Okay, excellent. Now, it's with great pleasure that I'd like to introduce Gloria E. Sigbonar for volunteering to present her session on the SHE Campaign Innovative Obstetric Critical Care Training Program to reduce maternal and mortality and morbidity. Gloria is a UK obstetrician and gynecologist, educator and founder director of the Institute for African Women's Health and for the longest time she's been driven to do something about improving women's health. Ever since seeing a friend's sister and a cousin die in childbirth where one minute they're alive and healthy and the next minute they were gone, she later trained to become an obstetric fistula surgeon and was struck by the terrible injuries inflicted on mothers that left them incontinent and able to have sex or walk. The inequities of all this deeply affected Gloria and especially once she realized how many maternal deaths and injuries were totally preventable and could strike mothers at any time regardless of social status. She didn't want to do something that had no longevity or sustainability. She really wanted to keep African women healthy and hence the Institute was founded. The first interprofessional body where all key stakeholders have an equal voice and role, especially the women themselves who are at the centre and design of the programs and have equal validity. So nothing further for me. I'd love to hand over to Gloria for a very interesting session. Welcome Gloria. Thank you very much Gillian and thank you to the virtual team for allowing me this second opportunity to talk about the SHI campaign and maternal mortality and morbidity in Africa. So I've had a fantastic introduction. I don't have to say much about myself but I do want to talk about this concept which is SHI and I'm hoping that you will understand it as we go through the presentation. So SHI was ready started once I became an obstetric fistula surgeon. So an injury which damages mothers because of childbirth and I came across mothers such as this woman here who wasn't dead but for me she was as good as dead because socially and psychologically she'd been so traumatised by her birth experience and having taken this photo and having looked at it several times I just thought this is mad. This was taken I think in 2007. Mad stands for mothers are dying. How can mothers still be dying in this day and age when we know what to do to prevent it? So I found it completely crazy that we should still be in this situation and then what was also quite concerning for me was doing quite a lot of voluntary work in Africa. I come across quite a lot of women and quite a lot of institutions and in one such institution I came across a room which was very darkened and in the local language there were words written which translated meant the wards for those with no hope and when I went in there I expected to see women who were maybe lepers or had these really incurable diseases but there were these mothers who had given birth or maybe hadn't even given birth but they had completely preventable conditions but they've been pushed so far in terms of their physiology that nothing could be done for them and they were just left there to die and that was for me really troubling and really concerning. So having worked in this space for a number of years I finally realized actually I think one of the reasons why we're maybe not tackling what's happening in Africa and maybe the rest of the developing world at the moment and even in the US where maternal mortality rates are now going up is because we're seeing this as a really complex problem and for me as an obstetrician and gynecologist or even I like to call myself an obstetric midwife, for me the problem is really, really simple. The WHO likes to talk about the fact that women die because of ruptured uteruses but for me the ruptured uterus causes her to hemorrhage and that's the reason why she dies.  Unsafe abortion or septic abortion is still a big problem because she has an infection and then you have all of these other conditions such as sickle cell disease, HIV, diabetes. All of them once again stem from the fact that the mother is dying because either she has sepsis or she has hemorrhage or she has preeclampsia or eclampsia and this is how she really came about because I felt well if I can collapse the reasons why women are dying down to three really simple things it should be really simple to address those issues. So she stands for sepsis or infection and you can see with the image sepsis at the bottom because usually it's an ascending infection which then travels up through the woman's body and causes morbidity and mortality, hemorrhage and then eclampsia or preeclampsia. So she for me was really significant and this really has been my message. I mean I've been working in this space for I think close to 15 years now but I think in the last few years since I've started using the word she it really has opened a lot of doors on so many different levels because people just get it. They understand that it can be really simple to prevent these things. So if you collapse the reasons why women die from a WHO point of view into those she conditions then you will find that roughly 27% of deaths and mobilities are due to hemorrhage or some sort. 33% are due to preeclampsia and eclampsia and actually if you look at it by institution eclampsia actually plays a bigger role than previously suspected. And then here this is not a misprint. The S isn't missing. I use the slide just to illustrate that when I go around and I talk about she people often tell me well you don't have sepsis in my institution that's not a big issue for us it's hemorrhage and eclampsia but around the world people have started to realize that sepsis is a big killer even in the west countries they've now started their world sepsis day and they've got the sepsis campaigns. People are beginning to realize how it can sometimes be such a big killer and it underpins so many other conditions so that's the reason why we have the underscore and the she campaign just to signify that sepsis has to be thought of as part and parcel of what's going on with those conditions and it really plays a big part in hemorrhage and eclampsia. So this is an example as to why I feel the conditions are really significant and why they really do need to be handled and tackled and understood together. If you think about a woman who has high blood pressure but then she hemorrhages and she hemorrhages because she's got high blood pressure maybe because her clotting is off she's more likely to hemorrhage. The two conditions go together. Let's say for instance she hemorrages but her blood pressure is so high that you haven't recognized that actually her blood pressure is now dropping. It's also become significant. It's known that sepsis can sometimes initiate preeclampsia. Studies have shown that it's known that women that have chronic hypertension have a greater chance of becoming preeclampic and eclampic and the progressional sepsis for those women are higher. So this is just to illustrate to you how important these conditions are and how they all relate together. So the aim of the she campaign is that we really want to stop women being pushed to the physiological limits. We know in Africa and in most other settings one woman come and they die because we've pushed them so far that even if we put these women with sepsis hemorrhage and eclampsia who are really sick in the best unit that there was around the world they still would not make it because they've been pushed too far. So the aim of my campaign really is to really recognize these women quite early and catch them early on before they get pushed too far and then you can't bring them back. The way that I have done this since 2013 is with a matrix or algorithm called Tua which stands for critical help early for women in Africa. And I developed a matrix because having worked in this space for some time I often like to use this term which is the problem that we have with research in maternity care is that we often talk about sensitivity that a woman have a condition. You have to know that women have problems with maternal mortality and morbidity but that seems to be the rampant cry. We focus so much on the fact that yes we've got one woman dying every minute or now it's one woman dying every two to three minutes and the whole rhetoric is really really sensitive which is important. We need to draw attention to the issue but then the specificity often is lacking because you know we now have a specific problem. We have to be really specific about how we're going to tackle it tackling it with just saying women are dying and how we have to be really sad about it is not going to work and that's the reason why we still have so many women dying in Africa today. So I said we need to move away from too much sensitivity and let's start getting more specific about what we need to do and that's what the she campaign really is about. So I wanted to deliver critical care within the African context for these women that were really sick, sepsis hemorrhage and eclampsia who were coming and they were dying because staff thought they didn't have the equipment they didn't have the knowledge and how to manage them they didn't have intensive care and I knew that opening an intensive care unit even in the biggest hospitals would not be possible it wouldn't be feasible so we need to have a very low resource system where we could deliver critical care for these mothers so that they didn't die and their babies were more affected and then also we needed a system whereby we could start to recognize these women really talk about the physiology because that was really important and also manage the women and then also really importantly think about prevention because I'm not about picking up the pieces I'm tired of sitting down as an obstetrician or an obstetric midwife waiting for women to come damaged sick when I know I could have prevented it out there in the community so I'm really about prevention and this is what Chua and she is about as well so to achieve this it was very clear that we needed processes and pathways by which women would be identified and sent to the right place we needed the right team of people talking to one another it had to be an interprofessional team and the midwife was key to being part of that team and then we needed good documentation and communication pathways so this was what we developed with the Chua matrix so in critical care you who are up to date with how we kind of manage resuscitation situations we'll know about the A, B, C, D, E A stands for airway B breathing C circulation D is damage E is exposure and then I've added into Chua F which stands for fetus because for me the biggest killer of these mothers sometimes can be their babies we haven't done something to maybe deliver the baby and give the mother the best chance but equally mothers can sometimes be the biggest killer of their babies as well so F had to be there and so with the algorithm we teach people to think about each of these sections of the airway breathing and circulation systematically so you have to deal with the airway first because of course if the mother doesn't have an airway and she's completely blocked off no oxygen then there's no point trying to mop up the blood because she's coming with hemorrhage you have to be really systematic so we teach that we teach in a really logical way which is okay what are the critical observations that you need to think about and the critical observations for me there's several but the three key ones are the respiratory rates, pulse and the temperature and the reason why these three for me are really important to start with is that you do not need equipment and in Africa sometimes especially in the health centers where people say there's no batteries, no equipment it stops them from doing basic observations that would alert them that the woman has a problem so always they start with these basic observations and then do something about it so you want to help the woman and you want to help her by just thinking about giving her three main things that she's going to need she's either going to need oxygen, she's going to need some form of fluid or to have fluid taken in the form of blood or she needs medication or drugs of some sort so just think about those three things and then E stands for early intervention so how early do you have to give these three things and what do you have to do with them, do you have to open the airway to give the oxygen do you have to position her, do you have to physically give oxygen if you can do that or do you have to adjust the fluid, stop them all together, do you have to take blood do you have to give her medication, stop the medication so it was a very simple matrix to introduce midwives who started on this program to critical care in the way that they could really start to build their knowledge we were trying to get them to deliver critical care competencies in four to five days instead of the usual six to twelve months that it takes around the rest of the world and that's what we've managed to achieve in three hospitals so it does work then the rest of the matrix really is about what comes after so it's not about these women coming and then saying okay fine we've saved the mother we really want people to start thinking about why did that happen, what's underlying the change in the physiology so it's kind of like self reflection, why did it happen, who was involved when did it happen, was it an antenatal problem, was it post-native, was it interpartum and then the A stands for you know what's your goal so for instance we might have an audit meeting looking at all of the pre-eclampsics within four weeks you want to basically look at the critical observations you know what help was given what was the intervention you want to think about who was involved when did it happen and then you want to say okay fine for the next month before we come back this is what this is our goal we want to try and reduce the mortality and mobility rate by this amount and we want to allow we need to allow certain things to happen you know so for instance maybe it's because we didn't have an anesthetist or maybe we didn't have a midwife or the midwife wasn't allowed to work because she wasn't paid what do we need to allow and then all of this goes into an audit so this is a really simple overview of the matrix I don't have time to go into it in great detail but this to give you an idea of how we start to break down understanding of the she conditions and how to manage them so like I said we have delivered this within three hospitals across Africa to date Queen Elizabeth Centre Hospital Malawi and this was the first program in November 2013 and the unit is still going strong having saved hundreds upon hundreds of women and their babies and then recently she and Chua has now gone to Pumwani which is the third biggest maternity hospital in Africa it delivers about 100 babies a day and then after that Lagos Island Maternity Hospital which is nicknamed the baby factory of Africa so this picture is from Lagos Island Maternity which I really count as one of my great success stories just because the team that came along and this is a bunch of midwives here were so proactive in taking it forward and really realizing that vision for she so hey you can see why it's helping one another with resuscitation a key part of each of these units where this has been set up is what we call the early warning score so the early warning score is a way of recognizing the woman based on their observations if you look on the left hand side you can see ABCDE so the observations broken down and then you basically take the observations on the mother and then from there decide whether they're normal or abnormal and you give a score so for instance if she had a post of 69 you so okay she's got a score of zero so this is a really quick way of scoring the woman and the problem that we have in Africa is that sometimes the ratio of staff to patients can be so great sometimes you have two staff to a hundred patients so it's not possible to go to every single patient and score them and of course you might not have the equipment for instance to do an oxygen saturation so what I say to people is that look just start by saying does the patient look unwell does she feel sick are you worried about the patients and that's how you start your hand over any patient that you're worried about that's the patient that you should try and score as completely as you can so this is what staff has started doing in each of these units now and I think this is the reason why their mortality has really really dropped because they are recognizing the woman early stopping them being pushed so far in their physiology and bringing them back and then managing them with the resources that they have so you can see here observations which are higher than they're supposed to be have higher scores and then observations which are lower than they have to be also have higher scores so sometimes you can have a patient that comes in with a score maybe of nine so she might have a respiratory rate of 24 her blood pressure might be 160 that gives her a score of four she looks extremely sick that gives her a score of two so she has a score of six maybe she looks really confused another score that gives her eight and maybe her temperature is really low less than 36 that gives her a score three so that's a score of 11 so she has a score of 11 and also what's really unique about this score so this early warning score system is something which has been used around the world in many obstetric units and even non obstetric or maternity units as a way of recognizing the patient but what they did in Lagos Islands maternity in their critical care unit that they call Limku or their service was they also put symptoms on there they recognize that sometimes patient staff did not take the observations either because they were busy or they didn't have their equipment but symptoms were very easy to score so they actually put symptoms on there and I think this will make a really big difference in our she campaign going forward because we aim to go into the communities to use this kind of score system with people who have no clinical background whatsoever and we want to kind of make it very visual and based on symptoms and get them scoring the symptoms that way and know where to refer them so that insight that I got from Lagos Island maternity has been really great in sort of establishing a sort of new way forward for the she campaign so once they've scored the patient what they do they now use what we call track and trigger to now decide what happens with the patient so if the patient has a score of zero to two as you can see on the left then it's okay this patient is fine she can go home but if the patient now has a score of three to five this is well patient and basically they're triggered to do something so either in the hospital they're told what the who needs to go and see the patient or if they're outside the hospital in the private hospitals they're told how soon they have to get the patient in and this is really significant because one of the reasons I'm sure many of you have heard about the three delays one of the reasons why many women die is because there's been a delay in getting them the help that they need and even when I went to Lagos I was quite surprised to find that there are many private providers who still sit on these women for hours and hours if not days before referring them in quite late to places like Lagos Island but that time it's too late to do anything for them but we thought with numbers it was like a common language everyone could understand if you're sitting on a woman with a score of six to eight you know that the chance that that woman is not going to make it or the outcome will be bad is quite significant and we have no excuse for not referring the patient so we want people to really start talking with a common language and in numbers and that really is making a big difference so to sit on a patient with a score of 15 is completely unacceptable and in Lagos Island now they've started to audit their figures for the past month and they're finding that the patients who are coming to them now have scores of 15 but quickly with intervention they're actually bringing those scores down to nine to six to eight so it's making a big difference and before they were having significant numbers of deaths because of late referrals actually for the past few weeks those deaths have gone down by 90% with the Tura and the Shea system so as I explained to you the reason why this Tura system and having that score system and really concentrating on Shea is really significant is that you can quickly pick out those women who are really sick so for instance in this world which is really overcrowded how do you know a woman is sick when you're the only midwife looking after 50 women it can be really difficult but when you start with that question is there any woman that I'm worried about any woman that's sick let me just go and pick her up let me just do what observations I can do it makes such a big difference so that's what has started to happen in the free hospitals so this picture illustrates how we pick up some of these women so I happen to have a post-soxymeter where I can sort of test the oxygen levels in the woman's blood and you can see here her oxygen level is 85 which is way way too low you can look at the urine which is what I call coke colored so that's another way that I sort of teach people to identify the sick patient does the patient look like coke, phanta or sprite this was a patient who was very very sick with sepsis and also had preeclampsia as well she luckily made it because we picked her up quite early now when we deliver the training we are very hands on and very practical we do not believe in sitting these midwives that you can see here and Miata who was my trainer from the UK a critical care trained midwife we don't believe in sitting them down in the room for four to five days and teaching them by PowerPoint it doesn't make any sense they need to be out there because we know as we're sitting in that room there are women languishing around in hospitals that need help so we were very very hands on so this was in Malawi Queen Elizabeth very very hands on in teaching them from day one how to manage the patient at the bedside the other thing that they had to do and the midwives are so great at this you can see here on the left the medical director in Lagos Island maternity Donald who's been such a fantastic champion and then one of our young midwives who is now staffing the the Lagos Island maternity critical care unit and service looking at all of these observation charts that I bought from around the UK because I was very mindful of the fact that if you want people to use things they have to understand it they have to design it themselves and it has to fit their context so I never go into any of these hospitals and say look this is the documentation you're going to use this is how you have to communicate they have to work at that for themselves because then they're more likely to sustain it and that's what they did in Malawi it's what they did in Kenya and it's what they've done in Nigeria and I think this has been critical to making such a big difference you can see them ready looking at all of these observation charts and working out how to design their own observation charts here's a consultant anesthetist and two he's left you can't see there's a midwife to have a midwife and a doctor sitting side by side designing guidelines it's not something that happens very often in Africa especially if you're not like a senior matron or you're not in a school you just don't get that opportunity to sit down share your experience and work on something with a common agenda but here the team actually have to sit down together and build the algorithms and the guidelines for managing these patients and that makes a big difference and you can see here people building guidelines on the wall so this is a pharmacist working with midwives to build the sepsis guideline and to help them I just bought lots of guidelines that I got off the internet told them this is what this hospital does in the UK this is what they do in the States this is what they do in Australia this is what they do in Sydney this is what they do in Italy look through it cut and paste stick them on the wall and come up with your own guidelines and this is the reason why they're able to do the documentation and the guidelines and everything else really quickly within three to four days because they're building it themselves from scratch in a really simple way similarly here you can see in this picture a midwife who is now head of the safe motherhood unit in Malawi on her hands and knees building the observation chart that would aid referral from the health centre to the main hospital Queen Elizabeth so it really is a very hands-on interactive program and this slide basically just demonstrates what a critical care unit looks like so this is the one in Lagos Island where they've got four beds and they've broken the beds down by the score of the patient and then opposite those four beds they have patients who are maybe not scoring as highly but need to have a closer eye kept on them just so they don't sort of get worse but in Lagos Island they quickly realised because they get so many bad referrals they quickly realised that they could not just offer a unit and this is the reason I loved the team so much they said no Gloria we have to offer a critical care service at the bedside so that we can give that service to women wherever they are in the hospital so that's what they did they designed pathways and flow charts so that even if you were not critical care trained you could step by step know what to do for the mother and that really has made a big difference so I'm really really proud of the Lin-Ku unit which has been staffed and headed mainly by Chief Midwife and her team but with support from the obstetrician and the anesthetist and you know a key part of she and Chua is like I said prevention we really want to prevent these women getting sick in the first place and the key part of that is avoiding caesarean sections as an obstetrician I have to say that especially when it comes to coverage avoid the caesarean section like the plague because the chances that you get sepsis especially if you have HIV or you're diabetic or you're sicker is this so high I've seen so many terrible cases especially among very young girls that I try my best to really implant the prevention of those conditions on the labour ward intrapartum so I'm very pro vaginal where it is safe, where it isn't safe caesarean section and then even then the process has to be quite tightly regulated so these are just a few more pictures they're showing you she can see her mother and child you try and keep mother and child very close together for me that's really really important and I think this process has really I mean I don't think it's something you can teach you know to have empathy for your patients but you can see her Sylvia and Betango in the Malawi unit the empathy that she's displayed for her patients I mean she's still working there now since November 2013 sometimes she does 24-48 hours she is so strong and she's such a good example as a midwife and I think she's the one that really spurred me on to keep going and now my plan is to use her as a trainer for other midwives across Africa to really embed this so she has really made a big difference for mothers mothers are really making it you can see this mother here who you know I actually thought we were going to lose her she had sepsis I thought she was she wasn't going to make it but actually mothers are now making it because of the sheave system where we have just concentrated staffs understanding and management on just those three conditions so as I said before I've delivered this in three units Queen Elizabeth in Malawi Pumwali in Kenya and Lagos Island Paternity in Nigeria they're seeing great results the big issue they have is just the late referral and this brings me on to the next part of my presentation and I'm aware that I don't have that much time so I just spent five minutes talking about the next part which for me is the next part of the sheave campaign prevention prevention and early recognition so recently in the Royal College of Surgeons and Islands conference they spoke about the fact that hospitals are for repairs and the community is where health is built and I really do believe that I believe that women are essentially healthy and the aim of the institute is to keep them healthy so in order to do that we have to really work at the community level we can't sit down and wait to pick up the pieces with these women because there's only so much capacity that these hospitals can accommodate so we have to deal with the late referrals which are really significant and she has really helped me to start tackling that late referral and the empowerment of women at the grassroots level so she has really helped me to tackle newborn mortality and the champions of newborn mortality and mobility and I say look the biggest killers of these newborns or their babies are their mothers and I don't say that in a bad way but actually most of the babies that are in that neonatal unit or the ones that die come from those mothers that have sheave or mothers that have not had their sheave managed carefully in labour at all so if we can tackle that we can actually have a knock on effect for a lot of those mothers so a lot of these babies in the neonatal unit or the deaths are due to pre-term sepsis so if the mother has a temperature we know the baby temperature would be one degree higher or a six year so if we start to tackle she we will start to really tackle what encompasses she as well which is the newborn mortality so think about it 23% complications from infections can be reduced if you start to tackle she the six year rate which is really significant I think it's even higher than 23% in some of the hospitals you can see here a CTG or CTG at the back horrible, horrible decelerations with this baby because the mother has sheen it's not being managed appropriately and then prematurity so I spoke about F in my algorithm in the matrix and I'm a big fan of delayed called clamping or what I call placental resuscitation the tendency is when you have a baby that's distressed or we're delivering the baby as an emergency we just want to clamp the cord straight away forgetting 70% of the baby's blood if not more is still within that pre-center so I have a big there's a big push for me now to say do not clamp that cord even if the baby is really distressed you have the best chance or you can give the baby the best chance by not clamping the cord and that also has really made a big difference with a lot of these babies in the newborn unit so this baby here that was extremely white actually had ended up having a blood count of about 2.5 when it should have been maybe 12 or 13 so I advocate just in Africa but even in the UK if there's fetal distress please do not clamp the cord you can resuscitate the baby on the cord and try and get as much blood into that baby as possible that really is what is needed for resuscitation so she has really helped to open doors for me when I started nobody will talk to me especially when I spoke about training midwives they were not interested but with that she campaign and also the gains or the impact that I've shown in Malawi doors are starting to open so in Lagos for instance you can see here the medical director Donald Imosemi a fantastic proactive leader who galvanized a very senior team to come for training and on the left hand side the director of medical services for the Lagos State Commission who is so passionate about this and wants us to sit down and work out a Lagos state strategy to try and reduce mortality across the whole of the region she is really well aware of the fact that death is just the tip of the iceberg if there's one death we know that there's 30 times as many nearnesses where women don't go home when they should when they're in intensive care and even greater than that morbidity in the community is huge many of these women that have preeclampsia go home with no follow up they come back again with preeclampsia maybe the second time they don't make it they're losing their babies so we have to tackle this at a community level and to tackle it means that we really have to think about the state of our healthcare workers midwives for me are key because they're so close to the mother but we still have a great shortage of midwives within Africa I think just today I was reading an article that said that we're going to have 12 million healthcare workers short by 2035 especially in the poor urban areas or in the rural areas we don't have anywhere near where we should WHO said that we need 230,000 head of the population in some countries in Africa you're lucky if you have 37 100,000 and two doctors it's not enough so we have to do a lot more and this is where the she campaign of fellows come in so the she fellow campaign is saying that let us start using our biggest valuable resource which are the women themselves and especially the adolescent girls who are more likely to get she conditions and also to die from the she conditions let's start to use them as community health workers at the moment we have community health workers who are tackling every single condition under the sun and they're doing a fantastic job but I think that we could do a lot more if we were more specific as I said before and not just sensitive target these adolescent girls teach them about their health what they're more likely to die of they're more likely then not to go down that route and they can also help other mothers as well they're young they're fit they can go around they can identify these mothers really simply these she fellows I keep saying they may be ignorant let's educate them but they're definitely not stupid they're more than capable like this group here who I was teaching about the obstetric fistula they did not know what the fistula was they're just been repaired we're about to go home I put my laptop on the floor and I said this is what your fistula looks like and I showed them photos and videos and they were fascinated and the discussion they had was one of the most academic discussions I've actually had the privilege to sit in on so I feel that we can really start to use these she fellows women and especially adolescent girls to really out there and start preventing and managing recognizing these conditions and helping the women so all of these mothers that I delivered I think potentially could be she fellows of the Institute the Institute is an academic body but it's not just for the professionals these women also have to be fellows of that Institute so I think she can really do a fantastic job I think she's able to do a lot of prevention I think she's able to avoid a lot of those conditions and she's educated and I think she can really start to tell us the reasons why women find themselves in these situations in the first place at the moment we are very sensitive we are not specific about what the actual issues are on the ground because we think we know in our infinite wisdom in our academic institution but I think we need to really start getting close to where the problem is and using these women to tell us what the issues are because then we can start to build sustainable programs so I feel that these she fellows they can't read they can't write they haven't gone to school they can actually start to work and it's really hard to reach spaces in the rural areas in the poor urban areas that qualified professionals they want to go to and they can really be a great asset to our service they can do simple things like identifying anemia so you can see my thumb at the bottom and you can see it's launched a little bit because I'm pressing down on her eyelid but even then it's not completely white this woman has completely white membranes she's anemic this is something that she knows have started picking up for me themselves they've got eyes they can see this is sepsis and this is a what I like to call a she fellow a relative who was a quite a young adolescent boy who was dressing his mother's wounds with brown sugar so this is something that can be done in the community because one of the big issues I found is that when you have a woman with sepsis the tendency in some hospitals is that they say okay she's got sepsis we're going to go in and do an operation again they cut her open even if they find nothing they think oh the sepsis must be coming from the uterus the uterus comes out she has a hysterectomy sometimes at the age of 17 and she has a dead baby to boot as well so I'm very keen on avoiding the sepsis but if she gets sepsis let's try and be conservative and conservatism can actually be achieved within the community as well so brown sugar has been known for decades to treat infections and the way it works is you've got bacteria eating away at the skin give it sugar to feed on instead it leaves the skin alone, desiccant to heal so brown sugar is what a lot of relatives are using now to good effect a number of the programs I've set up and it helps a lot and of course they do a lot they look after these babies anyway just teach them don't keep them ignorant about keeping the baby warm keeping the cords okay they can do a lot so there are many things that these she fellows could do to contribute towards the system and I think she will do that she needs something and at the moment community health workers are left in limbo we don't pay them they're volunteers and of course they have to survive they have to eat so they often do other jobs and therefore it means that sometimes they overlook sometimes the symptoms and signs that these women have my aim is that these adolescent girls actually should get paid they should get some kind of salary they should get some kind of security and along the way understanding what these she conditions are and helping these women to recognize and manage them they get to understand their health they contribute to the health system and also get an education at the same time because what we will be given them is health literacy which is almost like a gateway sometimes for them in becoming literate in other areas as well so salary health and education also spell she and that's our aim now to work with partners to start coming up with community health programs employing these adolescent girls almost as interns either a few years if they want to continue going to become midwives or continue as community health workers that's fine but it gives them a gateway and an understanding and a contribution towards their societies so that's the aim of the she campaign and my question to you is what do you think she can do because you know we've got lots of ideas of how we can start to fund this campaign and get these social enterprises started get these women paid get them generating their own incomes in the community and at the same time they're delivering a vital part of the health service but we need ideas and we need your support so my details are here I'm happy to have a discussion with you now about how you think the she campaign would work I'd be happy to speak to you privately by email you can follow us on Twitter or follow me at my personal Twitter thinking box and please tweet about what we're trying to do the she campaign we really tried to build this movement I think it has great relevance not just for Africa but I think all over the world where people are struggling to finance the health system and I think community support and prevention is key I think to really keeping our populations healthy so I think if this really takes off and I think it will take off it can really have a knock on effect I think for just how we deliver health in general. Thanks Corrie that's an absolutely wonderful presentation do you want to just finish up I just wanted to acknowledge the people who I mean I couldn't have done this by myself obviously so I've had quite a number of supporters who've really believed in she such as Miata, Chimma, lots of MDs from different hospitals my UK colleagues such as FIO and of course organisations such as the Virtual International Day of the Midwife are giving me this platform which Medical Association couldn't have done it without them and I think if we all start to collaborate together we can really start to make a big difference so thank you very much. Thanks very much Gloria as I said at the beginning of the presentation there's just so much information that Gloria had to give there and we could have easily done two or three sessions so I know certainly from the comments that everyone's really enjoyed it is there any questions just we might take one or two Corrine I completely agree with you I think that's the same here in Australia it would be great if we could concentrate more on the basics instead of the piles of paper work that we have to do. I was talking to Gloria about the CUMU charts you know the early warning charts that we use here and I think a lot of time is spent on them rather than actually looking at the woman so I certainly think that going back to basics is very beneficial. Okay I can see a question here from Cecilia about resuscitating the preterm newborn while still attached to the cords. This is not routine in the UK at the moment especially when there's fetal distress optimal cord clamping has had fantastic champions in the UK and it's really starting to spread in terms of sort of waiting for white waiting for the cord to go white after three minutes if possible. So I think it is starting to spread I think my issue is that the key group that really do need what I call placental resuscitation are the ones that are not getting it and they're the babies that really have fetal distress and especially the preterm babies we tend to just cut them off straight away and that's one of my big campaigns now which is number one slow delivery of the baby is really important but definitely keeping that baby attached to the cord as much as possible because I've found especially in Africa it really helps resuscitation. I've had babies who have come up with meconium really really sick and just a simple process of delivering the head really slowly putting the baby on the mother's tummy and then not cutting that cord is enough to the baby self resuscitate itself even the sickest babies and it gives the baby the best chance so I think there's a lot that we can still do in midwifery and I'd like to say I'll take credit for the placental resuscitation but of course it's working with fantastic midwives, my sister's a midwife and I've got lots of midwifery friends and colleagues just observing what they do sometimes I feel we don't understand what we do but we do it because it seems logical it makes sense but having now researched it scientifically it makes a lot of sense as well so I think in the UK we still have a long way to go in terms of dealing with a distressed baby for the baby that's not distressed I think people already started to take up that message do not cut the cord until it's turned white. Yeah we're finding the same thing here in Australia it seems such a logical thing to me I'm really unsure of why there's so much resistance so I think we're probably experiencing the same thing all around well thank you very much Gloria I think the she campaign and that acronym too is just a really really easy thing to remember and I think we're all going to go away with that implanted in our brain she can, she is able and I think what was the third one she is she has and she can. Thank you very much for that Gloria okay so we'll just finish off with a couple of the final slides I'll just end the recording


All right, so this is a follow-up to the back place hard drive stats of 2017 now I seen some people say that their BS they shouldn't be used for decision-making and I know this is just a factor in decision-making But they I think back place really provides some detailed statistics one They give you all the data if you want to remissage the numbers yourself, but let's dig into a couple things. I was linked to a video or someone says oh, they're not using enterprise drives therefore this comparison is very unfair and To the drive manufacturers and I'm like no Like you're right on some of them not being enterprise drives So they're not being used the way they should be used and if you use something not the way it should be used It's definitely gonna wear out more and not you know last as long as manufacturers expect so That being said I did some digging. So here's the charts the C gate drives the HGSTs WCWC's and one things we kept bashing on is been C gate because of some of the high failure rates that were higher than the overall average Matter of fact C gates was pulling up some of the overall averages on the failure rates on here Now an aggravation to me is that this is just a photo and I can't just click model numbers to do the research But don't worry. I took care of that for you. I threw this all into a Google drive Document so I can just link it to you you can click on these and do some of your own reading Do you some of your research and learn more about the drives now? I highlighted these in orange because these are The couple really bad failure rates and a perfect example of drives not suited for the use. These are standard desktop drives like Put them in your own computer not put them in even a NAS not put them in an enterprise environment with very high usage So it is fair to assess that these drives having premature failure makes sense it's not they're not suited for that level of use and Statistically when you look at the number of drives they have to see that only 1.65% of these drive failures You're talking about Thousands and thousands of hard drives to even come up with that number hard drive failures I mean they do happen often enough. We see them. I own a computer store But in the big picture of things I rarely ever had a hard drive fail and all my years one of mine It's not it's a it's just a gamble always back up, but hard drive. This is why it's so hard to produce this kind of data on These systems, especially when you talk about like a desktop system It would take to get this many desktop systems spin it up and down when you're not actually using them A long time to die because they're not being heavily taxed or heavily used my computers at home Off most of the time when unless I'm actually using it the same with here when I'm here I'm using it when I leave I shut it down suspended hard drive spin down So they don't see the near the usage and where you're gonna see running in a data center now These seagates like I said, they failed prematurely But we jump up just to this one here and granted It's 29% because you don't have a lot of drives But it is a barracuda drive and one above it which they have a lot more of this M 000 drive they have 32,000 hard drives with almost three million Day count on here. So that's days of all these guys being using in usage They have all their statistics. I guess I'll link the back way so you can see their formulas But that's a really high failure rate for these drives, and I know barracuda is kind of like okay I'll put them in my nastor a little bit better. They're not enterprise. So let's jump up to the enterprise drives Here's the seagate 8 terabyte enterprise class drive And I have a like said Amazon affiliate links for all these if you want to buy one 1.2 percent That's still pretty low failure rate overall The drives I put the prices of the drives here just can get an idea about how much they cost That's gonna vary with Ben based on when you're looking at this this video. So this drive at 1.2 percent That's a little higher 0.9 percent pretty low 0.99 and then this one here is at 2.01 percent, but all these top ones here. These are seagate enterprise I believe there. Yeah, these are the enterprise helium drives So maximum storage capacity for high Shrek space efficiency Blah blah blah lots of marketing stuff in here, but these are their this is the the king daddy of what they do This is their premium helium product Next to ssd. So this is their premium spinning product that they make for high capacity and it has a High failure rate. Okay, not real high. I know you're you're like time you're splitting hairs here But when I look at these hgsts the the first one here, I Have the data sheet pulled up on let me get it here This is the just standard Death Star hard drive.  This is like a consumer buy it put it in your Computer hard drive. I I have some prices in here But the prices are based on their new NAS drive which when you search the model number comes up So I have a link in there to the NAS one. I know it's not the exact same drive. So I'm qualifying that right now But it is the standard cool spin desktop hard drive point 32% failure really low. I don't know what the price of the drive was like I said They couldn't find I searched them and it was just really old dead links for this particular model number now The HM stood for a mega scale hard drives. Let me read you what the mega scale says Which is kind of weird. So this is the mega scale specifications They have a data sheet on them and where is it right here mega scale HP ships mega sale DC hard drives for low workloads and The mega scale 4,000 bees are not for high workload. This is some of the other You know data statistics they have on these drives So once again, not enterprise level drive at point one nine percent failure rate and here's another one There's a slightly varied model. I don't know exactly what the difference is. I actually I didn't type the B in here This is the B ones and a ones of B. So the B model has make sure I get them right Point four or five percent. Yes, there's the B. There's the a model I don't know exactly what the differences are in those. I'm not that relevant to me You can look forward if you want, but these drives look at the count of drives They have you've come into between all the Hitachi drives. You've got about two million drive days and See about 22,000 hard drives. So plenty sample and you're not skewing it by only having a few drives It didn't fail. So it looks like they're doing great. That's why I skipped Some of them like the Toshiba They have 45 hard drives with only 4,000 days none failed. Thank you good. That's good But that's not the best statistic compared to a million drive days and you know 22,000 hard drives But compared to we speaking these HDSTs super reliable and then we come back to the Western Digital's now I've always loved Western Digital for their warranties, but they're actually Not quite as good as the C8. Now. I know these are just the red NAS drives. They're not their Full-blown high-end enterprise drives, but still um, that's that's a kind of a high failure rate But oddly zero on this one here So I thought that was kind of strange the three terabytes apparently were rock solid, but the four terabyte and six terabyte now That's usually strange because when you double a terabyte you might sometimes just doubling the platter So usually you might assume that this one and this one are built on the same. It's a gas I don't know for sure aren't the same platform But they do have a higher Do have a fair rate versus this has no failure rates and they have a decent not a huge amount of dry So that's also with the Western Digital Take it with a grain of salt they have 180 drives installed and only 45 of the other one So I'm not gonna beat up too hard on Western Digital because it's a low drive count But the C gates we got some really high drive counts in there, you know, 7,000 and here 1,000 220 here So 7,000 220 there so really high drive counts on the C gates 180 drives and 45 drives on the Western Digital Maybe not quite enough for a statistic, but 437 we're getting up there with a pretty high one with this one here So this is a little bit deeper look into those statistics and they're not the only statistic maybe for buying a hard drive I mean price comes in as a factor. So, you know, how are they priced? Are they affordable for the project? But you have to calculate it especially as a business owner I think about all right if I have to build a rave for a client and I have to warranty it and I have to deal with The client any downtime that's related to that I want to take in that consideration and if I pay a little bit more now and I know if it's the drive is You know $30 more drive and I'm putting four drives in. Okay, that's gonna add up There's a hundred and twenty more dollars But what does it cost me to send a tech out there rebuild it go through the inconvenience of it and send that drive back Which means I usually have to get another drive and put it in there and wait for that one to come back and The headache of it all When you're a home user sure you can you can use it to shop price and go Okay, I want the cheapest one because this is what I have a budget for And then there's speed is going to be a factor how fast are some of these drives? There's some variations in here some of these have 256 meg cash means have 64 meg cash But overall I got a man. I am really impressed with these HGST desert now What I did link to with the Amazon here, and I'll click it for you is They I searched a model number these ones come up these nas ones and maybe they're the replacement for it They're a similar drive and now they just sell them as a NAS drive makes me kind of wonder if they go Hey, these are so right. Well, let's put NASA. I don't know if that really happens. I'm completely speculating on that But HGST, they've really they seem to have a good reputation We actually are running for eight of them now eight HGSTs in our Array, and I haven't had any problems and they've really held up well and not give me any crap So I haven't had any of them die on me Well, we had the one time we ever had one die was out of the box when it was shipped to us from the company And it was broke on the side and we put it in anyways because we want to see what happened And it lasted a week and then it just crapped out So that's the only HGST died and they sent me another one and we replaced it We've never had a problem since no bad sectors or anything and ours is you know pretty intensely used It's my freelance box that runs my array that runs my Zen server and we dump client files back and forth to it for our retail server backup So they're in constant use not the same hard use you're gonna get out of back plays But definitely in some pretty heavy use But this is a deeper look at the entire back plays drives And I figured why not link to them for you so you can do your own research and you know Look at the model numbers and make some decisions on this This is not the end all for everything But I wanted you know for people that kind of called me out on it You sure I think that was a fair assessment to say well if you're gotta be comparing apples to apples And so I highly these for they are absolutely high failure rate And they're completely not for use, but then I look just below it going not for use But wow these things are made really well So that's just my thoughts on this and some of the hard drives But if you're doing if you're here because of my free nas videos and things like that This is something when you're gonna build a free nas box. You have to make a lot of decisions On hard drives and it's helping influence my decisions to buy some HG STs I'm if I was gonna build another array. It's still a toss-up. I like the Western digital So I built a few of them with those and those are running fine Without any problem. They're not been a headache And all we've built a handful on the Western digital platform with their purples We've built a handful of surveillance systems with like four cameras and a WDC purple four terabyte Simple drives and knock on wood none of those to give us any trouble But I don't I'm not installing them at 29,000 drives at a time So I have to rely on anyone who can aggregate massive data I wish Google would give us more data any of these data centers Open it up a little bit be like the back plays guys We the more data we can get the better picture we can get mean share some knowledge And we you know, especially with the manufacturers themselves. This has got to be helpful to manufacturers to understand what's going on in these data centers I don't know what level of interaction they have but hopefully a lot because we want like to see some improvements on that So if you like to come here like a subscribe if this was helpful Hopefully it was let me know if I'm completely wrong and bonkers. So you call me out on it Feel free to leave comment below Give a thumbs up on this video and like subscribe all that fun stuff That's it for now. I'm gonna get back to work But this was interesting. This was my deeper dive into it and links will be to this document It'll be public so you can click on everything and you know not have to look at the stupid JPEG Man by the way back plays if you watch this can you not make that a JPEG that would make my life easier. Thanks


So our next speaker is Cecilia Bolion-Cous, who is a post-doc at the, this is an English translation, the Institute for the History and Philosophy of Science and Technology, and the lab acts, who am I? She is most recently a co-editor with Charles Wolfe of the volume, Philosophy of Biology, Before Biology, published by Rutledge, where she examined biological and protobiological writings from the mid-18th century forward. She has written on how nutrition shaped viadal organization in the late 18th century and forward. In her talk, The Concept of Metabolism, Biological Identity, and the Challenges for Microbiome Research, Dr. Bolion-Cous will build a theoretical framework for thinking about biological identity to connect a metabolism-based notion of identity with recent findings about the relevance of microbiota for all functions of life. So the floor is now yours. Thank you very much. Thank you very much, Chris. OK, so thank you very much to the organizers for inviting me today. What I'm going to present is a kind of work-in-progress material, so please be indulgent. And I look forward to your suggestions to improve it. It's part of a new postdoctoral project that I just submitted and that will start in next September in Louvain-Lenevin, Belgium. OK, so for a few decades, we have come to realize the extent of the intertwining between symbiotic bacteria and organisms. Various functions in animals and plants are carried on by symbionts or mutualists of different species. For example, termites rely on bacteria to digest cellulose. The cicatrization processes in mammals are due to symbiotes. And very probably the origin of placenta in mammals is due to symbiosis with a virus. And even though the acknowledgement of the microbiome's role in physiology and development is widespread, no consensus yet is rich about the impact it should have on our conceptions of biological identity and its maintenance. So in my doctoral dissertation, I have shown that the concept of metabolism had since the mid-19th century, I would say, has played a key role in elaborating the notions of organismic individuality and identity, sketching a view of organisms as self-organized, bounded, and autonomous entities. And therefore, I think that there appears to be a strong contradiction between this inherited metabolism-based notion of identity, which I will elaborate a bit in a moment, and the recent idea that heterogeneous elements can participate to the organism's identity. So any account of biological identity now faces a tension between the traditional reference to metabolism and the recent realization of the extent of the involvement of microbiota within vital functions. So metabolism, indeed, concerned processes through which the alien matter is made into matter homogeneous to the organism itself. But inversely, the contribution of the microbiota to the maintenance of the organism is precisely due to the bacteria as remaining themselves, therefore as remaining somehow heterogeneous to the organism. So this contrast between the two concepts through which biological identity has to be explained is a key philosophical issue that an updated account of biological identity should address today. And such attention needs to be solved if we want to make sense of the concept of biological identity in this so-called revolution in today's biology. So the goal pursued by the current project is to build a theoretical framework for thinking about biological identity able to connect a metabolism-based notion of identity with recent findings about the relevance of microbiota for all functions of life. The project draws on the historical and conceptual analysis of metabolism that I undertook in my doctoral dissertation. And it will contextualize the current problems raised by microbiome research for the notion of biological identity in the light of the inherited complex conceptual structure of the notion of metabolism. OK, so about biological identity. Making sense of the concept of biological identity means mainly two things. First, accounting for how an X is identical in the sense that it is X and not Y, and therefore is discriminable from any Y, hence distinct as X from Y. Second, accounting for how X is likely to be re-identified as X in many contexts and time intervals, especially how can X endure as X, right? So I have chosen to name the first question, the individuation question, and the second one, the enduration question of identity. Regarding biological identity, the individuation question often revolves around the general concept of information and has in the last decade often be centered on accounts that put genes and genomes on the foreground, whereas the enduration question arguably involves the concept of metabolism as metabolism captures the processes through which individual organisms maintain their identity through time and change. It has indeed often been noticed that general question about life and models of what life is are divided between two families, the ones that put replicators, gene and information and heredity first, and the ones that privilege metabolism. As to the enduration question, namely the maintenance of identity and the endurance through time, so this question is frequently framed either in terms of multilevel selection processes, that is, how is the collective of cells buffered against selfish mutants, for example, or in terms of self-organization in what is now called the Varellian tradition, which involves investigation of metabolism at any levels. However, as I have shown in my dissertation, metabolism arguably bridges those two identity questions, namely individuation and enduration. So metabolism is indeed a process through which a living body integrates external matter and possibly inorganic matter and makes it into matter akin to itself. And in the same way, metabolism, metabolizing means turning input substrates into the living matter proper to an individual with a given genetic identity. Yet, the notion of metabolism, because it's instantiated at various scales and combines an idea of specific chemical processes and a notion of biological functioning, is multilayered and complex. And most of the time, the philosophical users of this concept overlooks such a complexity. Philosophical accounts of identity that mention metabolism indeed mostly stem from the formal self-organization perspective or from research on origin of life so that authors hastily subsumed this concept under their favorite philosophical scheme or issue, that is, for example, self-organization, chemotone, origin of life protocells, and forget other aspects of the concept that would be relevant to the identity issue. In contrast, an approach that would be attentive to the conceptual genealogy of the concept of metabolism would allow us to capture those complexities and layers of sense. So that is why I now turn to the late 18th century just to give you a quick overlook of not the emergence of the concept of metabolism, but more the problem space of metabolism. Because as Hannah said earlier, it was Théodore Schwann, who, in the context of the cell theory, first coined the term metabolism. So in the late 18th century, just a quick overlook of the chemical and biological context, so it is well known that Lavoisier defended the conception of animal respiration as a combustion. And at the time, so that's the first part of the puzzle that I'm just trying to sketch here. This work by Lavoisier and Seguin was done in the context of the search for the physical chemical conditions of life in the late 18th century by means of chemical analysis of organic substances. People were looking for the composition of organic substances that would constitute the living organisms, namely carbon, hydrogen, oxygen, and nitrogen, each of which was characterized by the proportion of the elements they would contain. So in the late 18th century, the chemical theories of biological processes mainly relied on the elementary composition of organic substances and were then conditioned by the state of the ideas about these compounds. After the Lavoisier theory of respiration as a general combustion, there was this beautiful picture of nature that divided life into two rains and that would distribute the chemical works to the plant and the animal. The plant would be responsible for any organic synthesis in nature, whereas the animals would only be responsible for chemical analysis, that is combustion in Lavoisier's terms. So life in a certain way was kind of alienated because it was divided into, so the chemical work of life was distributed in two rains or divided in two rains, the plant on one side and the animal on the other side. In parallel to this great depiction of the chemical work of nature and this division of life in two rains, the knowledge of the elementary composition of organic compounds started to grow, for example, with the work of Bertollet and Fourcroix in the late 18th century. The main point here is that slowly nitrogen was considered as the main characteristic element of animal substances. So one puzzling question at the time was how on earth, well, why would animal substances contain as much nitrogen since animals could not be responsible for any kind of organic synthesis? Where do these great quantities of nitrogen originated? Where do they come from? Because animal could not synthesize anything. So the response to this question was that these great quantities of nitrogen had to originate in nutrition. So that at the end of the 18th century, early 19th century, you started to have this growing theory of nutrition as direct assimilation. Animal nutrition was a matter of direct assimilation. So identity maintenance for animal organisms was depicted as a direct nutrition. That is, the absorption of a nutritive matter had to be already identical to that of the organism that would assimilate it. In a way that a substance would be nutritive if and only if it was chemically identical to that of the assimilating organism. And that is why albumin and fibrin would be considered as paradigmatic foodstuff at the time. So for example, in the works of Jean-Baptiste Boussaint-Gault and Jean-Baptiste Dumas in their essay de statique chimique des êtres organisées published in 1941, they both write an animal constitutes in effect a combustion apparatus from which carbonic acid is continuously disengaged and in which consequently carbon continuously burns. So I forgot here to quote Holmes from his lectures on intermediary metabolism, where I take the quote. So Holmes says that Boussaint-Gault and Dumas held a vision of the combustion of foodstuffs in animals that was derived not from direct evidence of the processes occurring in animals, but from a general understanding of the elementary composition and chemical properties of the three basic categories of substances, namely carbohydrates, fats, and nitrogenous albuminoid bodies. And that the near identical character of each of these three types in plants and animals had made it appear self-evident to Dumas and Boussaint-Gault that plants would create all the substances necessary for animals and that the latter, the animals, therefore, did not need to create any themselves. They would directly assimilate them. So that is what I have called a pre-formist theory of nutrition because in that conceptual framework, the histochemical elements that compose an animal are a mere aggregate of the ingested foodstuffs, which immediate principles are only selected and separated during digestion. Moreover, there is a clear focus on blood rather than on tissues, and blood here is depicted as a dissolution of the elements already present in foodstuffs that are isolated, selected, and extracted during digestion. Blood is a kind of dissolution of the elements that compose the organism. So in the end, animals do not synthesize any original organic compound, and they are chemically passive, that is to say, they only destroy or directly assimilate what the plants produce. So they're right. It is in the plants that lies the true laboratory of organic life. In the same way, Justus von Liebig wrote, I like these two quotes because it's so about the general, about what Hannah just said about stov-vexel. I think it's not so clear that it's well, what kind of change from the plant to the animal Liebig refers to. So I think that there is a change, but it's not so clear that there is no synthesis from the animal part, at least. So Liebig writes, herbivorous received from the plant the components of the blood, albumin and fibrid. They feed from the flesh, the blood, and the cheese that are created by the plant. From the viewpoint of chemistry, a carnivorous eats itself because its food is identical with the constituent parts of its organism. And the herbivorous eats itself because its food is identical with its blood. So we'd like to contrast that with Claude Bernard's theory of indirect nutrition. So interestingly, Claude Bernard never uses the word metabolism, nor does he really use the word stov-vexel. In his carnet, he uses the word stov-vexel once, but to criticize it and to say that it's a kind of metempsicosis. I think maybe because it's, to him, stov-vexel keeps the soul of the substance that it assimilates. There is no genuine chemical change in the German stov-vexel for Claude Bernard. And maybe we will see why in a minute. So on his work on the origin of sugar in animal economy, Claude Bernard shows that it is mistaken to believe that the sugar in the blood derives from the digestion of sugar of starch. And he looks for the source of sugar within the animal. So he writes, it was evident that it was the liver from which the sugar arose. And it is clear that in the face of these facts that law that animal cannot create any immediate principle but only destroy what is furnished into them by plants cannot be true since animal in a physiological state, like plants, in fact, create and destroy sugar. So and after that in 1857, he showed that the substance that the liver was making sugar off was, well, he called it the glycogenic matter. So sugar was not made from the blood, but rather from something within the tissues. And the liver could generate both external secretions, such as the bile and internal secretions, such as the glycogenic matter. Those works led Claude Bernard to separate, and again Hannah said that earlier, nutrition and digestion. Digestion would occur in the stomach where nutrition is a more general process occurring through the body. So digestion is the process by which food comes into the body and undergoes a first series of transformation. But nutrition refers to the processes, a series of processes of change and of genuine chemical change occurring in the internal foods, tissues and organs. And this is why Claude Bernard defines nutrition as a general characteristic of living beings, even more fundamental than reproduction in some sense, because it's the constant reproduction of one's own organism, or rather the constant production of one organism by itself. Sorry. So I just want to read this quote from the lectures on the phenomenon of life common to animals and plants to contrast it with the views that were held by Juman Boussango. So Claude Bernard writes, nutrition is the continuous mutation of the particles which constitute the living being. The organic edifice is the site of a perpetual nutritive movement which leaves no part of trust. Each one, without seeds or respite, takes its food from the medium that surrounds it and into it. It rejects its weights and products. This molecular renovation, which is a top of the time, is impercitable to the site, but as we see it's beginning and its rest, the intake and output of substances we conceive of its intermediate phases and we represent to ourselves a flow of material which passes incessantly through the organism and renovates it in its substance and maintain it in its form. The universality of such a phenomenon in the plant, in the animal and in all their parts and its consistency which suffers no interruption makes it a general sign of life.   So in such a way, what Claude Bernard says here is that nutrition is not a direct assimilation process, it's rather a genuine process of changing what you eat. So it's an indirect process of organic synthesis, organic and organizing synthesis. He writes that animals must have within themselves mechanisms that drive similar materials from this very diet and regulate the proportion of them that must enter the blood. Finally, I like this one, the living organism is made for itself and it has its own intrinsic laws, it works for itself and not for others. Okay, so there is nothing, for example, in the law of evolution of grass that implied that it should be cropped by a herbivore. So just a detail here, when Claude Bernard speaks of evolution, this has nothing to do with Darwinian evolution, rather it's a synonym for individual development. Nothing in the law of growth of the cane that announces its sugar must sweet man's coffee. The sugar from in the beet is not distinct either to maintain the respiratory combustion of the animal that feed upon it, it is reserved for consumption by the beet itself in the second year of its growth when it flowers and fructifies. So the organism through this indirect nutrition makes its own substance for himself. So initially, the concept of metabolism emerged in the mid-19th century in a position to a view of identity maintenance as direct assimilation, namely a process through which organisms directly integrate the elementary organic building blocks that would compose the foodstuff they absorb. The emergence of this problem space of metabolism therefore provided biology with the view of organism as bounded individuals and autonomous entities. This is the individuation side of the problem. It likely to self-organize and to self-maintain this is the enduration side of the problem in a wide variety of contexts. So ultimately, metabolism had to integrate the mechanisms to support the regulation activity and the maintenance of identity through time at various integrated levels. And metabolism thus made it possible in a sense to link the specificity of organism to their chemical conditions of existence and determine the scheme from which the specificity of organisms, namely the soft production and self-preservation, could be understood in a naturalistic way. There is therefore a clear sense in which metabolism has underpinned organismic individuality and biological maintenance. So however, as I said in the introduction, the last two decades have witnessed theoretical breakthrough that have affected these two paradigmatic answers to the identity questions, namely information and metabolism. First, epigenetic phenomena, possibly transgenerational mitigate the assumption that the answer to the question of the distinctive identity lies in genes. Even the inherited identity may not be purely genetic and thus multilevel selection accounts of identity which assume a traditional gene center, which assume a traditional gene center in view of inheritance are challenged. Second, the acknowledgement of the extent of the turn-twinning between symbiotic bacteria and organisms led to new insights such as the Holobion concept, namely the set of host and microbes, supposed to be a unit of evolutionary processes and of physiological functioning. Regarding identity, this means that the genome of an organism while essential for its life, as it has been often claimed, is not only the genes of the host. Moreover, the microbiota and especially the gut microbiota is involved in many metabolic processes, including assimilation functions. So those challenges stemming from epigenetic and microbiome sciences, suggest that the individuation and duration questions of identity are more intertwined than generally assumed. And this new development in the understanding of identity is the context of the current project. So in this recent context of the acknowledgement of the constitutive role of heterogeneous symbiotic bacteria within organisms, some philosophers have suggested that biological identity is in need for conceptual clarification. I especially refer to the paper by Scott Gilbert who claims that we have never been individuals. Such a challenge is the major motivation for this project where I would like to tackle the issues raised to a metabolism-based understanding of organismic individuality and biological maintenance by recent microbiome studies on the basis of a historically informed notion of metabolism and its various layers of sense. So the project can be decomposed into three interrelated objectives as listed below. The first objective would be to reassess the self-centered view of identity. That is to say to determine the role, the concept of metabolism should play in any account of the maintenance of biological identity according to physiology and cell theory. This would entail to decipher the individuation and duration aspect embedded in the metabolism-based notion of identity. So second objective is to map the challenges raised by microbiota studies to the self-centered view of identity. That is to say to identify and tackle the obstacles that the implicit use of a metabolism-based notion of identity raise regarding the integration of microbiome science in a renewed theory of biological identity as both individuation and duration. So that would mean to undertake the revisions of the concept of metabolism required to supersede those obstacles. Thirdly, so the third objective of the project is to integrate a theory of the microbiome's contribution to identity within a renewed account of biological identity. And it implies to specify the conditions according to which a renewed metabolism-based notion of biological identity could integrate the contributions of the microbiota to the biological identity. So the first objective concentrates on what I will call the self-centered view of identity, where identity relies on metabolism as a process warranting a constitutive homogeneity of the organism while integrating alien substances. There I would discuss the consequences of focusing on metabolism at distinct levels of the organism, which will define several ways to develop the theory. So I can skip this. So the systematic examination of meanings and roles of metabolism in the self-centered views of biological identity will pave the way for the objective number two, that is the mapping of the challenges raised by microbiome science. So to what extent does each of those views prevent making room for processes in which heterogeneous elements, namely other species organisms, such as bacteria or fungi, fulfill or contribute to fulfilling a vital function. And especially which aspect of the complex meanings of the metabolism concept are most problematic for integrating the role played by heterogeneous elements within an inclusive account of biological identity. And with regard to this question, the difference between organism integration, regulation and self-maintenance of the cell will be explored. And inversely, what specific aspect of the role played by various bacteria species in the microbiota are most challenging for the self-centered view of identity. So I will especially investigate how the concept of metabolism underpins the received and now challenged view of organism as bounded and autonomous individual, which contrasts with the emphasis put by microbiota research on the contribution of specifically and genetically heterogeneous elements to organisms' function and endurance. On this basis, the objective three will lead to sketch an account of identity alternative to the metabolic self-centered views that were exposed in objective one. The objective here consists in suggesting how the aspects of the complex meaning of metabolism identified as most antagonistic to the idea of a key role of heterogeneous elements within identity could be modified in order to make sense of such a key role. So the fulfillment of this project should provide the elements for a future discussion of the immunological views of identity, held, for example, by Pradeux, that explicitly distanced themselves from a self-centered view of identity because, ultimately, the project should lead to a general map of alternatives to self-centered views of biological identity. So I would like to finish with some concluding remarks. So metabolism has indeed appeared to us as the process by which a living body ingests an external matter, possibly inorganic, and transforms it into its own substance. Conversely, metabolizing implies transforming foreign substances into a living matter specific to an individual with a given genetic identity. I have determined that the conceptual space of metabolism emerged in the mid-19th century in contrast to a conception of identity maintenance as direct assimilation, that is, the process by which organism directly integrate into their organic texture the elementary constituents of the foods they absorb. The emergence of this conceptual space seemed to me to have provided biology with a conception of organisms as autonomous individuals capable of self-organization and maintenance in a wide variety of contexts. However, the last two decades have been marked by theoretical advances that have shaken profoundly this pattern. We're now realizing the extent of the interweaving between symbiotic bacteria and organisms. And therefore, any account of biological identity now faces a tension between the traditional reference to metabolism and the recent awareness of the importance of microbiota involvement in vital functions. Okay. So, if we were now to map the stakes of a philosophical reflection on biological identity informed by a genealogical study of the constitution of the conceptual space of metabolism in which this problem crystallized for general physiology and therefore post-Bernardian biology, we would have to distinguish what we would call the traditional self-centered vision of identity where identity is based on metabolism as a process justifying a constitutive homogeneity of the organism while integrating foreign substances. And there are, of course, theoretically varieties of this egocentric vision, depending on whether they focus on thermodynamics, organic chemistry, as frameworks for formulating the requirements required by any metabolism. And whether they focus on integration into the body or self-maintenance as key objectives of the metabolic process. To this selfish vision or self-centered vision, we would oppose an alternative vision in which identity is the result of the cooperation and conflict of organisms of different species that compose an organism. What the concept of olobion tries to name, but perhaps by posing more problems than it solves. Such a vision would integrate the theoretical contribution of the evolutionary biology of symbiosis or the metagenomics of cellular activity, but it is clear that it would struggle to accurately reflect the limits of identity, namely the distinction between all those myocrobes, viruses, and possibly insects that contribute to the identity of a given living organism. It seems to contradict the traditional equation between metabolism and biological identity, but at the same time, it probably requires a renewed understanding of metabolism. So to what extent does each aspect of the selfish vision prevent the development of processes in which heterogeneous elements, or organisms of other species, perform or contribute to perform a vital function? In particular, which aspect of the complex meaning of metabolism are most problematic in integrating the role played by those elements into an inclusive account of biological activity, identity? Probably the difference between the integration and regulation of the organism, the self-care of the cell should play a major role here. And conversely, what specific aspects of the role played by various species of bacteria are most difficult to reconcile with the egocentric view of identity? These are questions that would probably emerge from taking into account this new frontier of the metabolic space that is being built today by the renewed knowledge of heterospecific contributions to the biological construction of identity and understanding where this history of nutrition, which was a kind of preformation of the history of metabolism could extend, is a philosophical challenge of perceiving this new frontier. And I thank you very much for your attention. Questions, comments? Let's go ahead. So I'm really, thank you so much. Really rich and thought-provoking. And I'm kind of struck at this level of kind of philosophical analysis at how recursive the problem is and what metabolism is doing in terms of trying to grapple with the problem of unity. So I mean Aristotle is really coming up with a notion of soul to solve the problem of nutrition as the assimilation of like to like and saying actually that's insufficient to account for how you actually get an emergent organism. So in a way it's a recursion of the philosophical problem. And so I'm wondering, so I kept thinking in terms of the question you pose about the challenge of these symbiotes. And I'm wondering I guess the question of how like or unlike is your problem to the broader question of parts and whole. So I mean that's the, maybe that is the million dollar question if everyone is nodding. But I mean the two soul problem is in a way to say, well on the one hand you have a kind of commitment to total eminence and total unity everywhere and on the other you have a directorial one but nevertheless all the parts are working together with the whole. And so I guess I wanted to ask you more about the kind of specific function of heterogeneity and how the kind of figure of the bacterium is functioning to shift the challenge and whether you think that's productive, whether you think in fact symbiosis asks us to think I mean the whole biome is maybe a concept which would change the way we think about organism that may not be so different from other part whole formulations. Thank you very much for your question. I don't have an answer to that question but definitely I think, so I think that probably microbiome research raises more question that it solves problems at least today and because well one interesting thing is that it clearly changes our received conception of biological identity and biological individuality as a bounded autonomous closed image of what is a biological organism. It does not really tell us what would be an organism, I mean it opens the frontiers. So in such a way that for example Chadeau's work on immunology has contributed also to open the boundaries of the organism and to say that the self and the non-self view of immunology is not right, is not a good theoretical framework for thinking about what is a biological organism and what is the self and the non-self, what is a biological self. But still that does not tell us so what kind of integration must be achieved so to speak of an individual like we know we have to open those boundaries in order to integrate those symbiotes but still any cluster of heterogeneous organism is not an organism per se so that leaves the question open to regarding the metabolism what I found interesting in that context is that so if you go back to the 18th century you also had these old ancient theories of direct nutrition where the quality of the food would pass directly to the eater and that the qualities of the food stuff would not be transformed into a genuine organic substance that would be proper to the assimilating organism and interestingly the conception that Claude Bernard developed in the mid 19th century of indirect nutrition challenged this view so that the living organism would not dissolve itself in the environment that metabolism, this constant exchange with external matter would be a necessary condition for the construction of or the elaboration of its own identity and autonomy in regards to the environment, its environment or the cosmic condition as Claude Bernard say. So metabolism and this is not often acknowledged that so for example in the Scott Gilbert paper we have never been individuals, he lists a number of individual properties that substance our conception of organism as an individual and but he doesn't really speak of metabolism so this is often metabolism is overlooked in the contemporary debates on biological identity and what's interesting with the microbiome is that it challenges this received view of metabolism that contributed to shape this view of organism as an autonomous entity different from any other entities. It's not just that the gene-centered view that contributed to shape this view of biological identity. I saw Charles but as we say in Croatian, Kratka-Pitan, small question, short, okay. Because we're running out of time. Okay, okay, I won't be long. It's just to push, to sort of push you on your framework, although I guess you're, because there was a lot of conclusions in this talk and so I was trying to digest it halfway through and thinking what's the methodological message in a way and I was thinking this idea and I didn't get the exact phrase down from Claude Bernard that the organism does what it does for itself, it doesn't obey kind of foreign external laws, that kind of idea, that kind of intuition. People take that and do different things with it, meaning that this kind of material, so Dennis Noble and people like that who are into systems biology, they take that and they say, ah-ha, we have here uniquely vital laws and processes, therefore we need it. Moreno and Mosho, right now, right? We'll take that kind of material just to insist on the uniqueness of the biological. Others like Tobias Chung will take this kind of material and say here's an interesting episode in a long history of negotiations of inner outer relations and physiology or whatever. Duprey can stick a processional label on to it as you mentioned and others with their internalist methodologies will want to make this a chapter in the history of vitalism. What do you, what flavor, what method, it's not really a question of methodology but what would you like to do with it or what do you do with it in that sense given, I just gave some examples that speak to me in their perspective. I mean, with Scott Bernhard? Well, what would be the example about that? What would this kind of material be?  Yeah, like, but I don't, to me, it's more problems that we open than questions we answer or it's, so what Claude Bernhard, so it's not like a school or a label that would be process or vital laws or it's, I mean, it's a bit of every, of that there are processes, inner and outer relations, the relationship between chemical conditions of existence and specific vital realization of those chemical conditions like, so the intertwinning or the relationship between the chemical and the biological in Claude Bernhard, in Claude Bernhard's view. But mostly the fact that, well, Claude Bernhard explicitly challenges a view of life where, so you have a complementary processes, distriction and creation that were supposed to be distributed equally in nature for the plant and the animals. And ever since Stalin before those two complementary phases of chemical activities and vital processes were supposed to be exclusive of one another or to fight or to have an antagonist action between one another, what's interesting with Claude Bernhard is that Claude Bernhard at the best of my knowledge is the first to say that there is, so the living is not about fighting the chemical forces of dissolution, the living is not about a harmonious distribution of complementary chemical tasks in nature, but living is about fulfilling in cycles those complementary chemical works. So each living does the work of synthesis and analysis. So to me, that's the, so if I were to speak in terms of framework and this dialectical history of the relationship between the vital and the chemical, that would probably be the most interesting part in Claude Bernhard, but to me, that's, thank you very much. In the interest of time, we're going to break but if you have questions, you can email me and I can email the author. Thank you very much. Thank you to all of our presenters and to the audience.


Thank you, Reva. I know you can dance. Mako mi tenea, Baba. Naisha. Na praja ni kuwami bifo wungi. Thank you so much. Thank you, Kenichi. Nisha, nisha, nisha. Baraka sana kuwa. Standing in the grab. Na piyapu tulene na pamoja. Tuleza kusimama. Tuleza Kenichi ni tafabani. Thank you. Tuleza kusimama. Kusahidea. Ryan. Lemi tell you. This is one of the times that TikTok iwekuja pamoja. All the. Watu wote wa aina yote. Watu wa biyashara. Watu wa kutap. Watu wa kugift. Wana na Liliubia goapa. Eh, kutoka maju. Familia yote. Familia groups zote. They have come together. Enwa Batalisha has coordinated all that. Tomba teneima kofi tenea. Revisi Jeremy. Hi, guys. My name is Faustin. Mostly known as Baba Kalisha. So, my name is Faustin. Baba Kalisha. I really appreciate for the love, the support. But there you mean our shkuru too. I really don't know what to say. And to me, one thing that matters in kaitne is to be asked here. Kaitne is above everything. Be very humble and be very kind to anyone. So, sit on here and be in disana. Me mean our shkuru. I'm a very shy person. So, kaitne listen. That is why I decided to help is because I've been there. Ati waka tengini muli kwa muna chika rikiwasha jumba. Nili kwa 2 hako nana. But then, when things happened, let it happen, I decided to go back to Dogu. Nika kwa pichini. Me have been visiting Kenaprayan, Ui Urayan, Nakiyan. I've been going there to support Shoshu. Idi kwa pikiya nani nana. So, the only contact, me mean do liya, mea shushu ni ni mehape. Yos ikudulu wa timenda kubanda bilin. Nili kwa nanguna. But unfortunately that is what happened. Nili to kahuko, nika rudi, and I've been with Shoshu. It's in the Shoshu, I did anything. Susani gemuacha nana, ke kumusaitia dai. So, it's just that kind of kindness. And another reason is why I decided to help is when you remember back then, 20, 20, when my left wife passed, talisha li kwa, ame baki kwa ICU, kuna muda li kwa Ndungunyoro, wanda kwa nangu? Ya. Ndungunyoro called me, yos a kind of kindness li li fanyan Ndungunyoro and his idea, because the same hospital talisha li kwa nalana, muda kwa neksa apo, Ndungunyoro and kwa ni misaige. So, me kutuma pichatu pekiake li fanyami Ndungunyoro and kwa misaige. Within 24 hours, Ndungunyoro and kwa me raised 1.5 million Kenyashili. Ndungunyoro. So, that, ni niya isu say mas kumonja tumumu inibatia to, any means that you do, tumumonja to wata pikiake. At least, niya kwa ni mesema asante kwa Kenyashili. So, that is why I've decided to be there for Shoshou. And tonight, na takatun fikisha 10 million, so tonight, janali li wani kwa revaya, but tonight from 10, 20 tumalize, Shoshou tumu jenge, kama dalu nulia wa nyumba, kama dafa ni ni ni. Ndungunyoro. Because, wata matangi, misha ni mite liwanti. After chair, atas bikuwa. Ile kwa wama wata daba hi ni Shoshou. Up there, ni use the truth. If I've never barred somebody, she will never hear this. Mi, kwa matangi, people came with promises. O, I'll pay for it. Alisha ni isu, most of the bills ni ni ni isu. Oh, I don't want na bigger zima na kumonja, wana shikan. So, I've seen that life. Na taki Shoshou, ni malize. Atina tunaka wa nuik Shoshou tamikuwa. No. Let us help her while she's there. A lot of people came through for Chira. Ndungunwa wana celebrate suakenya Instagram, wuko, waka na 4.7 million. Wana zima wutuku wa pana Chira. We, Chira tuli tukwa only 1 hour tukwa na nyakwa ni remember kuna krena. We, tuli changa more than 400,000 kapa tia Chira. Onga kwa nukwa kwa your life. Sasa hiri, kwa sapo Chiwani. Kizu wa zote tumefani. Tama usapot. Awa doa na wamiya, nobody even wanted to get close to Pran Chira when he was alive. Nobody. Only tiktokas. Yoha mi shtuka tiktokas on dezafana pitu kama hi. Apunam dasha tangisha fezei waka yamzima doa selectrity. Nobody. So, let us wata tupenikuwa kidiana apu muzike na Shoshou ake atashukulikuwa badae. Ima boya headtrip. Mia don't hold things to my heart. That is one thing that I don't have to know. I'm always open. I've been my own woman kusia bimi sinatitongia na wewa 2. Kwa shmangatupo ameni ongelia biba na kini badae ongelia na. I've always been doing that because when you hold too much to a heart, it really threatens you a lot. Okay? So, maba yama 2 situaichi. Let us just be kind. Ikefika Tuesday kwekikuwa deka tumeva vizuli. Walo atongia atongia. So, it is a Brian. I don't want to mention it asongam bela. So, I really want to appreciate you for the love, for the support. Even I didn't know that I'm not atakuna space. I don't want to get on your stage, I guess. But, thank you for the love and everything for every team. I couldn't help you for my one group, for my three group, up to 200,000. Okay? So, I really want to appreciate right now, I guess we are 7.7 million, I guess. So, I really want to appreciate it but also I really want to appreciate it and I want to appreciate it because, I really want to appreciate it because, I really want to appreciate it and the expert who helped me last time. I don't know what kind of work I want to do and this is one of the things that I'll be doing now. So, I really want to thank you for having me. And I really want to thank you for that. And I really want to thank I really want to thank Nasi dali kali panameginia kongi ya Nisha mazatalisha wewe Abadalisha Gonya, Abadalisha Kwa ima mo yama yo julepura piti ya Stilu, Kim, Thru, Fochira Abarikiwe Abarikiwe Mamatia pati wewe