, there's more than one way to kill women and women are dying in their droves from physical, social and psychological complaints. So the critical help program was really a way of trying to make a dent into that. So it really tries to tap into what I call the preventable conditions and we hear a lot about the preventable. And I think those things are really important but at the same time we have to appreciate that there's also the unavoidable conditions that women are faced with. So it's not a simple case of that we can prevent women getting sepsis or preeclampsia. In the most part we can but sometimes it's unavoidable they are going to get those conditions just because of their makeup and we have to be ready for them. And then of course there's the attributable. So the attributable means the things that we contribute towards making a woman sick in terms of not having the right equipment, not having the right staff. From my experience working in Africa, we have a huge number of women for instance that have preeclampsia and it almost seems as if the African woman is more sicker than woman anywhere else in the world. But it's not that. If we start looking back at their history we actually find that we're not picking up their blood pressures early. So they're going through the whole of the antenatal period not having the blood pressures picked up until the very last minute and then they come to us very sick. And if we don't have that critical care approach for them they are going to die. So we are trying to sort of work within these three main areas. And I feel that the midwife is really, really important to working in the critical care field just because we know that mortality goes up when you do not have enough health workers. So the WHO says that health workers should there should be a ratio of 230 as a bare minimum per 100,000 of the population. And this will enable you to give at least basic care. But we know that in most African settings you're lucky if you have two doctors and then maybe 37 or 40 midwives per 100,000. So we are way off the mark and it should not be any surprise that we are having the really, really bad numbers that we're getting especially in the rural communities. So we have to be really innovative in how we're going to tackle maternal mortality and morbidity. And I feel for my experience especially having trained midwives from close to 10 years now in different African settings, Nigeria, Ghana, Kenya, Malawi. The midwife really is key to that. I mean the Malawian midwives are extremely, extremely highly intelligent people. And you know as midwives they do this kind of constant watch of the patient anyway in labor. So it's in their psyche. They have the empathy to do it. So I felt in terms of the numbers even though they're very low in Africa per 100,000 of the population in terms of numbers and also in terms of the inherent skills to deliver this intensive care. The midwife is the ideal person and I call her the madwife. And in the UK if you use the term madwife it's not really seen in positive terms. But for me in Africa with the experience I have I think madwife should be seen as a more affectionate term. You know we need more madwives in Africa, madwives who are really upset and angry that mothers are dying and really want to do something about it. And I feel that if we have more madwives or midwives who will help them with CPD it will help to improve the environment in which they work which is extremely poor and of course will help with motivation and retention. So how did I go about setting up this critical care unit in this hospital in Malawi? Well it was done in four days and even now I still can't believe that it actually happened within that four day period. But we started in a central hospital in Blantyre which is the commercial capital of Malawi called the Queen Elizabeth Central. And this hospital has sometimes as much as 15,000 deliveries a year and for those 15,000 deliveries they're lucky to have 35 midwives in total caring for those women. So the midwives are really working flat out. The hospital has a forbed intensive care unit which is for the whole hospital not just for women's health and often we cannot get our patients in there. And of course that was leading to a high number of maternal deaths because many of the health centers were referring their patients into the central hospital and of course they were arriving in really poor condition. We couldn't get them into ICU. There was no specific area to look after them in the hospital. So there were 12 maternal deaths when I started this program in November 2013. And if we use the ratio of every woman that dies they are maybe about 20 to 30 who are severely injured then that basically equates to about 360 near misses or morbidities. And then we were losing about 60 babies a month. So I went out with Miata Kapaka who's a HDU trained or critical care trained midwife from the UK to help deliver the initial training. You can see here on the left we have Ellen Sherwa who's the director of nursing and midwifery, a very visionary passionate director of midwifery. And we collaborated together to start this program and she invited midwives in Queen Elizabeth Hospital but also representatives from the 25 health centers who feed in to Queen Elizabeth Hospital and send the really bad cases to us. And we started with the premise that these people they're experts. So I didn't want to stand in front of them you can see me on the right saying I know everything there is to know about critical care and I'm going to tell you how to do it. They really had to work out things for themselves. So we started with three basic questions at the beginning which was why do we need a critical care unit? And they quickly realized after lots of discussion that there was not a need for something like this which was lots of staff lots of equipment because of course they couldn't reach that level. Why did I need a critical care unit? What does it involve? And what would it look like? So what they decided was it was not enough just to have a unit or an area within Queen Elizabeth Central Hospital. We needed to be able to feed into the health centers feeding into Queen Elizabeth because what was happening is that women were coming extremely sick because they were not recognized or treated quite early on and then Queen Elizabeth couldn't cope with them. So we really wanted to establish a network feeding around Queen Elizabeth. So the philosophy that we started with was the midwife decides if you live or die and that's such a profound statement the midwife decides if you live or die and we went forward with that because you know the midwife quickly understood that she stood between the woman dying or staying alive you know if she didn't take those initial actions she's with the mother she's by her bedside all the time she doesn't take those actions to recognize and then intervene and refer then that woman is going to die. So the midwife immediately took ownership of this critical health program and another principle is that we tried to instill in them was what we call the art of critical health. So you know what we were trying to do is not just sit down in a unit and wait for the woman to come to us really really sick we wanted them to understand that you know we do not want to push babies and mothers to their physiological limits so the art of helping these women was to stop them getting pushed so far that the limited resources that we had at Queen Elizabeth for instance was not enough to sort of meet their needs. So it was really about anticipation or prevention and this is the reason why the health centre midwife was so important anticipate prevent these horrible conditions but then if a woman is becoming sick recognize early so we can bring the woman back from extremists quite early on and then timely intervention and that basically stands for art. So we gave a quick pre-test just to see where they were in terms of their knowledge you know not just advanced critical care knowledge but even this basic thing such as observations what's the normal blood pressure what's the why is the respiratory rate so important as the first indicator the woman is sick and that pre-test actually was extremely low it was three percent even when it came to things such as you know what's the normal blood pressure we were getting values such as 210 over 170 is normal so that helped us to establish where people were in terms of their knowledge this is an example of one of the questions that we gave them and then we just went straight into physiology and pathology and as I said we focused on the she conditions so sepsis hemorrhage and eclampsia preeclampsia because we felt these were the main reasons why women are dying if you go to any African hospital you know if anyone bought me their stats and asked me to look at why women are dying these are the three main reasons I know we've got other issues such as obstructed labor unsafe abortion but they all fall under these three main conditions we really want to concentrate on this because we felt if they understood how to manage these conditions they could manage more or less anything that came their way from a critical point of view we wanted to move away from doing something really complex like this because midwives even though they're highly highly intelligent even as a doctor you get flawed trying to learn all of this information within four days so we needed to sort of come up with a simpler framework that they could start to build their knowledge on so we introduced things such as this within the book that I've written such as you know when a woman comes with altered level of consciousness or temperatures high or low or she has high breathing or fast breathing or slow breathing low blood pressure high blood pressure pain bleeding we introduced a book full of algorithms so that as soon as a woman came their way and they picked up an observation was wrong or worrying they could actually go to the book or to the guidelines and immediately start step by step to manage the woman we also simplified all of the observations just down to these three observations so pulse respiratory rate and temperature and which I thought was really important BP of course we covered and we covered during output but we focused a lot on these three observations because one of the issues we were having in Malawi was lack of equipment so I told you before about woman coming with eclampsia preeclampsia and it's because their BP is not getting done because there are no batteries BP machines are not working we all know from a physiological point of view that the BP is one of the last things to go off anyway and these observations here actually give you a lot of information quite early on and you don't even need equipment to do these observations you don't have to be clinically trained to do these observations so we focus on these three observations and of course focus on the other things as well such as the urine output so we use novel things such as you know knowing whether a woman was dehydrated or was passing urine okay by equating it for instance to soft drink so Coca Cola means that yes this woman is really dehydrated it goes sometimes along with eclampsia preeclampsia sprites usually means that she's well hydrated so we use really innovative techniques to really get them thinking and then one of the big innovations we had was thinking about the management so when we think about managing preeclampsia or sepsis sometimes the algorithms can be quite complex for people to get their head around so you really want to make it quite simple so what I said to them is you only have to think of three things when it comes to the management just like you have to just think of three observations you don't have to think about three three interventions that will help the woman is either that she needs O2 she needs something to be done fluid wise and she needs drugs and if you've got these three things in your head it's very easy to use this as a framework to start putting things on to those for those conditions so this is an example of what we came up with so those of you that are familiar with this basic resource will be familiar with the left hand side which is the ABCDE and how when someone comes critically um well you have to go for that algorithm so we stuck with that but on top of that we had the anticipation part of it and then we had the recognition so the recognition had all of the observations underneath and then timely intervention was oxygen fluid and the drugs so if we go to the next slide I'll just give you an example of what I mean by giving somebody oxygen so it doesn't physically mean you have to give oxygen because of course in the health centers in the villages there is no oxygen but there are other things that can be done to ensure that that woman has good oxygen delivery so if she's pregnant we know that we have to tilt the mother 15 to 30 degrees that will help to give her oxygen or you open the airway if she's obstructed and from a fluid point of view we were talking about IV fluids or giving blood or whether the patient was bleeding or not so you want to think about maybe giving her fluids if she's very dehydrated or she's septic stopping fluids or restricting fluids for instance in the pre-eclampsic or clamptic and taking fluids by way of blood to ensure that you know where what you're dealing with and where you're going and then for drugs it was you know do you have to give drugs you have to stop drugs so just having this framework I mean it seems very very simple but having this frame really helped people to start understanding how they could start managing the she conditions and then it was from there very interactive so they had the framework they understood that they were the experts they understood that they decide if the woman is going to die or live and then they started giving them scenarios really and step by step on that first day they started working out using that framework how to manage quite complex real-life conditions that we've picked up on the world and then we talked them about recess so it was very interactive and hands-on now a number big part of what we had to do on that first day and this continued throughout the three to four days was we had to teach them about communication by way of documentation because one of the big things I found training in Africa the documentation or the paper paperwork is not fit for purpose so without that paperwork it's very difficult to communicate and of course to see that trend of when the patient's become an unwell or getting better so they had to get their head around being better with their communication and their documentation and once again because we really wanted them to take ownership I didn't go to them with this is the documentation you are going to use instead what we did was we downloaded lots of examples from around the UK and we then also asked people from around the UK to sort of send us their guidelines and we stuck them around the training room and we said okay look you've got 10 or 15 examples of observation sheets 10 or 15 examples of medication charts we want you to have a look at it look at what you like and what you don't like and design something which is fit for your own context so they spent time doing that and it was really enjoyable seeing them sort of looking at in their groups looking at each of the observation charts and the medication charts and working out how they could design their own for their purpose and I think this was really important and I think I think it's the reason why since November 2013 this unit continues to thrive even with just four full-time midwives continues to thrive because they designed everything themselves bottom up bottom up so for instance they designed the early warning score which is used quite a lot in the west but in Africa still when needs to take off they designed something like this themselves from scratch worked out what the normal observations were and what the abnormal variants were and like I said they designed it by drawing on paper Chester here who was a midwife and one of the furthest health centers is very good with computers he designed it printed it off so finally it looked like this where's them going where you can see here from Bangui health center who's now head of the safe motherhood program was on her knees designing an observation chart which would help or aid communication between the health center and Queen Elizabeth central hospital so this is what they've the the first edition of the observation chart looked like we're now currently on version four they continue to improve it time and time again and then one of the biggest challenges that we had to overcome really was the place because we knew in the hospital 15,000 deliveries there were sick mothers everywhere from the labor ward to the postnatal ward to the Guiney ward their woman just languishing languishing in bed not because the staff didn't care but when you only have one midwife looking after 100 patients it's very easy to overlook what's going on with them with the mother so there really was a need to really have this central place I was very lucky when I arrived that companies such as rotary and old mutual had actually rehabilitated and redesigned a space next to the labor ward for a critical care unit they had been sitting empty for some time and that was because they felt that there was a lot needed to open up that unit and it couldn't be open let's say in the next few months or so I was quite low to do training with midwives in a room knowing that there was sick mothers up and down the hospital and I had as far as I was concerned 19 experts in front of me from a midwifery point of view who were being trained in critical care but we couldn't use this space so one of the first things that the midwives agreed on that first day we're gonna we're gonna almost do like a coup and we're gonna open the critical care unit and there was resistance but the midwives were very strong instead fast and they decided to open the unit so they divided into four teams and each of those teams made up a bed ready for a patient to go into and while they were making up the bed and trying to source equipment for each of the beds myself and Miata the midwife from the UK went around the hospital trying to find the patients that will go into the critical care unit for the first time and it was very difficult because we find the patient and we think yes that one definitely needs to go into that unit but then an expert or somebody even sicker so it was it was a real challenge but we finally settled on four very sick women one with sepsis one with hemorrhage two of hemorrhage and one with eclampsia preeclampsia and we started putting them in the bed so we then set to the teams by their beds you've made up your beds now you've got your equipment half of your team needs to go and collect your patient that we've identified and bring them to the bed and the other half needs to stay by the bed and get ready to admit the patients and so using that process they worked out how to design documentation to aid transfer from one area to another and also how to stabilize the patient on the ward so here you can see a picture of team A which I fondly refer to as my best team the A-star team because they were so good you know assessing a patient on the ward who was very sick 10 days postpartum with sepsis after cesarean section so she was transferred to the bed and then day two to four was really very much bedside teaching they didn't see the inside of that room again the room where I put all of the documentation around because it was very much bedside teaching there's no point having sick mothers of critical care and you're sitting looking at PowerPoint so it's very much bedside teaching with myself and Miata teaching them at the bedside how to manage the patients and using that they started to work out their guidelines so what was the outcome of that four days training well of course at the end of four days we met quite a number of challenges but at the same time we found things such as the post test improved from 3% to 93% which was huge and these were not easy questions it was questions such as you know what's the circulatory disturbance in preeclampsia so they were quite advanced questions for midwives who were not used to thinking from that point of view but the test actually rarely skyrocketed from three to 93% and a number actually got 100% on the test the midwives were so excited they danced they sang you know they printed t-shirts such as this because after just four days this critical care unit which people had dreamed of for like several months or if not years was finally open and when I sort of looked at the data and I just give you a brief overview of the data after just one year so we started in the 18th of November 2013 the same time last year 2014 411 women actually have gone through that unit and been successfully discharged and as I suspected there were three main conditions the she conditions which were treating and managing woman force so it was a sepsis hemorrhage and eclampsia preeclampsia and of course there were a few other conditions that had to go for the critical care unit as well so those ones with cardiac or with epilepsy but these were the three main conditions and I can say as a result of that critical care unit the mortality rate actually dropped by half at least so whereas we were maybe losing between 12 mothers sometimes higher than that per month from these referrals coming in from the health centers and of course we're having a lot of near misses where women were extremely sick but they were not dying we actually reduced quite a number of those bad outcomes and deaths by 50% where we find that mothers are still dying so now instead of losing 12 mothers a month maybe we were losing one or two where those mothers are dying it's just because they have not been referred in early and they come in so advanced that even the ICU cannot manage these patients so this is something that we need to work on but from a critical care point of view and then midwitery point of view they have really impacted on outcomes and another thing which I you know I'm so proud of is just the empathy demonstrated by the midwives I mean I've been training midwives for close to 10 years in different African countries I love love love the malaria midwife I mean all the midwives I've trained in every country they're absolutely wonderful people but the malaria midwife I mean especially here Sylvia metango who's one of the key core staff in the critical care unit she is I don't know so empathetic I mean this picture is the front of the book that I've written for critical help early for women in Africa so empathetic and I was really stepped up to the plate so I'm really really glad I sort of demonstrated that people do care about their people and the midwife really is at the forefront of that the midwives have continued to demonstrate their CPD and to improve the unit by continued to develop the documentation and the care that they've given and they've also started to recognize that prevention is key so they've been really really key to try and stop six sick women coming to the unit and trying to scale up critical care competencies across the whole of Blantyre and then they've started to write their operational guidelines because once the unit opened it was amazing people from around the country asking for guidelines from that unit and asking the midwives how do you manage preeclampsia how do you manage sepsis so they really have stepped up to the mark the other thing that was really really fantastic in the black in the middle you can see here Wese Ngungwe who you saw on her knees designing the observation chart she's now head of the safe motherhoods department in Blantyre and she was so impressed and empowered by the training the initial four days training that when I went back in January to start phase two training she said Gloria I really want us to train all of the health center midwives especially in the in the early warning alarm or the early warning score I think it's really important so can me arrange training I've spoken to the district health officer he's agreed to sponsor them to come for training so using our help we actually managed to train 84 health center midwives and I think that this really has also impacted on the outcomes at Queen Elizabeth because now they're not coming as sick as they were before so the midwife for me has really really stepped up and I think if we can really start to take the midwife at the forefront of all of these initiatives in Africa I think we will start to see a big difference of course there are always challenges so we're dealing with a system where antenatal care is still not that brilliant we're still missing the fact that patients are anemic I showed you that Venn diagram at the beginning where I said that sometimes it's unavoidable or we attribute to the fact that these patients will become sick so you have patients coming with a HP of 1.6 we know that women are going to bleed hopefully not more than 200 300 meals but even with that amount HP of 1.6 of course she's going to be pushed into that critical level so there's a lot that needs to be done antenatally we're having to reuse a lot of our equipment so ambu bag bags the oxygen masks especially the ones with the bags all of these things we have to re-sterilize dry and then use again because it's very difficult to get equipment but despite that people such as name Sangaya who you can see here on the left and Silvia Mitenko that really empathetic midwife are continuing to make strides in that unit I mean as it stands at the moment the unit is run just by four people Naomi on the right Silvia on the left or vice versa actually on the left Naomi and Silvia on the right Andrew McQuincher absolutely fantastic midwife and Esther Malanga and that's because with 35 midwives in that department of 15,000 they cannot spare any more to work in the critical care unit so sometimes people like Silvia will work 24 hours they will work 36 hours it's absolutely amazing but they're so dedicated to what they're doing and they don't really ask for anything for themselves other than this really basic things like Gloria next time you come from the UK can you bring us scrub suits because we don't have scrub suits so you can see them here wearing scrub suits embroidered with their name and how proud they are to have simple things like that and to be to be recognized so now they've been elevated to quite a high level and I think that would really help their CPD this is one of the very first patients in that four days who was discharged she was the patient who was so sick at one point we were up with her all night and I actually thought she was going to die her respiratory rate was 50 blood pressure was in her boots and post was 155 I really didn't think she was going to make it sepsis after serine section and it was amazing that day five having gone through that critical care unit and intensive intensive care by Andrea Miquinja and Silvia Mutenko you know that she's actually here today she has a live baby and she still has a uterus so we are now trying to scale up this critical help early for women in Africa in other African countries the book is more or less written now and we hope you can get funding that we can actually start to push out these very simple basic but advanced principles across the whole of Africa and the midwife as far as I'm concerned even as a doctor have to be at the forefront of that initiative thank you very much Gloria can you see that question would you consider introducing this training in the UK um yes I mean I think they do have um training in the UK um not specifically for all midwives but I think midwives who are trained from a critical care point of view and who run the high dependency units um do undergo this training so I think a number of universities such as kins college do offer a critical care program but I think it's important that every single midwife should understand critical care because critical care doesn't just happen in a place it happens everywhere um and I think this rarely is um one of the key areas that will really help to reduce maternal mortality and morbidity even in the UK so even though our numbers here are very very low um we are still losing sometimes 10 to 12 mothers per 100 thousand and no mother should die if it can be prevented so I think definitely there's there's a need to scale critical care um and even if they don't go to four more qualifications such as at kins college I think a program like this would really help them and you can do those other comments Gloria yes I can um so I'm not asking um they would like to get a copy of the book so my details are there so you can email me and I'll see how I can get a copy um to you um and then there's a comment here about the lack of interest in the respiratory rate um I think even in the UK um the respiratory rate really has been overlooked as the first marker that a woman is beginning to go off and I think it was only when the confidential enquiries um highlighted it I think a few years ago that people have now started to go back to that but um I think the respiratory rate is so important and like I said with the other observations such as temperature and post you don't need specialized equipment you don't even need to have specialized training anybody can do it so I think it's such a shame given that is the first marker that the woman is beginning to go off and there's sometimes that time to intervene that we don't pay more attention to it so I'm very hot on that when I do my critical care training that the respiratory rate has to be seen as that gold standard or the benchmark for what's happening with the mother um and then in terms of whether the training can be delivered in other languages I mean my first language is English um but you know I'm mindful of the facts for instance in Africa that we have francophone Africa um and I've had people approach me for instance from Niger and Senegal um interested in the program um but their main concern is that um it needs to be in French so I am looking into um interpreting the training materials into French and Creole and I'm also looking into I mean it's only one of me um it's a lot of work to do the training even though it can be delivered very quickly within three days um but I'm looking into establishing trainers on the ground so for instance I've got like a cohort of midwives now in Malawi who are more than capable of taking this program forward by themselves um and then in terms whether the package has been developed um so a trainer can access it um as director of the Institute for African Women's Health um I'm looking to develop quite a lot of online materials and downloadable materials that people can sort of access because I think education should be open source and it should be free um I don't think we should when it comes to women's health we should be putting a barrier in terms of money um between knowledge um and getting help for the woman so um I'm looking to sort of get a lot of these materials online for free um but if you email me um I can add you to the mailing list and once that's available um I can get that to you and I think if there are no other questions I think one of the key things I mean that term Mad Wife I think is really important I think we have to really start getting mad I think you have to start using quite how can I put it um language which rarely tugs at people's emotions that this rarely is mad so I mean critical help early is one of the programs that I've established I've established the Art of Delivery um training program um because one of the big problems I find going to Africa I mean in the UK we still have that problem as well but it's not as bad going to Africa women still flat on their backs in labor um and then we're wondering why the baby gets asphyxiated um we wonder why we have bad conditions why the mother ends up with a caesarean section even that full dilatation so Art of Delivery is one program and then recently I've just come back from Malawi again where I've started a training program in ultrasound for the midwives um and I've been I wouldn't say accused by the doctors but you know there's a lack of understanding why is a doctor am I focusing so much on the midwife well in terms of numbers it makes a lot more sense um and then secondly I just find that the midwives rarely do get it um and I think we need to have more mad wives or more specialist midwives that have these high level skills because like I said they will stop the woman getting so sick we do not need birth for instance to become a disease where we allow the woman to get so sick and then we now develop big institutions around how to deal with it that is absolutely and completely wrong so for instance we've got fistula surgery now which is now becoming a speciality in its own right fistula which is so preventable um we are now allowing the woman to get to that point where they have these horrible holes within their anatomy and then we're now saying yes we now have fistula specialists that's wrong um and the same thing with um ultrasound allowing the babies to die and then developing a big specialty around it so we need to really start dealing a lot with the prevention and I feel that midwives get that preventive aspect um a lot more can you answer the question about the changing life attitude um I can't see that question where is that um I think training to change attitudes rarely it has to come from the grassroots people often say that we don't want top down approaches and that's true um they feel it should be bottom up for me my understanding is that it should be bottom up until it meets the top halfway in the middle and so that really means that you have to I don't know really tap into the hearts and minds of those people at the grassroots those people at the front line tap into their understanding and you know what's in it for them and why is it so important empower them that their voice will be heard and that their solutions actually make sense and then I think you actually find the attitude changes so in this particular hospital I have done so much work not just from a critical care point of view but on the labor ward where we were getting so many bad outcomes and then recently ultrasound training guiney ward postnatal ward and a lot of it has come about by really inviting the midwives as experts as an example and telling them that look do you think there is a problem what problem do you think there is and how do you think we can go about tackling things and giving them a voice for the first time so we've done quality improvement um workshops with the midwives where they have designed solutions so I mean this particular unit really has started to change in just a few weeks because the midwives have now felt empowered to actually start changing things and I think that's the only way to go really I don't think you can foist things on people and then expect their attitude to change they have to understand what the issues are and they have to understand that it's within their power to change it and why it should be within their power to change it and then I think you will find that the attitudes and the empathy naturally comes from there so in that critical care unit for instance the midwives have rarely taken ownership of that unit it's the cleanest place not just in that department but in the whole hospital I mean when you walk into the critical care unit you think you're in a completely different world and this midwife see it as their area these are their patients it's part of their job to ensure that the mothers come in and go out in one in one piece and they're not mechanical in what they do either there's so much empathy there's the caring and the feeding and the washing and the cleaning and I think like a lot of that has come from them feeling that they have designed that whole program by themselves and I think this is the way forward for training I think not just in Africa but anywhere else in the world it really has to be learner centered and they have to drive the training because then whatever outcomes come about will be sustainable well I think we all really want to thank you so much Gloria that was some cash that thank you so much the slides are brilliant and as we tell you the slides will be available for viewing later so thank you again fantastic presentation thank you very much I'm now going to turn off the color


Hey guys, how are you doing? This is your boy Rich from Rich TV Live and you too can join the club at richpicksdaily.com where you can learn how to win and trade. Hi, how are you doing today? I'm your host, Rich, and we have a Rich TV Live with a very special guest, the president of Benchmark Metals Inc. Jim Gregg. How are you doing today, Jim? Very well. Thanks for having me, Rich. Always a pleasure. Really excited to have you on the show. So Jim, good to have you back on the show since we talked last. You guys have had some press releases in regards to drilling and permitting for your gold and silver projects. Can you go through the last few press releases and how they impacted the company? Sure. So about a month ago, we put out news just showing how the company is advancing our permitting process towards building a mine. And so we're very advanced on the geotechnical and engineering portion of our program. All of this work that is in progress as we speak is going towards a feasibility study. And that's anticipated for early next year. So about 10 months away, we'll have a feasibility report. And this is a production decision. At that point, we decide to put shovels in the ground. But in addition to that, we started drilling in January, February and March of this year. And that drilling is already paying off dividend. So we saw some numbers from the Dukes Ridge deposit area. And these numbers were below the current resource. So it's providing new gold and silver ounces, but 52 meters of 3.7 grams per ton gold equivalent. So gold and silver. So extraordinary numbers that will go towards expanding the resource. Jim, those are great numbers. What can we expect in the next few months? So we've got two big milestones on the threshold here. The first is an updated mineral resource estimate. This resource estimate is based on all of the drilling from last year in 2021. And it's also including some of the drilling from 2022 that was completed right after the new year. Excuse me. So we anticipate this updated resource to be published in approximately a month's time or under. All of the drill data has been passed on to our third party engineer. And they are now crunching and building the wireframes and resource models now to calculate the gold and silver numbers. So last year we reported approximately 3 million ounces. And I expect the new numbers to be much larger. Wow. Congratulations on all of your drill results and findings. Now, one of the questions I have is obviously drilling is very expensive. So does the company have enough capital to run all of its programs currently? We do. In December of last year, so roughly four months ago, we completed a broker private placement for $40 million. And that was the capital necessary to do work through 2022. So we have a $30 million budget this year to advance the project. So capital is in our books for completion. Fantastic. Jim, are you able to comment on the dealings with any majors? Obviously, when you're a small cap company that's in the metals sector, gold and silver, there's always going to be majors poking around looking that might be interested. So are you able to comment on any dealings with any majors and what their interest level may be for benchmark metals? Yes, I can. The company has signed a handful of confidentiality agreements. Great. I cannot mention those companies, of course, but they are performing due diligence. They are looking at our data. There have been site visits completed where there have been boots on the ground with engineers and geologists. During our brokered placement in December of last year, Yamana Gold invested in the company. And it's fair to say that they invest in companies that they have their eyes on. So not only are we just in an investment, but I think you could stretch it out to say that being an investment, perhaps we are a takeover candidate for that company. But I think in general, benchmark is a takeover candidate. I think there's good potential for this company to be taken over during 2022. It's a bold statement, but given our treasury is strong, we have a new resource that could approach close to 4Moz gold and silver. And we have a preliminary economic assessment that's in progress. So there's big milestone events and we're most certainly undervalued. And that's what makes us attractive to these corporates. Jim, can you give us your view on commodity prices with all of the things that are happening in the world? Inflation issues that are happening, for example, what is that in your opinion going to do with commodity prices? I think commodities are entering a bull run phase here. Certainly debt, inflation numbers and geopolitical risk around the world will have an influence on precious metals. And even though gold currently is at $1,950 USD an ounce, which are quite honestly astonishing numbers for the miners to be pulling gold out of the ground, these create very good margins in the reporting record net earnings. I think the gold price is spring loaded and at some point in the near future, it will be above $2,000 an ounce. There's too much inflation. The inflation numbers, the only method to control these are to increase interest rates, increasing interest rates also causes issues. So certainly it's a bit of a spring loaded precious metals market at the moment. And I think companies like Benchmark and the miners who actually have cash flow will be rewarded here soon. If there is anything else you would want shareholders to know about Benchmark metals in today, what would it be? I'd say keep an eye on the drill results, the updated resource, and a pending preliminary economic assessment. These value added results and numbers will move the share price, will improve the market cap. And best of all, as we mentioned, it's covered with our cash and treasury balance that's in the company right now. So there should be some good movement with this company. And I'm a big shareholder just like people watching your program. Management is here to win with the share price. So we've got skin in the game as well. That sounds fantastic. If anyone has any questions about Benchmark metals, what is the best way to get a hold of the company? The best method is to visit our website www.benchmarkmetals.com but we also have quite an active Twitter and Facebook and LinkedIn accounts. So I would follow the Twitter results but also take a look at our news releases and sign up for the emails. Fantastic. Now I must remind everyone that Rich TV Live is strictly for information and education purposes. We are investors. This community has been built by investors, for investors. We really like metals right now. Like Jim is saying, this is a high inflation year right now. There's going to be many more interest rate hikes happening and that is not really good for the global economy but investors will be looking for safe havens and gold and precious metals like silver has always been a place where people will put their money when they're looking for a safe haven. That's why I believe everyone needs to put their attention right now on Benchmark Metals, Inc. The symbol in Canada, BNCH. The symbol in America, BNCHF. We believe here, Rich TV Live is undervalued, underappreciated, underexposed. I want to thank the President for joining us today, Jim Gregg from Benchmark Metals, Inc. Thank you for joining us today, Jim. Thank you, Rich. Always a pleasure. You're not winning. You're probably not watching. We bring you the winners and we bring them to you first. If you like this video, please smash the like button, comment on the video, share it everywhere and subscribe. This is Rich from Rich TV Live with the President of Benchmark Metals, Inc. saying, have a nice day, everybody. We'll see you soon.


My name is Lindy Burke, I am the Towner County NDSU Extension Agent. I am here with Naeem Cowar, our soil specialist of the Langdon Research Extension Center. Water is the key to remediate unproductive areas. Most unproductive areas have moderate to high levels of water soluble salts. Apart from salt issues, these areas either have excess sodium that causes sodicity or magnesium levels that are high compared to calcium causing excess swelling of soils. These issues affect plants and soils resulting in unproductive areas and net revenue losses. Wet weather created shallow groundwater depths and has brought excess salts and sodium into the topsoil. However, recent dry weather is not helping these issues. We need quality water in sufficient quantities to force excess salts into deeper soil depths to remediate salinity and to dissolve soil amendments such as gypsum to remediate sodicity. In the fall of 2016, Towner County Extension initiated a demonstration on a saline and sodic area. Based on soil sampling and testing, this unproductive area was separated into three acres. On one acre, gypsum was applied, the second acre received beat lime, and the third acre did not receive any amendments. After spreading and incorporating amendments, a mix of perennial salt tolerant grasses were planted on all three acres. However, due to the drier weather in 2017, 18, 19, and 20, soil salinity and sodicity levels mostly remained unchanged. That was due to the lack of quality water to push the excess salt into the deeper soil depths and dissolve soil amendments to remove excess sodium from the topsoil. In order to see if more rain could have helped, a soil water infiltration demonstration was performed on the actual soil samples of the gypsum, beat lime, and control plots for 0 to 12 inch and 12 to 24 inch soil depths. In this demonstration, soil electrical conductivity, or EC, was used to measure salinity, whereas sodium absorption ratio was used to assess sodicity. Except one sample, there was a big drop in soil EC after infiltration. Decrease in EC ranged between 60 to 90%. One sample that only had an EC decrease of 4.89 or 5% was from beat lime plot for the depth of 12 to 24 inches. The lowest decrease in EC could be that this sample infiltrated water in 24 minutes, which was the fastest. This fastest infiltration happened in 255 minutes. Decrease in AR ranged between 39 and 83%. Highest decrease was in gypsum samples followed by beat lime and control samples. There was not much change in soil pH after infiltration compared to before infiltration. The takeaways from this demonstration is that there were no noticeable differences in pH. Five out of the six samples, including control EC levels, were lowered 60.62% to 90.01%, and the reduction in soil SAR levels ranged between 39.64% to 83.65%. Again, wet weather created shallow groundwater depths and brought excess salt and sodium into the top soil. However, recent dry weather is not helping these issues. In order to remediate these areas, we need quality water in sufficient quantities.


Hi there, I'm Sandi Allnock, artist and paper crafter here on YouTube, and today I'm going to Copic color a fishing lake.  The sentiments in here are particularly punny, so you might want to check that out, link in the doobly-doo to all the supplies as always. I'm going to color these as one African American guy and one white guy. Do a little of the human rainbow, which is my attempt at bringing some diversity to our card making coloring here on YouTube and on my blog. If you're interested in seeing more of the human rainbow, just look for that here on YouTube and you will find hopefully more than me, because I've been trying to inspire more people to try it and to get some other ethnicities into our coloring by coloring different people. You can pull up pictures of people and try to match those skin tones, you can match the colors of the people you're giving the card to, or if it's you and someone else pictured in it, then heck, make one of them look like you and one of them look like them. Why not? I don't look like either one of these guys because I am not a middle-aged dude, so there you go. I am just making them two guys. Anyway, I'm using my favorite YG combination for the jacket. I used to actually have one of these jackets. I was a fisherwoman when I lived in Montana many, many, many moons ago. Love to fly fish, did not fly fish in a boat. I fly fished from standing in the water in actual hip waders, which I still own. They are still in my garage. Don't know why I keep them, but you never know if you might want to wear hip waders, I guess, maybe. So I'm going to color my fish with similar colors to the vest that he's wearing, but I added YG03 because I wanted a little bit of brightness to him because seen around it, I want him to pop out from. But I wanted him to still be kind of that dull, fishy green. Add a little bit more of that to try to blend some of those colors.   I don't know if they use little flies from the boats, maybe. They probably use more of your standard lures rather than something that looks like a fly fishing little doobobby. Here I am saying doobobby after I just bragged on used to being used to having been a fisher person. It was a long time ago. So I don't remember much of what I did and I was not very good. I was a catch and release girl because I don't eat fish. Something about fish never really appealed to me, but I like going out in the outdoors and waiting around in a river was always a lot of fun. So here I'm using the same colors for his, this guy's vest as I used for the boat. It's also the same base colors and the same ink colors as I used for the African American guy. So you can see you can get a lot of different tones from the same markers depending on how much of each color you put down. If you put down a lot of color, you'll get a lot more of that shade. So if you use the darker one, you'll get darker shades entirely. Really depends on how much of each one you use. Doing the same thing here on the boat, same colors. And it also is going to pull all of them kind of together. So it's not going to be as colorful on the card because they're all of those colors are going to be united. They're not going to look disjointed. And there's reasons for doing both. You may want to have them be disjointed for a particular reason. So I'm going to throw a background in here because that's the name of the video that we are creating a fishing lake fishing fishing dudes here. So I'm basically trying to give myself with a very light green, some sort of horizon tree line, figure out where that's going to be. So sketching that in really lightly and then start sketching in some water. I'm using a really, really light touch. My marker is barely hitting the surface, but I'm using the side of the marker because I don't want skinny stripes. So if you're not very good at flicking, this is going to be really hard to do. But if you're a good flicker, then rock on. I'm also going right over the fishing rod because I'm going to color that in later because I wanted to make sure that that fishing rod didn't bleed into all of the background around it. So I put it in after when I was all finished with it. That color in most of like three quarters of the water. I want to highlight out there on the right hand side. So the sun is going to be out that direction and color in all the stuff on the left hand side. Start adding in some of my darkest colors. I considered going B nine nine. That was a little too dark. So B nine seven is my darkest shade. Going to give some color back here on this side. And this is going to create a real atmosphere because I'm only putting it on one side, not making the whole thing full of the same color. Just letting that color stretch out here on the left. And I'll use progressively lighter markers to start carrying that color up toward the horizon out there. Typically, your darkest colors are going to be seen closest to you. And the further away they get, the lighter, the paler, the duller that they're going to be out in the distance. So I'll switch to lighter and lighter pens as I start carrying that color out toward the outside edge. And it's also going to help me to create really soft wave, soft ripples right around where the fishing boat is. And let's see, add a little bit more here right around where his line is going into the water. That also is going to give me the contrast against all that white space to make that light really look like it's shining on that side. Light marker strokes, again, same thing the whole way around. Super, super light touch with it. And this did take quite a while. It's sped up a good bit to try to squeeze this into a reasonable length video. And now I wanted to add some really soft trees way off in the distance so that we're on a lake or a river. We have a horizon out there beyond us to be able to see, see just a tree line. And I wanted to leave my sentiment sort of being the thing right up front that you see there. So I'm going to make my tree line slowly go down below it. I don't want it to be perfectly even. So you don't want to have some sort of officially artificial, weird looking tree line, but I'm going to create some real distance here now by adding a little mountain, just some little peaks of mountains, soften them out with a really light color. And I'll add, of course, my white pen details. This is the Signo Uniball white gel pen, depending on what white gel pen you use. Some people don't have any success with this gel pen. They have other gel pens they like. I am a particular lover of this particular kind of gel pen. And there we go.  How about that? And I decided to go back and add before I did too much of the white, I wanted some splash for my fish so he can be jumping out of the water. And I'm adding some colors, blender dots, so making them different sizes right around the tail of him randomly laid out there, not not like perfectly even that sort of thing. You don't want them all to be the same size. Bubbles will be all different colors. And then I'll go around some of them with the white gel pen as well. Put a few in front of him so it looks like he's in the midst of all of those bubbles. And there we go, the finished card. Pretty fun, huh? To create a whole scene for a dude card. Lots of fun to create a whole atmosphere around a stamp set. And this one definitely inspired me. So I hope you enjoyed this video. If you did, hit that like button down below. You can watch some other videos. If you would like, click on my face to subscribe to my channel. And there's also a Copic class there. If you are interested in learning more about Copic markers, check it out. And I will talk to you guys later. Have a fabulous day. Bye bye.


Item Number SCP-653 Object Class Safe Special Containment Procedures SCP-653 is to be kept in a securely locked box in Storage Room B, its site- The keys to the box are to be in the possession of researcher- Removal of SCP-653 requires at least two armed guards. If skin contact is made with SCP-653 outside of experimental conditions, the affected individual is to be separated from SCP-653 and taken in for testing. Test subjects are to be kept under sedation in order to prevent self-injury while attempting to reacquire SCP-653. Due to many individuals having become obsessed with SCP-653 prior to containment, people may attempt to enter Site B in order to regain possession of SCP-653. These individuals are to be apprehended and brought into Site B for testing. Description SCP-653 is a plastic multi-colored boomerang measuring 25 centimeters from tip to tip. SCP-653's shape is the typical returning boomerang. However, it is more durable than its makeup would indicate. If a person makes skin contact with SCP-653, they will instantly become obsessed with it and will not allow it to leave their possession. After approximately 48 hours, they will develop a condition similar to magnetoception, becoming aware of SCP-653's approximate position at all times. Testing has shown that removing SCP-653 from the subject does not affect the rate at which the condition develops. Once the subject is aware of where SCP-653 is, they will be compelled to throw it, as they would a typical boomerang. Instead of returning, however, SCP-653 will travel large distances away from the subject. Once SCP-653 has been thrown, the subject will immediately begin to seek it out. Aided by their magnetoception, the subject will invariably be able to locate it. During the time that SCP-653 is being sought out by a subject, it is possible that another person will pick it up and become similarly obsessed with it. This has led to an unknown number of individuals actively seeking SCP-653. SCP-653 came into the possession of the Foundation when Agent Gilson reported finding a boomerang stuck in the ground of Site- She took a photograph of it, pictured above, but did not turn the boomerang in. Two days later, Agent Gilson was reported missing from Site- and when contact was eventually established via her handheld transceiver, she refused to return to Site- Her reason for this was, I've just gone out to get my boomerang back. Agents S and Anchor were dispatched to follow her as this boomerang could potentially be an SCP. Nine days later, Agent Gilson found the boomerang roughly 17 kilometers away from the town of... At which point, Agents S and Anchor were ordered to engage and retrieve the boomerang. Agent Gilson was killed and Agent Anchor accidentally made skin contact with it and became very possessive of it, threatening Agent S to stay away. Agent S was then ordered to retrieve the boomerang and was forced to eliminate Agent Anchor to recover it. The boomerang was then safely brought back to Site- so its properties could be established. Addendum 653-1 At 11.04, 9.43 p.m., an individual was apprehended attempting to gain entry into Site- The individual reacted very aggressively when being stopped. He has been taken in for study to see the extent of SCP-653's long-term effects. At the time of writing, 06-9, 7 other individuals of varying age and ethnicity have been apprehended attempting to enter Site- and gain hold of SCP-653. Lesson complete. If you missed the previous orientation, go watch SCP-652, Meteorological Dog, right now. Or for the complete course, watch this playlist.


That leads well to the next topic about does the end justify the means and this raises a question of ethics, but not only we see there is a problem of transparency, there is a problem of an open conversation, there is a problem of what we can say or talk about or not. And for this session, I'm pleased to have with us Daniel Lundler, who is a professor at Sorbonne University, member of the French Academy of Moral and Political Sciences, and he will be accompanied by Arthur Stream, who is vice president of corporate development of Selectis, a biotechnology firm and a member of the Cordemine. So Daniel, I let you set the scene for this debate. Thank you. Thank you very much. So ethics is important. Why is it especially important in healthcare? Because on the receiving end, our people who singly and collectively have a lot at stake are a captive market and are vulnerable. And because on the providing end, in both public and private arenas, the budgets are enormous, as are the opportunities for enrichment. And because, finally, research and clinic are intermingled, yet pursue different agendas, raising serious conflict of interest issues. That much is obvious. The question before us today is whether the advent of hugely powerful, disruptive technologies alters the problem situation, and in what ways. Part of the problem is globalization, which both amplifies these technologies and is largely enabled by them. Their governance must accommodate interdependence between nations on pain of remaining ineffectual, and intergovernmental ethics is no simple matter. But first we must ask a more basic question. What is ethics? We know an ethical issue when we see one. When we hear about handicapped children having been injected cancerous cells to further research programs in oncology, our ethical bell gives out a loud ring. When we find out that Boeing let the 737 Max fly after the first crash, although they knew what caused it, our bell sounds again. These are cases of what we think of as clear violations of ethical norms. A different sort of case is exemplified by end of life decisions in intensive care units. Ethics is involved, we clearly sense, but in the form of dilemmas rather than violations. Being familiar with a phenomenon doesn't entail being clear about it. Knowledgeable sources struggle to provide the definition of ethics. The best I can offer today is that of philosopher Joseph Raz. Ethics is the endeavor to give substance to the abstract category of the good. To give substance can be understood in two ways. If we allow ourselves to look back in time, we can imagine a moment where oncological experimentation on handicapped children was seen as a dilemma, not a violation. Physicians looking for a cure were laboring for the long-term benefits of humanity and pondered about whether this noble end justified the means. Going back just a little further, it perhaps did not occur to physicians that it may raise any ethical issue at all. It is precisely that sort of case which gave rise birth to the field of bioethics. And what these examples show is that ethics isn't just about making sure that established ethical norms are followed. It is also, in fact for the most part, about creating and discussing the norms to be established. Moral codes connect these two ways of giving substance to the good. They provide a temporary conclusion to the search for norms and they make precise what it is to violate them. The Ten Commandments specifies what it is to honor the good in a number of generic familiar situations. It may be thought that such a code of conduct suitably amended and completed should suffice. It is important to recognize that it does not. First, because no code can come close to covering all the types of situations that people, organizations and societies run into. Second, because when new possibilities arise and new practices emerge, they often require fresh ethical treatment. The existing ethical blanket, so to speak, cannot be stretched to cover the new territory. And this is precisely what technology brings about. New possibilities and new practices. The more powerful the technology, the more areas it can penetrate, the more numerous the possibilities, the more actlandish and possibly transgressive the practices. The potential for disruption is even greater when cutting edge innovations converge, creating synergies that defy extrapolations. Examples in the health sector abound were about to hear from Arthur about genetic engineering and the ethical red line of germline modification. And in the next session, about enhancement and the goals of transhumanism. The commodification of DNA sequencing raises a series of ethical conundrums bearing on privacy violations and incidental findings. E-health can lead to the accumulation of untoward amounts of personal information on some or all members of a population with the attendant risks of surveillance and control or unequal protection and coverage. Generalization of systems of e-health can cause increased inequalities, either because the underprivileged lack access to the minimum skills to navigate the system or because the more opulent sectors of the health system can afford the best up-to-date information and apps. Or again, because personal face-to-face care might increasingly become a privilege and so on. So what is the right time for ethics? It is often suggested that intractable ethical issues arise when technology is allowed to release new tools before due consideration is given to what consequences may follow. Look at artificial intelligence, which is at last wondering how it can be redirected toward the good. Look at the internet, which is due for a reset according to critics, including its founding father Tim Berners-Lee and our speaker in the next session, Carlos Marrero. Look at digital social networks whose destructive effects are well-known. Notice also that these three are mutual enablers. So the suggested cure in the face of these examples is to think first. But this is generally inapplicable. One reason is that before the technology is at least somewhat developed and deployed, debating about its potential risks remain abstract and general. No consensus can be reached. Even when one can begin to discern the shape of the proposed device or setup, it is impossible to foresee how, once deployed, it will interact with other novel systems emerging at the same time. And yet, more importantly, it is impossible to guess what scenarios will play out as society at large and communities take hold of the new technology. So the right time for ethics is neither after nor before. It is now. Ethics is a permanent feature of human action. It is guided by action as much as it guides it. It is an ongoing task that proceeds by spurts on the fly as fresh challenges are brought about by new types of situations arising, new practices crystallizing, new expectations being expressed, new understandings emerging. Finally, how can ethics find its place in today's technological surge? The present technological wave creates purgent problems for ethics and at the same time it makes things especially difficult. The responsibility for developing new technologies rests on a miniscule group of people with exclusive access to knowledge, power, and money and who answer to virtually no one. Deployment involves governments and thus to some limited extent, by democratic representation, a larger set of people. In practice, however, the decisions rest essentially on the technocratic structure. The social gap remains immense. Just as wide is the temporal gap. By the time a technology which has been selected for development and deployment hits the world, it has gone from emerging to already entrenched. And previous ways of doing things or inhabiting one's surroundings have been foreclosed. And as I said at the beginning, governance is the large extender global affair. National policies are mutually dependent and must be coordinated in order to have any lasting effect. Indeed, there are many obstacles standing in our way. Anthemological fatalism may convince too many people that any attempt to change the course of events is futile. The battle cry of putting humanity first, founders on the issue of who do we take humanity to be? Values, situations, and priorities differ. And we know from experience then that when push comes to shove, ethics tends to be an afterthought. In the face of these obstacles, we need to be imaginative and tenacious. But there's no reason to despair. We must be naive. We're witnessing a vigorous pushback as a matter of fact against fatalism. I do have a worry though. We also need to be patient for, as Joseph Rass puts it, and I quote, the new forms of the good take time and require the density of repeated actions and interactions to crystallize and take a definite shape, one that is specific enough to allow people to intentionally realize it in their life or in or through their actions. What we're witnessing in AI, robotics, and above all biotechnology is the beginning of a revolution or so we are told. The rush to dominance by nations, corporations, scientists is underway. In such a moment in history, how on earth can we be collectively persuaded to slow down so to leave time for the new forms of the good to take shape? This is the question with which I lead you. Thank you. Thank you Daniel. Brilliant overview and introduction. Thank you very much. I'm sure you've triggered a lot of thinking within our participants and broader when we communicate.


Saurabh Joshi is currently working at IIT Hyderabad. His research interests are formal methods, program analysis, constant solving. There are many tools which came out of his research work like OpenWO, PINACA and these tools have won many accolades at events like SVCom, MACSAT, valuations, etc. So, this is a joint work with two of my undergraduate students, Prateek and Sukrut and Ruben from Carnegie Mellon University. So, one primary disclaimer usually the theory people that you know whenever, so approximation here I do not mean approximation algorithm sense. So, there is no approximation factor here. It is just a very loose way in which I am using the word approximation something like you know 343 divided by 341 is almost 1. So, something like that right. So, let us get right into this thing. Techniques are very simple, but as I think Venkatesh mentioned today in the morning that in the solvers space very simple things you change little bit here and there and you may get a lot of advantage or sometimes the other way round. So, here I will know. So, let us get right into it and since this is about using applications of SAT and SMT. So, one of very good application of SAT solver is maximum satisfiability. So, we are going to use SAT solver as a black box for solving MACSAT. So, one of the words for example, what do I mean by incomplete MACSAT? So, MACSAT is an optimization problem where we want to know that what are the maximum set of maximum number of clauses I can satisfy. If the clauses the formula is unsatisfiable then you want to hit some optimum number that give me an assignment will satisfy the maximum number of clauses. Incomplete MACSAT means that incomplete MACSAT solvers or incomplete algorithms do not guarantee the optimality of the answer. But the motivation is again I mean I will refer to Venkatesh's talk in the morning. Motivation is that you want to find a good enough solution in a very, very short amount of time. So, there is the idea behind this thing. And in fact, since last few years. So, in the MACSAT evaluations what has been happening is that usually people just you know use complete algorithms even in the incomplete track. So, it is like the same solver and they have been winning. So, last few years the organizers have changed the benchmarks such that no complete solver will be able to find the solution within the given time limit. So, benchmarks are like very huge and what not. So, forcing people to come up with like fundamental incomplete strategies and algorithm. So, this is our contribution. So, this got published in CP 2018 and the extended version with the theoretical analysis went into journal JSAT in 2019. So, now let us move on. So, this is a formula and this is all four combinations of literal X1 and X2. So, it is easy to see that this is not satisfiable. This is unset. Since the set solver gives me answer in binary that either I can I mean is that it is satisfiable or not satisfiable. So, how do I use it to solve an optimization problem? Right. So, the way this is a very clever thing that most of the MACSAT solvers do is that you introduce a new set of variables R1, R2, R3, R4. Many times it is called relaxation variables. So, you relax a clause. So, these are a new set of variables. And now you know that this formula is satisfiable. Right. But the thing is that this is not the original formula. So, now you add this additional constraint. You say that you satisfy the formula, but use the least number of RI's to satisfy the formula. Right. So, when RI is 1 that means that the original constraint was not satisfied. When RI is 0 that means the original constraint was satisfied. Right. So, that is the idea. So, this is called a cardinality constraint over here. And now here our idea is that for this K you want to minimize K. So, use least number of RI's as least as possible as less as possible to satisfy this formula. Now many times for lot of practical applications there are certain some constraints are more important than other constraints. And for that basically you have weights attached to these every constraints. So, all of these clause. And now the idea is that you want to minimize the cost of this thing. So, if you could not satisfy a constraint then the corresponding weight is added to the cost. So, that gives rise to for the constraints like this. So, this formulation remains the same. But now what you have is a pseudo Boolean constraint where your RI remember is a propositional variable. This is 0, 1. But your constraints are positive integers. So, you have weights now. And now again is the same thing that you want to minimize K over here because you want to minimize the cost. And yeah, it is important because it has lot of applications. In fact, in CP 2015 we took some benchmark from computational biology and showed that certain kinds of problems, certain encodings work very well. And there is very nice paper by Rupak Majum there for localization and there are several uses. So, this is the motivation that what you want to do is that you have very limited amount of time just give me a good solution and forget about if you do not hit the optimum that is okay. And that is where the incomplete solver comes into play. Yeah, that is a good question. So, I will discuss later that what good means, the measure of goodness. It comes later in the talk. So, we propose these two techniques. This was part of our CP 2018 paper. So, now let me just explain this encoding. This was in 2015. It is a very easy encoding. So, let us say that I want to encode this summation. So, this weighted summation I want to encode. You want to capture the summation. So, the way you do is that for every literal, so this is the literal has weight 2, weight 3, weight 3, weight 3. You make some kind of a binary tree out of this. Now you want to capture the running sum that depending upon literal was true or false. What was the total sum? So, one, for example, if L1, if L1 is true, so this clause is going to force the corresponding A2 to be true. So, here for the A2, all these internal nodes the subscript means the weight. That means that yes, I have witnessed that weight of 2 is sort of the corresponding literal is true. So, this is a school. So, please feel free to ask any questions. So, very simple encoding. Similarly, I will say that if L2 is true, then it is going to force A3 to become true. That means that registering that I have witnessed the weight of 3. And then you can say if both of them are true, then 2 plus 3 is equal to 5. So, you have these constraints like this.  So, this is your encoding, the sigma wiri, you remember. So, this is my encoding. Now, the thing is the upper bound. So, how do you ensure that this? Pardon? Both of them force it does not matter, right? Because I want to do upper bounding. So, let us say that if it is the if I want to encode greater or equals constraint, the things might change. But let us say for example, if I just want the at most constraints, then I do not. So, if they are 0, it is good for me. Only thing I want to ensure that they do not overflow this bound, this upper bound. So, now the threshold I can do because now all these sums all the way propagates up to the top level. And now all I do is that I say that negation 06, negation 08, etc. So, that means that whenever the sum is going to cross 5, it is going to conflict with these unit clauses. So, this encoding ensures that you will. So, this is satisfiable if this formula is satisfiable only if this constraint holds, right? Okay. So, now the problem with this thing is that this is the worst cases exponential because you remember these set of variables in the clauses for every different combinations of weight, you have to have one variable, right? But if I have weights like this like 1, 2, 4, 8, etc. That means that every combination is going to generate a unique weight. That means that I have to have another variable. So, you can have exponentially many variables in the tree and corresponding exponentially many clauses. But if it is becomes polynomial all the weights are same because that means that because even if you pick different literals, the total weight is still the same. For example, if all of them are 1 or all of them are 2, right? Then it becomes it is quadratic actually this encoding. So, we want to the intuition is that you want to leverage this idea that all the weights are same, then it is polynomial. And this is another extreme that if you know things like this, then it is exponential. So, what you want to find out is that somehow you want to adjust your weights so that they become same. So, that is what we are going to do that because the weights are same then becomes polynomial because some of the problems that we have had it does not even fit in the memory it goes mem out our solver actually mems out. So, this is where we want to strike a balance for this thing. So, for this algorithm we have a parameter m which is that how many clusters of these different weights we want to form. So, let us say that I am going to run an example for m is equal to 3. So, first so these are all let us say different weights of all the clauses. So, first what you do is that you sort them by the weight and now I want to put them into three clusters. So, one of the way that one can do is that initially I put everything in one cluster then I keep dividing cluster so since this is sorted so I can say that basically the subsequent numbers what is the difference between two consecutive numbers. So, whenever this difference is highest you put a cluster boundary there. So, for example, 25 minus 12 is 13 which is the highest the subsequent difference. So, between any ai and ai plus 1. So, you put a cluster boundary there and then you can keep on doing this. So, since now I have three clusters I stop there because this is my parameter I have achieved. Now that I have formed the class see the idea behind dividing a cluster at this boundary because eventually you want to do weight adjustment. So, for example, after I do this I change all the weights to arithmetic mean of the corresponding cluster and that is why I have to make cluster so that this is to ensure that when I make the weight adjustment it is not too much. So, that is why when the difference is too much you try to put them in a different cluster. So, that is the intuition. So, again I mean you can pick either median or people can debate that what but this is what we implemented but in general you can put that what is the representative weight of the cluster you want to put over here. So, now you see that now because these are all equal you know that at least for this cluster this is going to be polynomial this is polynomial this is polynomial and so now there is a tradeoff. So, obviously depends so if you keep increasing n. So, now what I do is that now this was the original problem right but now I have changed my weights some completely different weights now I am trying to solve the problem. So, what I try to do is that now I minimize k. So, I ask that whether for this k it is possible then I reduce k for this k it is possible or not. But because I only encode this thing my polynomial is I am hoping that it is of manageable size and you keep decreasing until you reach unset. And even if for example you reach unset that does not mean that you have reached optimal because you are not even solving the original problem you are solving some different problem. But the assignment that I need at the end when I print in fact the thing is that even if I am reducing k over here that may not mean that the this k corresponding to this formula is monotonically decreasing it does not even mean that. So, that is why I internally whenever I find an assignment for this you keep track of the what is the corresponding cost in the original formulation and then you record that assignment because that is easy to do I do not have to encode it right ok. So, it is sort of easy to see that as I increase my m which is the number of cluster my accuracy sort of increases because my weight adjustment is not too much yes. So, it gives me an assignment right. So, now with that assignment I see that that assignment gives me how much cost in this formulation because I can compute the cost since it is 0 and 1 I can see that what is the weight of all when all the arrays are 1. And I keep track that which is the smallest cost I have achieved so far this is with respect to original one because this is what you really want yes when the modify the one is unset then you stop. So, if you still have more time so the thing is that incomplete solving because in the competition there is a limited time like 60 second and 300 seconds and whatnot. So, depends upon so if you have time then what you can do is that in this particular case in this algorithm what you can do is that you can actually increase your m to increase the accuracy and do that. From the last value of k that you know it was satisfiable because now with the modified m it is possible it again becomes satisfiable.  What was the strategy it could go back. So, if it is sad you use that assignment to find the. Find the what is the cost yes with respect to the original formula. And if that cost is lower than what I recorded if for example some earlier assignment then I keep that assignment because at every point of time I want to know that what is the lowest cost assignment I have found so far. Yes it does not mean anything yeah. So, in fact because the thing is because we have taken average. So, if you take a max or min then you have a one sided guarantee that if one is unset then so something like that. But if you take arithmetic mean that you do not have any guarantee whether this is the upper bound or the lower bound with respect to the original problem. But you record the cost with respect to the original one for every assignment that this guy gives me. And when you hit unset now if you have time you can what you can do is that you can increase this m and start from the last k that was satisfiable and ask that whether now it is satisfiable. If it is not again increase and it is sort of also easy to see that basically when m hits the total number of unique weights. So, and there can be 1000 clauses but the weights are only 2 different then only m is equal to 2 after that there is no approximation you are doing solving the original problem exactly. So, you can keep on increasing if you have time then you can keep on increasing m until this limit and but also as you increase m the size of the formula also increases. So, that is the tradeoff that you have accuracy versus formula size tradeoff that you have. So, this is the first sort of strategy that we used. Another one is so look at these weights. So, let us say that you have weight 111 for these clauses. The property that it has is that at every level a single weight in this level is greater than strictly greater than all the weights combined at a level below and so on and so forth. So, this is 16 and 319. So, this is 20. So, let us call this property a Boolean multi-level optimization property BMO property. Now, what I can assume for a moment that your formula has this property the weighted formula have this property. If you have that property then what I can do is the following. So, now the thing is that I know that set is basically you know making this single RI false is much better than you know trying to make all of these 0 because the all the weights combined of level below is still less than my weight at a given level. So, now what I can do is that I start with the highest level and then I impose this cardinality constraint. So, this is always polynomial because the weights are all same. So, I ask that whether it is possible that you know you set only two of them to true. If that says that yes it is possible then you reduce only for that level and then if this says unset then now you freeze this constraint over here saying that because now you cannot do any better. Now, you move on to the next level below and now you ask that whether since there are four of them you ask that whether you can set only three of them and make the formula satisfiable. If yes then you keep going and whenever you hit unset you freeze the last one which was set and you just keep on. Now, this is kind of a greedy strategy that you basically you want to minimize the cost from the top level onwards and it will produce optimal if the BMO property holds which is kind of obvious because the weight of this guy alone is greater than all of these combined and so on and so forth at every level. But if this property does not hold then there is no such guarantee. I mean you can do that but you do not know how much you are going to deviate. But the thing is that let us say that your formula does not have that property let us implement this algorithm anyway and see that what happens and how much it deviates. So, yeah there is no guarantee that it will converge. And here also for example after you are done with all the levels and if you still have time left on the clock then what you can do is that then you can switch to a complete search algorithm. So, this is an incomplete algorithm by default because even if you terminate it is not guarantee that this is the optimum. You can switch to a complete search algorithm or a local search algorithm. So, yeah so now the measure of goodness the way we do and this is the standard in the competition is that for all the benchmark you find out that for a given benchmark what was the best solution known for that benchmark either by this solver or some from some prior knowledge etc. So, that is called the best of me. So, this is the remember we want to minimize the cost. So, this answer is always going to be greater or equals this one. That means that score for an individual benchmark is somewhere between 0 and 1. You sum them up and divide by the total number of benchmark. So, that is the score and now here the goal is that you want to improve the score you want to be as close to 1 as possible. So, that is the so if you already know the actual answer then that is going to be the best of me otherwise. Yeah, so this is how the scoring is done and we have done experiments for this three particular time out now and the score of 0 if solver fails for some reason. So, in the in the first strategy you see that basically so when you do not apply so m is equal to 0 that means that you do not do any clustering. So, this is the I think ratio of I think it is the summation of entire benchmark that how many total new clauses have been added as compared to the original one. So, it goes 3000 times the original ones. But when the cluster is 1 so now there is the you know so as m increases the formula size increase this is what it shows and this is the score. So, so you can see that as the m increases the accuracy kinds of increase. So, but you will see a little bit decrease over here because also when m increases the formula size increase and you may time out before you can do. So, this is for the first one this is for the the second strategy where now the thing is that is in the second strategy only uses cardinality constraints. So, size is not a problem. So, you can keep on in fact the thing is that almost for all formula we have been m is equal to hash weights. So, all the way we can do but remember that in the second strategy even if you do not do clustering even then it is not guaranteed that you will come to an optimum. So, here you can see that the accuracy increases kind of monotonically the second strategy. And yeah we have compared with so this is an old slide that I am using. We have some new set of experiments but so Q max set was a complete solver which one in max set 2017 WPM. So, I think one was the first ranker, second ranker. Max roster was the winner of max set 2017 and these are the two of our work. And you can see that this guy is best in all these three time out whereas this one when you do the clustering it is doing good when the time is very less. But as you give more time the for example this max roster is doing better than this thing. There are lot more plots that I have in journals and plots but these are old slides and I just so yeah I mean so these are others. So, the same strategy we won for the first strategy we placed fourth in 60 second and 300 second time out in max set 2018. For the second strategy for 300 second we were second and for the 60 second we were first. For max set 2019 it was sixth and fourth the first strategy. Second strategy was placed third both of this time. Now even in max set 2019 that the first place holder which is TT open WBO Inc. It uses actually open WBO Inc our solver. They use the same algorithm and everything they change the variable selection heuristic and the bump activity and what not. So, those variable heuristics is the one that you change. So, we are the ones we are using set solver is a black box they are not using at a black box but it is the same algorithm same everything else is the same. So, in fact so yeah one thing to know for example in yeah so max set 2019 so we are switching to this so since most of the time we do not time out for the second strategy. So, we switch to a local search algorithm that means that we have an assignment and from that assignment you just look at one particular variable and keep flipping with some heuristics and see that whether that decreases your cost. So, there is a local search strategy. So, that combination is working very well and that is the same thing that even the TT open WBO Inc which is the winner of this year max set 2019 uses. So, this is the tool so open WBO is a complete solver open WBO Inc is an incomplete solver both of them are available out in the open. Now another part is that basically yes so far I mean I did not talk about that what are the guarantees of this thing. So, in the general version we make theoretical analysis about this it turns out that it is actually you can exponentially deviate from the optimal solution. In principle you can construct pathological formulas. So, if I n variables and even if I pick weights like 1, 2, 3, 4 like that so it is not like I am directly picking very high weights even then it is possible to construct formulas which can exponentially deviate from the optimal one because the you can do all this Boolean combinations of variables exponentially many Boolean combinations of variables it is possible to construct formulas like that. So, that we have shown so yeah theoretical guarantees are not there but at least in practice this is working very well. Generally in max set solver if you have hard clauses then the weight is infinite. So, do you find any like any difference in the evolution if there are like lots of hard clauses compared to the number of soft clauses? So, here because we are using set solver right. So, if it is hard clauses you do not relax those clauses. So, essentially if it is hard clauses you do not introduce this relaxation variable. So, any satisfying assignment by a set solver is forced to satisfy the original formula. So, this relaxation you do only for soft clause and then rest everything follows. But I agree that for example if it is a local search kind of scheme that is where it happens that if it is a hard clause usually you know you initialize your weights which is like very high weights and that is how the local search strategies work. Yes. Some of them could be or introduce variables R's right. Yeah exactly. So, what is the yeah. So, for example in in this year the winner Titi opened WBO Inc. So, they used the exact same our framework our algorithm and everything what they did is that see for example these variables. So, these variables what they called they call these target variables and whenever a solver has to make a make a choice on the polarity that basically when you are making a decision on these variables whether the polarity should be 0 or 1. So, if you do not mess with it usually the set solver takes whatever the last best known polarity. But here what they do is that they always say that basically initially the first choice that you should try for a decent variable is always 0. So, so they are being optimistic. So, that is one thing that they did. Second thing that they did is that for every variable of importance for example in the way seeds and all this kind of variable heuristic there is something that is called activity of a variable and whenever a variable is involved in a conflict it is called active. So, you bump an activity whenever. So, these variables are initialized with high a little bit high activity. So, that mean that the variable selection. So, it is going to give some bias to these variables. So, that is what they did in 2019. That is not our work that is from Intel, Alexander, Nandale. So, yeah I mean when you do not use it as a black box and when you have some domain knowledge it is good to actually go inside the solver and play around with these things. Thank you for the talk. Thank you.