Yeah, we on boss talk one-on-one one-on-one. Yeah, we gonna man we here man. We over in Las Vegas, Las Vegas Man, how do we make it here? Huh, right man? God. Oh man. That's only God man. Check it man Hey, man. Say man. We here with mr. Clint saying mr. Mr. Payback You cut me payback for show man. So man, how you doing man? And I'm blessed and highly flavored man Man, so hey, I didn't know where the payback come from mr. Payback. He must have You know from LA South Central We had the racial profile with the cops is pull you over for anything and whatever and be just super disrespectful Got pulled over mistaken identity guns drawn out the family take down the whole get out and then after they We weren't the person they were looking for you expect a we can't handcuffs. You think they all be sorry You know saying they said sell the ground May the son occur. We're on a freeway Helicopter who stopped traffic to hold you down. It looked like a movie and then he went I was the last one in line and he was like, yeah, you in a gang He asked and they all of us right at the time like if you're in a game, you're gonna say yeah I'm in the game Right, but if you saw us, you know saying we all musicians we look like you pulling over with the revolution You know saying like Princeton revolution.   That's that's what that's what it reminded me when they pull them over and That's the air. That's the time. Okay. It was 1990 when it happened to me.  He said reach for my shirt. See we had a tattoo I was like, we're gonna do a tattoo. You got a nickname. So at the time, you know, my dad's a lawyer and my mom worked for People mayors. I'm like, you know, I'm gonna have this fool in trouble. Whatever. So you see a nickname It's my guy, of course But they have black ops, but it don't matter. So it was the same day America's most wanted came out Oh, so the first line ice-cream say is I heard paybacks a motherfucking nigga.  Did you ever get them in trouble? Hell no, let's see you ain't no real payback then. No, me and part.  And so we went down to the police station You gotta file at least five complaints against the cop before internal affairs even looks at him So we went down there had the gangster to get the complaint going My dad's a lawyer. They try to run the game on us. No, who are you? Let me investigate your son. We ain't gonna give you nothing blah, blah, blah My dad ran the cold on him. No on the cold. No, no, no, no, you ain't kind of in real life I was a lawyer and he gave it to us I was there. I never heard back. They never called me in for nothing. Nothing nothing happens You know, I never knew that and you have to file five complaints. I don't play Separate yeah, five different people need to file a complaint So it has to be five different people So if you keep having a run in with a certain cop and it's five different occasions. Yeah, that doesn't count No, it does. He needs to have five complaints to get him here Where there's me he did it five times to me or five different people doing that internal affairs is okay Let's investigate until then they run them up. That's why they do what they do So people were like so I got smart with the cop. Mm-hmm.  They they don't know that side of me I'm saying and so then oh payback and it teased me payback payback and then through the hood everybody Hey, what's up payback? They're kind of stuck. You know Sam. Yeah, we on boss talk one-on-one


You're in me. You just shot your own guy. No, that was somebody shooting him. All right Well, you're down. Okay


Great. Thank you. Okay. Thank you, Keith and Liliana and Parmendra for this opportunity and the introduction. Some of you might have heard about the telemedicine program that we have embarked upon at PHFI. So what I'm going to do is just to give a background of what we have been doing and the technologies that we have prepared and how we are reaching to a larger population in India. And we look forward to having a fruitful discussion with all of you in terms of scaling it up beyond India. So let me start sharing my screen. I hope you're able to see my screen. Yes. Yes. Okay. Right. Oh, sorry. I have forgotten to put my name here, but that's fine. The topic given to me was telehealth for low and middle income regions. So I just wanted to start off with this quote from the tale of two cities by Charles Dickens. So if you look at the health of populations across the world, it's clear to us that it's the best of times as well as the worst of times because a large majority of, I mean, a small minority of the population across the world enjoys the best possible care, care that uses several advances in medicine such that, you know, people have started living longer, not only they're living longer, but with the best quality of life. On the other hand, we have even worse than 20th, the 19th century type of care in many parts of the world. And therefore we require innovations in terms of improving care across the world and providing a continuum of care starting from prevention to rehabilitation for individuals. And in this regard, the question that I posed was, what are the technologies that can address health disparities and what is needed. So the first thing is we need to keep a good count of what is happening and we need surveillance and for that we look at electronic health records biomedical sensors and data collection through mobiles and tablets. There's early diagnosis and screaming of the population. And again, here there are several technologies that are available for us that includes computerized risk assessment and so on. In terms of the management we have the electronic decision support system, pharmaceutical innovations newer drugs, but also simplified drugs, I mean usually repurposing drugs. So there are many of the things which have been given up in the past have been repurposed at low cost and have been used. And the next one is the telehealth program. The last includes capacity building on scale on massive scale, which can be which we can use online and learning management system, improving drug, drug distribution, digital clinical trials using geographical information system to identify hotspots of disease and so on. But due to paucity of time I'm going to talk about only two aspects today the electronic decision support system and the telehealth program that we are conducting. The first question that people ask us in terms of ML technologies this was published way back around eight or nine years back as to what the role of ML technologies will be for the consumers it provides improved convenience, more active engagement in self care and greater for clinicians it reduces the demands on their time and refocuses on the art of the art of medicine, and it had the potential or has the potential to change every aspect of the healthcare environment and do to do so while delivering better outcomes, better quality and substantially lowering costs. But at that particular point of time there was a real need for clinical trial evidence to provide a roadmap for its implementation and innovation that is low cost and potentially scalable and sustainable and make real differences to people. So we had done a costing analysis of task shifting because I mean one, the other thing that we needed to do was to pair these technologies simple technologies with community health workers and non physician healthcare providers so Dr Tom gaziano from Howard and I worked on an economic modeling to see what would be the benefit of just providing a three day pro training program and training community health workers in the management of hypertension and we estimated that there would be almost $700,000 in hospital savings for million population annually and this was done for India actually 700 cardiovascular deaths awarded for million and 750 hospitalization for stroke or am I awarded. Now this repeat the annual salary of the community health worker at around $3,500, but given the fact at that particular point of time, the annual salary of community health workers was close to $1,500. The program itself was cost saving, but there was this was just an economic modeling and there was a need for a proof of concept, as well as to see whether it was it could work. The second thing was a plan to develop disruptive innovations that would change thinking and practice. So we embarked upon this journey where we paid task shifting and task sharing with technology enabled improved health quality delivery models and quality improvement studies. So these were the principles that we used in all the study we have some representative studies in the last 10 years that we have done I'm putting it up here that included electronic decision support system integrated care quality improvement program. Rehabilitation because I work in this piece of cardiac cardiovascular disease we said cardiac rehabilitation and team based care. So this studies were conducted across the whole spectrum of the health system, starting from the community to primary care to secondary care. We have surpassed several innovations, including traditional approaches such as yoga for rehabilitation quality improvement program through audit system within the clinics and integrated care for example managing diabetes and depression together. So there are several features that we studied in the last 10 years and showed that actually these ML technologies apply to elaborate upon that a little bit later. So what is this ML system we call it the empower hard ML system, which is a clinical decision support system for evidence based care. So it had three packages a clinical decision support system, which provided a holistic approach for evaluation screening investigation clinical management and follow up schedule. It was based on accepted guidelines. There were algorithms validated by experts and proven in clinical research. There was a personalized lifestyle recommendation for patients. There was inbuilt record keeping trending and charting at patient level and at practice level. And there were other required features for care and delivery management. In fact, in the back end we had put in 2500 case studies and paid it to the machine learning algorithm so that every patient could get a personalized management plan when they use when the system was used. In terms of the task shifting we empower non physician workforce to deliver quality care by using technology and we've provided training and access to expertise through structured training program, well research and international knowledge clinical models with regular refinements by experts in clinical and technology domains. Now this is how the workflow looked for these people who use the empower platform. The patient would walk in and get referred by the auxiliary nurse midwife or an equivalent worker and go to the nurse care coordinator who would enter the initial assessment exam and examination details into the nurse portal. Now in India, the nurses are not allowed to prescribe drugs. It's only the medical officers, a trained physician who can do that. So we created a system in which the nurse entered all the data that was required from the patients. It would take around seven to eight minutes of time and that would be printed. I mean based on the inputs, there would be a personalized management plan, the diagnosis as well as the details of the patient which would be printed and sent across to the medical officer. I might ask why are we using this non environment friendly method of printing paper but the reason was because medical officers doctors at that time were very, very reluctant to use tablets or any kind of ML device and therefore we gave them the printed information. They could accept the, they would accept whatever was suggested, or they could rewrite the prescription based on their thinking but majority of the time nearly 70% of the time it was accepted and therefore we thought it was quite a big success at least in terms of the physician acceptance. Then the patient would come back to the nurse care coordinator who would update the patient recording their app and in addition provide lifestyle advice because the doctors are not providing the lifestyle advice, nurses are providing lifestyle advice. They would actually schedule the next appointment and there were auto texting features so that the patient can come back once again once they get the alert or the nurse can call the patient if the patient doesn't turn up. So this and then the patient walked out with the prescription. I mean this looked like a great model but it required evaluation and this is what we did. I mean prior to this we had done randomized trials and showed that it worked. Now we wanted to see does it work in real life settings where we're using the at a community health center where we are using the health system staff, as well as some assisted research staff. So we did this demonstration project in the state of Himachal Pradesh which is around 350 miles north of Delhi. It's a hilly area and over a period of 21 months in six outpatient clinics. We screened around 21,000 patients which means that anybody who was above the age of 30 years was screened for hypertension and diabetes, and we found that nearly 6,800 of them. That's close to 30% had either hypertension and diabetes, but the important point that I want to make is that nearly 50% were first time detections and therefore it was very important that these people would have gone without detection, because the general crowded OPDs, patients who have just been managed symptomatically, like for example if they came with a fever they would get a Tylenol or some investigation and go away. No opportunistic screening for hypertension or diabetes will be done and in this case this was done. The second thing that happened was we ensured that the simple drugs were available in these clinics and what we found was the end of three months. The systolic blood pressure had fallen substantially and not shown diastolic blood pressure which is also the same, but a very high fall in the fasting blood sugar which persisted till 18 months. And in fact we were surprised when you saw the result that there was a 15 millimeter drop in systolic blood pressure, 7 millimeter drop in diastolic blood pressure, and nearly 50 milligrams per deciliter drop in glucose levels. And this we published in the Journal of American Art Association where back in 2016, there were no fancy drugs, no fancy investigations, all that was done was a very simple model of care which used easily available drugs that were inexpensive for the system. So building on this we actually scaled this up in a state in northeast in part of India called Supra and in Mizoram and we recruited more than 200,000 patients from all the healthcare centers, the primary and the secondary healthcare centers in the state of Punjab which is widely accepted by the clinicians and also by the government. Now we are attempting a national level scale up that includes referral linkages and other innovations in multiple in a city in the state of Punjab which again is to the north of India and it's ongoing so we'll get the results in another one and a half years or so. We also assisted the WHO in digitizing its M-PEN package and we call it the M-PEN package and it's being used in Maldives. So we have covered the following diseases over the last several years which includes hypertension, diabetes, depression, alcohol use, tobacco use and dyslipidemia, but we are moving towards symptom based decision support system because the patients don't come with hypertension they do come with symptoms and from those symptoms we try and branch off into identifying non-communicable diseases or even if they come with antinatal care, we have created a system in which we can detect pregnancy induced hypertension gestational diabetes early and we are moving towards identifying co-morbidities. So this was the background of the package that we have developed. Now came the COVID pandemic and the government actually liberalized the rules for telemedicine and that gave us an opportunity to integrate many of the innovations that we had carried out into this integrated telehealth package which I'm going to talk about. Now despite this liberalization, there were several technological divide that existed. There was poor penetration and acceptance of the telemedicine in rural areas and subpar utilization in urban areas. So the challenges were three-fold. The first challenge was in the patient level. There was challenges in accessing telemedicine services due to illiteracy language or even digital illiteracy among patients and most of the system that we have in telemedicine is just getting a virtual consultation with the doctor and they had to initiate the consultation. They would go to the wrong physician or wrong specialty and therefore the doctors would get frustrated. Moreover, the doctors did not have any details. There was a lack of good clinical history. They had to get it from the patients. There were no physical examination findings and many times laboratory parameters are not available to aid physicians in the evidence-based decision-making. And in the terms of the health system itself, there are several multiple innovations freestanding in digital health technology. Interoperability was a big issue and so we needed to put them on a single platform and that's what we attempted. So we call this Digi Sahayam. Digi is for digital. Sahayam is health in many Indian languages. So we just paid that and called Digi Sahayam an assisted telemedicine solution. So the aim was to improve access to quality healthcare through bridge personnel trained in providing assisted telemedicine solutions. So what are the salient features of this program, Digi Sahayam? First, it involved upscaling skills of health workers in providing assisted telemedicine. It aimed at improving access to primary and tertiary care through trained personnel. It improved quality of care, point of care diagnostic and electronic clinical decision support system. It also reduced the need for follow-up visits to health facilities and there was real-time monitoring and feedback mechanism that ratio quality standards. Yes. So just to summarize, these are the three important barriers which I had mentioned earlier and the solution was for the first thing, literacy language and technological barriers among patients. The trained healthcare workers connected, conveyed findings to facilitate doctor-patient interactions and also prevent wasteful visits. The second was at the physician level. So here the trained health workers collected history, performed physical examination and carried out lab investigations before initiating tele-consultations, thereby saving time and improving quality of care. In terms of interoperability, the PHFI telemedicine platform emits electronic health records, point of care diagnostics, in-built electronic clinical decision support system and numerous state-of-the-art digital technologies. So we call this the PHFI innovation cortex to just rhyme with the brain cortex and let me describe the platform. So the platform comprises of electronic health records, point of care diagnostics, electronic decision support system and numerous state-of-the-art digital health technologies. The first is the Empower electronic clinical decision support system which I spoke about a little bit earlier and I'm not going to delve further into it, but it's a very robust electronic decision support system format. The second technology that we paid was the Saucis Hyde device which is a point-of-care diagnostic device which is an affordable Android-based point-of-care device that integrates multiple diagnostics to cater to the needs of the frontline health workers to facilitate service delivery to the population they serve. There are two versions of this. The basic version is aligned to the Indian public health standards, mainly aimed at anti-natal care, but the advanced version that we are planning and we are actually in the process of developing would get investigations that are relevant to non-communicable diseases such as serum pre-attendant, lipid profile and hemoglobin A1c. We added an ECG machine called CardioScreen which is a scalable 6-to-12 handheld portable ECG device developed by an Indian company. It's quick to use and works in conjunction with other Android devices. It has a cloud-based system with AI interpretation and risk classification. It has actually been certified by the FDA and CE. The next two devices are the conventional stethoscope, but this is a digital stethoscope which is a fully-assembled stethoscope that travels between analog and amplified listening modes. It enables remote oscillation by the treating physician and serves as the physician's ears at the telemedicine center. I'll actually demonstrate that a little bit later for you. The next one is we wanted to give eyes to the physician, so we paired it with a high-definition camera which could be operated by the physician who was sitting remotely to examine the patient and to talk to them. This is how the software looks like. So if I go to the next slide, I can just show some of the features actually because of the positive time, I'm not demonstrating the whole thing, but I'm just kind of explaining the various features in this platform. So when you press on this general physical examination provides general physical examination findings which are captured by the healthcare worker. There's a template-based history. I spoke about the symptom-based DSS. This is a variant of that through which a presenting personal past family and drug history are captured. Then we get vitals from the visits with the trends. Like, for example, you could get a trend of the blood pressure over three or four visits. Pulse are likely, if you're managing COVID patients, actively you can get the heart rate and you can get the SAO2 and many other investigations. Lab results also will be provided with trends. Then ECG readings will be available based on the AI report but will require a physician interpretation. And the electronic decision support system is there for diabetes, hypertension, cardiovascular disease, chronic obstructive lung disease and asthma and will give the personalized management plan for the patients. Finally, there is an e-prescription entry and a prescription history that's provided and a markup for follow-up visit and markup for reference. The interesting feature about the auscultation you can hear, there's a noise cancellation feature. You can very clearly hear the second heart sound at the level C. We have marked this so that the nurses or the community health worker can place this step for the physician to hear remotely. And you can very clearly hear the second heart sound at the second heart level. And we can clearly, the split of the second heart sound is clearly audible here. So this is the system that we have. Now coming to the mode of service delivery, there are various modes we are adopting and we will adopt in the future. The conventional mode is a brick and mortar model where the telemedicine center is run by a trained nurse and the lab technician that provide assisted telemedicine solutions under the supervision of a project quality assurance officer. The general physician specialist as well as super specialist tele consultations are made available through this assisted telemedicine platform. Existing private as well as publicly facilities can be upgraded to perform assisted telemedicine. Now the workflow was very similar to the electronic DSS program. Here the patient visits the clinic, the trained nurse takes history and examination. Any lab tests are done if necessary with the point of care device that we have provided, a consultation with the doctor is initiated, a virtual consultation with the specialist doctor if required can be done. Actually this also can be done away with but because this is an initial proof of concept program we thought to have a doctor would be useful. But actually this particular thing is redundant because we can actually position this doctor at this level and escalate the higher consultations from there. So the post consult counseling is provided by the nurse. I'm not getting into the full details of this because this is how the Indian public health system works with multiple levels of care. So at the lowest level we have the health and wellness center, then we have the primary health center, then we have the urban health center and we have the community health center at the secondary level. And we have actually identified the human resources for each of these which is given here, but what I want to say here is this is generally applicable to any part of the world because most systems are with minor variations are similar and the, and because the lowest level of provider is involved, even in very low resource settings, we can use this telemedicine package. The second is an on foot telemedicine assistance for small populations of less than 1000 or so, or also for people who are unable to visit the clinic because of physical disabilities or because they're better than or many other reasons they may not be able to come. So one might ask how did we manage this, all that is required are these two small bags a backpack and a small bag which will carry all these equipments, the total weight of which is not more than four pages comfortable to carry and and you can just go to the houses and initiate a teleconcertation here is an example of a teleconcertation that has been initiated. So it can be used both for rural as well as urban population, and services could be charged for generating revenue for trained healthcare workers having one business model is we could give it to healthcare workers train them, and they can become the agents of this program connecting to the telemedicine consultation also will be a livelihood for them. It can improve health access for elderly and veteran patients. Then we have another program called the mobile kiosk setup which can actually come into a small suitcase and you can just go ahead and set it up wherever it's required like it's very useful in surveillance program or in programs to create awareness but also it can be used for creating consultations, but it can be it is most likely to be used in small villages of populations of less than 5000, where you are unable to establish a brick and mortar clinic. So somebody can go assemble this and have it in their community centers where people can be screened for chronic conditions and also provide facilitated facilitated assisted telemedicine services. The next one is this I am on wheels. This can be used in sparsely distributed small population of less than 5000 individuals here physical space will not be required because this vehicle would be customized to perform like a brick and mortar telemedicine clinic. And these are useful and hard to reach areas. It again can perform both screening as well as management of patients. Now this is the concept with which we developed I'm going to give a practical example of the community reach and impact of the program that we have done. So apart from the telemedicine program itself, we also organize specialist scams health promotion visit so that the community actually the health of the community improves so we do health promotion visit. There are two step consultations and assistance services, educational webinars weekly community improvement live sessions and collaborations with different institutions to extend our services. So essentially what we are attempting to do is to bridge the gap between the community technology and digital health care to train personnel, provide continuity of care and longitudinal health data through use of inbuilt electronic health to create an innovative model for health service delivery that enhances sustainability accessibility and accountability of care. It also would reduce indirect healthcare costs related to travel and loss of daily wages, provide valuable data that can inform the development of suitable healthcare models prevent complications through improved awareness early detection treatment. So we are improving the quality of care and in our modules for primary care physicians we emphasize the importance of looking for example, when we did a survey around 10 years back, only 7% of the doctors were annually screening patients for neuropathy or retinopathy but once you give them a structured package that screening level improves and it actually reduces the complications. So the health technology that we're using helps to address cost. There is a tremendous quality control over there. It's interoperable. It's scalable which we're shown. There is an enhanced user experience it addresses the contextual needs and get us to the issues. In addition, it is environmentally friendly. In fact, one of the recommendations to prevent climate change or to mitigate climate change and reduce air pollution is the use of telemedicine. Because in countries like India it's not only the patient who comes to the clinic the footfall is very high because at least two relatives accompany the patients. And second they have to use some form of transport to each the hospital. So all that can be avoided if we can have a hybrid model where people really require to visit the clinic or the hospital make the visits and others are provided to get through telemedicine and this was featured in in COP26. This is one of the technologies and PHF had four of the technology which included the drones to deliver drugs and to collect blood samples and get it analyzed in different cases and the point of care device and others. So let me do some practical examples now. We are conducting telemedicine programs in three clinics one in the northern part of Tamil Nadu in its capital Chennai and in the southern part of Tamil Nadu in a place called Pasuvankanai which is in the far south of Tamil Nadu. So three clinics have been established and these are some of the glimpses of the clinic where you can see people working on the point of care device then teleconceptation which is ongoing and consultation with the local doctor here. The second thing is the WHO was very impressed with when we presented the data on the telemedicine in Chennai so they said we should demonstrate that it works in a government setting the previous one was with CSR funding a charity program but they wanted to see whether we can work with the government systems to So we spoke to the government of Karnataka and South India and they have agreed we have signed an MOU and we start the program next month. These are our partners which includes the WHO and several others we are adding new investigations for example the Irvind Ikea system program is a leader in ophthalmology care and it has been featured as one of the sustainable models of healthcare and so we are working with them in terms of providing Ikea. So what does mean the impact so far. So in the last eight or nine months we have provided almost 5,640 consultations of which 3,750 were general consultation and around 1,800 900 specialist consultation and ECG was actually rationed and taken so it's somewhat lower and these are the lab tests that were conducted. So in terms of the specialist conduct distribution, a large majority were general medicine followed by pediatrics and gynecology but currently we are focusing on four major specialities that is general medicine, pediatrics, psychiatry and dermatology. We also provided 80 plus doorstep assistance for people who are unable to come to the clinic and at least 18 patients of these 80 were treated of their conditions. We to create awareness and interest in the community we have conducted specialist clinics. So we conducted a total of 19 camps of various diseases and treated around 1200 patients or so. We make home visits for health promotion. So each month was a specific disease entity to spread awareness in the community for example the importance of salt reduction or alcohol use for hypertension as an example physical activity for diabetes and so on and so forth maintaining hygiene water sanitation and hygiene. These kind of promotional activities were conducted in this community so the community becomes healthier as a whole. So this is the summary of the whole program in Chennai and we touched 14,000 plus lives including home visits and the people we have interacted with and we identified new NCDs in around 600 of these people and were referred to the consultations. Another newly detected hypertension was 250 patients with high DMRs identified to this number and were provided advice with regard to how to reduce that so it is a composite activity of everything that is required for the completing the continuum of care. So what's the patient feedback, I mean that's the most important consumers I won't take too much of time on this, but these were the five domains in which we asked using a Likert scale and we surveyed 139 patients. On a scale of zero to five, we were somewhere a little higher than four for all these domains that we looked at. So in terms of satisfaction again there was overall satisfaction with the healthcare services of the clinic, satisfaction with the healthcare delivery model and likelihood of recommending clinic for diagnosis and treatment to others was almost at the level of four. So there was good satisfaction for this program. Finally, what is the way forward. We need to indulge in large scale capacity building initiatives for health workers in providing assisted telemedicine, we need to pilot different modes of assisted telehealth delivery, improve quality of care through integration with additional digital health technologies, adapt and expand these to other countries with similar health system difficulties and embedded research to evaluate and improve existing technologies. When we look at this whole program that I presented on the surface it looks like we are just trying to improve access to healthcare through bridge personally using telemedicine, but there are several other features that are embedded in this which are under the surface. Then you generate a lot of electronic health record data, which can provide real time patients entered records for secondary data analysis. Second, there is a large number of well trained staff nurses paramedical staff and digital technologies to carry out complex data collection and they can be used in research of this program and in surveillance. There is a community outreach arm with an opportunity to conduct population level surveys and studies. There's infrastructure to evaluate and scale up digital technologies platform to test interoperability acceptance and appropriateness of the health technologies. We can use this for digital disease surveillance and for capacity building so we can use this for building capacity of students and research staff to embedded research projects. I wanted to say and thank you very much for having me and listening to this presentation a bit of monologue here. Thank you. Thank you so much. Fantastic work that you're doing and I'm in awe really of all the amazing things. That's related even the the status cop. I had no idea that that existed and it could be used in in telehealth. It's quite amazing. I'll start with the questions and then we can see if others have questions. Interesting understanding what you found as the major barriers to implementing this across India and whether there were contextual factors that made it more difficult in particular areas or other types of barriers. I think in terms of barriers, if you think there are multiple number one, I think in a philosophical sense, this is a total disruption of the health care of the patient doctor patient relationship which was compromised on the touch and the feel and that is not there. So that's one which people are unable to fathom. The second is there are competing telemedicine programs, the government itself has got a program called he said you need but many of them are basically in terms of remotely connecting patient to the doctor, but many of the features here are not there. So, initially people are saying that no no we have done this on scale so why do we need another platform. Now, now it has been accepted in Karnataka when he spoke to the government, they have agreed that this is a good program and they're willing to implement. So the biggest challenges people worry that such kind of programs like ours is creating a parallel system and not integrating but the ultimate aims to integrate with the larger system and use it. So anyways, we are largely focused on government health care we are not focused on the private health care and so that's another area where we should work on because 70% of the care in India is with the private providers and therefore I think there's a huge market potential over there. There are a lot of achieving problems about the equipments and in fact, it took me took us a lot of time to get the health workers to use the stethoscope because they were quite, they found that it was a little different from the conventional scope they found it daunting they were not using it. And we, yeah, but it took some time so it takes time it takes perseverance it takes training and it takes advocacy and it also also they get feedback from patients and patients were fascinated that they were getting something very different. So again, you give them the touch that they're required. Very interesting. I have a question here from Roger Ram, who asks, what are the impacts of this ncd management program implementation. Right. Yes. I can. I can add to that because there was also something that I was interested in. I can add to that because there was also something that I was wondering about. Do you have any sort of cost effectiveness evaluation or is that plans. And can you talk a little bit about the impact. This is a very short term evaluation that we have done cost effectiveness is a larger evaluation. So we will have to do the impact evaluation in terms of how the ncd care has been the obviously we cannot do any hard outcomes it will be only process outcomes. Like how many visits they made are they taking their drugs regularly are they getting their drugs and what's I mean we can of course get blood pressure but it's a pre post design you just sometimes you know when you measure blood pressure multiple times or blood glucose multiple times there is a regression to the mean and it may appear that it is reducing but the fact is it's important for us to look at some of the process outcomes which actually would translate into real benefit and those include the the time saved for the patient the daily the wages that they've earned because they didn't go to the hospital it takes a day full day for them to go to a hospital and come back all those kind of intangibles you'll have to measure of course cost effectiveness is one of those which is very important which we are looking at maybe take one more year also amazing and just touching on that I think it would be interesting to so you had some sort of patient feedback via a survey maybe interviewing some patients and doing a qualitative kind of analysis of their responses would be interesting because I'm guessing there might be very interesting aspects there on facilitators barriers things they enjoyed or things that could be improved I think you hit the nail on the end the current thinking is code design we didn't really do the code design component but as we scale it up and as we move along to different territories we are embarking on code design plans where we involve patients in the design because they are the consumers ultimately and they know what the pain points are and they would help us in terms of modifying and rectifying any mistakes that are on the way. Great. We have a question here from Anna Louisa and she says congratulations on such an amazing program of work. I was wondering if you have performed or are willing to any evaluation on safety of remote care. Yes I think we should do it because as a as an epidemiologist and a person who has been active in clinical trials I'm always very of you know the pre-post design showing that things improve. So I think it's you need a you need some kind of a trial maybe a cluster RCT or a delayed intervention step-by-step design trial or so in terms of showing but given that it's becoming so popular and getting well established maybe little difficult to do but we could look at communities before introduction of telemedicine after introduction some kind of thing like that. We require to innovatively think in terms of the evaluation. Great. Any other questions Keith. Yeah, thank you. I'm always impressed. I think this is the third time I've seen this presentation and learn each time I view it. I think just a comment where I am most impressed with maybe we'd like to hear a little bit more with the leveraging of the community health worker. And the reason behind my question and there are some other programs that use this but one of the concerns was, and I think it's healthy entrepreneurs for example in Africa leverages community health workers but they're not funded as volunteer. And those community health workers are expected to come up with the what can be financially burdening the cost of the equipment to engage. So add in that along with assigning them fairly significant health responsibilities on a pro bono or for free basis. So I wonder the you mentioned the salaries. Can you expand a little bit about the economic model because that's where a lot of these programs really struggle right to sustainability and funding. So I'd like to hear a little more on that because that's very impressive. So a few points that I want to make is that the programs cannot be sustained on a voluntary mode. That's number one because we are actually focusing too much on the innate goodness of people to contribute to the success of this program. So in India also there is this voluntary program but they are paid like there's something called the accredited social health activists for the Arshas who are women from the local community who are between 18 to 24 years and will provide assistance to anti-natal care and delivery. So it started well intentioned it worked very well they were getting a kind of stipend not a full salary and for and also getting incentives for hospital deliveries. So the incentives for the hospital deliveries were very high so the focus largely became getting the patients they forgot about the importance of anti-natal care so one needs to be very careful in terms of how to incentivize these patients. They incentivize these individuals but I think the way to go is to use the existing health workers and like there are many health workers who have become redundant because in India we have several vertical programs. We had a program for control of guinea worms. We had a program for control of epilepsy. We have the polio immunization program. Many of these diseases they get conquered. These people become redundant to the system. So they can be retrained and repurposed and used for this program because they're already employed. The second is in the national program of India for noncommunicable diseases it's called cardiovascular cancer and diabetes prevention program. There is an extra personal who was sanctioned by the government of India and it works in a partnership model with the state governments and the central government and that extra person can be used for these kind of activities. But we have to be very careful that these health workers are not overburdened because there's a tendency to use them for all kinds of programs. So there has to be that multi-sectoral dialogue even within the health ministry. I'm not talking about beyond the ministry of health but even within that there has to be a dialogue with the workers, with the physicians and with the administrators in terms of how to optimally use these individuals. In terms of Africa itself, I think we can create a business model where for every service they provided there's a small amount of incentive which would be provided from the profits that are earned if you're providing it on a private basis. We can skill these people and give a franchisee model so that they earn money as well as treat patients. So you can think of other means, I mean there may be other ways we should talk to the management guys to see if there are other mechanisms. Do you ever foresee a blending of private offerings that could stoke revenues or a revenue share with public based? Is that a model at all that would work? People have been talking about the public-private partnership model. It requires refinement because the private sector thinks that the government or the public sector should provide the infrastructure and they make the profit. So I don't think that model would work. So we require to refine. It's a long process because inherent in the DNA of private sector is to make profit. Inherent in the public sector though return is to provide service is inefficiency. So I think we need to overcome the inefficiency of the public sector and the profit motives in the private sector. So related to that, I'm curious about where the funding came from for the work that you presented and when you think about scaling it up, what is the plan for funding it? Right. The first branch of funding came to us from an insurance company because they had this corporate social responsibility program or the CSR program as it's popularly called. In India, every private concern has to pledge one percent of its profit towards social services and it's called corporate social responsibility. So they had some funds and they asked us whether they would do something about NCD care and that's when Arun and I had a discussion and we came up with a plan of creating the Stehli Medicine program and of course Dr. Dave Jindal is here who's worked actively on the ML program and we paid all these technologies. We did this very rapidly within a matter of two months or so. In fact, the first approach to us was last November and by February we had everything up and running. The clinic started in February and so within four months we had the discussion with them about the funding. We employed people, we actually rebuilt that building in terms of organizing so it was an amazing job by Arun and Group and we rolled it out. So that was the first level of funding. The second question is about scale up. The scale up has to happen only with the help of the government or with large private sector organizations. So we are advocating with the government in terms of looking at how to scale up across the country. So we need a little bit more data to provide them with the robust evidence that it works. Second is we're also looking at large grants like we recently applied to this NIHR center grant, which aims to, with the aim of using telemedicine for multi-mobility as a thing. So once you have the evidence, once you start doing such big projects, I think people will gravitate towards this kind of the system. There will be resistance, but we will have to work on that resistance. That's great. And just one more question for me and then I'll see if anyone else has questions. I was wondering what was the impact of COVID with all of this? Were there any particular challenges or did COVID accelerate the adoption of this program? Actually, the program came up because of COVID. Because of COVID, there was a liberalization. The government realized that patients cannot visit hospitals like before and door to door crowding, et cetera. But the second part of the problem was when actually a huge surge of COVID happened, we had to close down for some time basically because most of the care, most of the people who came were for COVID and not for non-computable disease. So for some time, maybe a week or so, we closed down. But it has actually helped screening, advocacy management and rehabilitation processes of non-computable diseases. And it's a great idea to do it virtually. Like, for example, post-MI rehabilitation, post-TROP rehabilitation, the conventional program entails that the patients visit the clinics for at least once a week for 12 to 13 weeks. Now you can do all the training of these patients virtually. And you have very high quality pictures and videos for them to be trained after the initial visit. So I think the pandemic has actually helped advancing the cause of telemedicine. Great work. Any other questions? Dr. Rohan, one has asked whether we can write to you. You're welcome to write to us. And Arun, can we put the email ID on the chat? I was just going to make a comment, what I'm also impressed with. You mentioned Dr. Prabhakaran, the interoperability. And I can tell you even in developed part of the world, like here in Canada, we think we have a very robust health system and we struggle with this, right? We have the pharmacies, the hospitals and primary care providers all on different systems. And the fact that you've created or have a telemedicine platform that the specialists can see the same information that I'm seeing, the pharmacist can see the same information I'm seeing, the nurse, the healthcare worker. I think really that that's a critical point. And I'm also just thinking, you know, of how much I do on a day to day basis as a primary care provider. A lot of it is, you know, maybe it sounds hard to say frivolous work, but I'm so caught up in the day to day stuff. It really, you know, do I need to be seeing the patient myself for their blood pressure for their diabetes, some of these non-communicable diseases. And I become the choke point in the system because the patients can't access me because I'm burdened with these other responsibilities to delegate that task into the community really makes so much sense in workflow. Kudos, right? I mean, I think this is disruption that we need. And I'm sure there's there's challenges because there's some of us that maybe hang on to that concept that I'm the doctor, I'm the physician, I know best. It's me that should be doing this and delegating those tasks to be a challenge, but I think it's where it's got to go for sure. It's amazing. Thank you. So I thought in conclusion, in terms of way forward, I forgot to mention one more thing is how do we address the issue of privacy and for that I think we should borrow from the Bitcoin technology, the blockchain technology where it's disaggregated data, which is owned by the patient and the patient actually permits the doctors or is going to use the data to see the data. So I think we need to think out of the box in multiple ways, but ultimately whatever we do, we have to think about the cultural culture, culture sensitivity, the context in which it is being used, the cost and the cost and the equity of the program, the ease of the program and I mean obviously the interoperability is also a major issue. So I think we need to solve this and think from these multiple angles to make this skill of them. Fantastic work. Do you want to close the session, I think we should let Dr Prabhakaram go because he's been so kind and generous with his time and this was a great session. Absolutely, thank you so much and I can see already this is a great warm up for next week. I don't have much to talk about and collaborating with who and the IEEE, this aligns as well. Thank you Dr Prabhakaram, Dr Jose, I see you're on the line as well. We really appreciate it guys, this is wonderful, and we'll be shouting your accolades for times to come yet. Thank you very much. Thank you for having me. Yeah. Thanks. Bye.


You know what? For having such slow lows, I didn't even see him go behind me. How's it going everybody? Datoi here back with some more Dragon Ball fighters, rank matches. This time playing a suggested team of Tell, Cooler, and Jiren. And I believe our assist go Cell B, Cooler C, and Jiren B as well. So a couple of really unique assists and not usually the ones I use on these particular characters. Even though I believe Cooler C assist is a beam, right? So that's going to be good regardless. Woo, we got the Cell Games music with Goku and Cell. Okay, it wasn't Super Saiyan Goku though. Defense, never mind. I don't know why I'm playing with analog stick right now. Over the beam. Hey, we're switching right out to Cooler then. Stop this man to the corner. The range on this tail is still wild to me. Every time I play Cooler, I think that the range on some of these attacks. Oh, nice jumping air to air. My man saw me in the air. He was hunting me. Hold on. Oh, we clashed. That was sick for him. Not for me. That clash is going to undo Cooler. Look at the damage actually. That was insane. Off a jumping light. Nice. I'll give it up. Cooler was not long for this. My man was gone. He came out, got a few hits in, and was just quickly taken from us. I wanted to beam really badly there. Stop that. Get off me. I'll take it. I will definitely take that.   That's not how that works. Oh, the back dash heavy. That was smooth. No, I need to get one good hit in one good hit. That'll restore my confidence that I'll get the game plan rolling. Oh, that was risky. There we go. There we go. Oh, that wasn't even a good hit. There we go. Okay, hold on. Okay, there we go. That's kind of what I want to see. That's kind of what I'm more about right there. We have to take a level three to kill. But at that point, I'll take it.  We're going to even up the game a little bit here. Maybe even take the lead. Wait, how much health do we have again? I don't know. Either way, it's going to be close. And I think we both still have sparking. Yeah, this game is back to being even. Oh, that was a risk I didn't want to take. I'm going to make a read. Give me that. Nah, we take those. Shoulder attack. Wait, that sells biases? Sells biases is just the second part of his auto combo. Whoa, why? Nothing provoked that. Wow. Wow, nothing really provoked that. I just jabbed. Man, I was upset. Take that. I am not sparking for that. I am just going to recover that all natural. No, no, no, no, no, no. Don't vanish. Don't vanish. Oh, can you just drag us here? I'm regretting not sparking. I'm going to spark. I regret sparking now. Crazy how the times the times turned. Oh, OK, I mean, we still have sparking activated. So it's not a complete loss. But if he gets a triple, if he gets a level three sparking trunks, that will be nothing but bad for us for you. If you free hits on trunks, a little bit of damage. Now the real boss battle starts. Oh, that was smooth. I got to give it up. Oh my goodness. He is giving me a run for my money.  But it's getting close. It is getting intense. What a hit. Is that still not going to be? It's not even close to enough. I saw my life flash before my eyes. Didn't get the fourth bar for the vanish until the very end. This attack decides it, but does it really? No, the hard counter read. I was hoping you'd do something. But ironically, vanish was actually the best thing we could have hoped for because he vanished. He couldn't vanish again, which means he couldn't counter the counter. We'll take it. Game one by the skin of our teeth. Actually, we did. That was really close. All right. Hopefully we're hoping for a cleaner game here. Dragon rush started off with a grab.  Let's go. Beautiful love to see it freely. I'm surprised we got away with that. All right. We got him back into the corner. That was mainly the goal. The death crusher. Nice. All right. What does he do now? I whiffed my I whiffed too many attacks. He stood up and punched me in the face. Unfortunate, but I deserved it. I'm not going to pretend like I didn't. Okay. Man, cell is so good. He just feels so solid. He's got good normals, everything like that. He's a bit tall, but you know, that's not no big deal. Nice hit. No, I can't afford to drop those. Go Gucci T white. All right. We're switching. All right. We're sparking. I couldn't stand to lose him. Well, especially when you can pick up a knockout like that. Well, I'm feeling good. You know what? I don't feel bad about the sparking at all. Actually, last time we got punished for it. So this time I'm feeling good. Oh, baby. Look at the speed instant teleportation. I'm going to do it. Actually, I'm going to do it again on trunks. I'm letting you know right now. I'm going to look at my speed again. Same exact thing. Oh, it didn't work. Let's go. And it's so good. Dude, why do I keep dropping that? Oh, it actually did hit. Okay, good. Wow. Last tick. Oh, man, I saw I had three bars. I was like, okay, I have an idea. It might not work. It might get me killed and lose three bars. But if it does, I'm going to feel good about it. And you know what? I feel great about that moving on to the next game now. And hopefully we can get two more wins under our bell. Okay. This is bad. We're going up against DB fighter zero, who based on his name is the original DB fighter, which if you don't know is the original name you get when you first launch up dragon ball fighters. So we're going up against the an icon living right now. He is playing real aggressive with it. Oh my goodness. Overhead, right? Forgot about that. That you know what? For having such slow lows. Mine. Why didn't even see him go behind me? He truly is the original DB fighter. Oh no. Oh, the original. Damn. That pickle assist is still really good, by the way. No, not a DP. You wait. What? How do you appear on that side? I shouldn't have blocked that, but I did because his mix was too good. I can't believe I did. I blocked that because I tried to block that and failed. That is crazy to me. I'm just going to take a level three here to try to get a kill. Maybe maybe I shouldn't have done this, but we'll see how it goes. We will see how it goes. I'm going to go in two s. I should have two s right there. I'm getting attacked. I am getting absolutely attacked. Medium slicer into Vegeta into the demon. All right. It's sparking time and it has been for a little while. Bring hit back out. No hit. Dragon Ball. Oh, Dragon Ball. Very Dragon Ball moment. Very much so a Dragon Ball moment. I guess is what I should have said. What the? What just happened? What if it's so sick? Fine. I'll take a level three. Man, I wish I would have gotten that counter. All right. If we're going to win this, we need to step it up now. We need a few good segments where we get a lot of hits. And that was cut short very quickly. The original DB fighter. He's too good. Oh, it was an assist. Oh, man. Doesn't go through Key Blast. Love to see it. Got him though. Igloas, this is so nice. That A assist is too good. I have always been on the side of that. This is crazy. But it is really. What was that? I don't know about how we're going to win this one. But I do want to get a little more information for the next few rounds. Okay. Hate myself. I hate myself for doing that. I keep constantly trying to make plays around these piccolo orbs and failing spectacular. I keep, I keep seeing the orbs and I'll go, ah, this is where I'll make my move. Bad play. All right. Hold on. Rematch. We got a little more to prove. The original DB fighter putting on a show. This might be the best that I've seen by the way. That could have been that could have been the start of something beautiful, but it just wasn't. And that's the part that hurts the most. I think let's go. Nice. This is the part that hurts the most. The rolling crush. Can't believe I ran into that medium, but that was nice. Whoa. Whoa. I tried to down take flag on the plane. Flag on the plane. My down take didn't happen. No. Am I dead for that? Oh, come on. That's going to hurt. That's going to hurt emotionally more than physically. Don't do it. Oh my down. Oh, why?  I'm going through it right now. We need a miracle. I need to gain control at some point. Do we spark for control though? It just doesn't seem worth it right now. Oh, it's not worth it. It never was worth it. Get out of there. Just take a level three. I need control in my life. I need stability. I'm going in stability. Really? He clicked a button. Raw tag in my video game. Yes. That was beautiful. Could not have drawn it up better myself.  Like counters. This is why I can't. This is why I actually can't be a Jeremy because I'm too addicted, bro. I'm too addicted to the counter lifestyle. All right, we're going to spark here. Beautiful. I didn't want to do that, but we'll take it. Okay. I'll take that as well. That was crazy. I actually can't believe I got that off with the limited sparking time I had. But we'll take that as well. Can I get a dragon ball check on aisle three?  What? What? I can't believe he timed that perfectly. But good job. I mean, that was impressive. Level one to three. Does that kill? Like grenade, please. Oh, baby. Oh, I should have countered. I should have done the other counter. That was my bad. I don't know why I was afraid of a physical attack there. We could still win this. If we just play really, really well. Grab this, man. I like how my ideas of playing really well is getting a raw level three. Hey, what are you going to do, man?  I didn't think the recovery would be that bad into Vegeta assist, into a whole combo. I might get reset here. No, just going to be a level three for the knockdown. I'm expecting a dragon rush or overhead. It was an overhead into a dragon rush. Beautiful. I know there's got to be a lot of comments out there like, I can't believe you lived that. And to be honest, neither can I. Come on, man. I'm upset with myself for not punishing the first one. I'm upset with myself for not punishing that first one. Oh, then I got too, I got so upset that I tried swinging when it was too late. It got hit with a second one. The original DB fighter was too much of a match for me. I couldn't overcome the original Dragon Ball fighter. Well, hopefully you enjoyed this one. If you did, let me know down below in the comments section while you're down there. Make sure to like button and subscribe to the channel. If you like the videos you see here and want to support it so you can see more of them. Speaking of seeing more of them, there is some more videos that should be on your screen right now, similar to this one. So give those a watch if they catch your eye. Other than that, I have been Dr. Doha. Thanks again for making it all the way to the end of this one. And I will see you in the next video.


Are you sure? Good morning, YouTube! I got one of the Automous boxes. Yeah, I brought the other one. Okay. There goes the cat. I think she said the cat can go out. Why would you want to go out? I'm in Linton. Emma said Linton, Nebraska. No, Linton, North Dakota. It's pretty chilly. Negative seven currently in North Dakota. And that's all right. You know, I keep talking about the weather, but when you're filming outside and your tripod's freezing and your camera, your batteries are draining quicker, it's a big deal. So you've got to watch the weather. Joe, how's your camera? It's nestled between my legs. Stay warm. He's keeping his camera warm. And it's just more efficient. Jump out of the car, ready to go. Speaking of which, we're brainstorming how to be more efficient, centered around equipment, and condensing, if we can put it that way. All right, the sun's gonna rise soon. We're producing stories. Your focus is the stories and the ISO and the white balance and audio levels. It's not the vlog. So, we're out here, this guy, out here on the road, and you just have to kind of say, hey, YouTube and vlog, you got to take a backseat, because Leland, who we just told his story, interviewed him. You know, we were 100% focused probably for three hours with Leland, and listen, the day marches on, it's already one o'clock, well past one o'clock. And so, anyway, we're up here in North Dakota. Just wanted to update you that we're doing well, because it's a little tough to keep vlog up, but we're keeping it going, we're keeping you guys with us, and Leland was gracious enough to yes, top off our gas, amazing, thank you, that helps a ton, out here on the road trip. But then also, his wife cooked us this delicious chili lunch. How was it, Joe? It was fantastic. It might have been homemade ice cream cake, I think. Was that homemade? That was homemade. It was good, though. It had a homemade look to it. It was definitely delicious. Either way, it was great. We made it. Bottom line, we're being fed pretty well. Being fed pretty well in North Dakota, so you don't have to worry about that. In fact, I still got to get my run in today, so. All right, here we go to more interviews, and we'll just kind of see what we can do. Maybe we could show them a little bit of our filming setup. Stealing Joe's line. There's a new sheriff in town. I sent Joe out into the cold to get one more shot at our last story of the day. We're surviving. It did warm up a little bit. It's above 10 degrees, so that's a bonus. That's a bonus. Thank you, North Dakota, for the little warm up there. Our equipment has not frozen. We got some really amazing footage, some amazing stories today. It's awesome. We're heading back to Bismarck now. Going to go stay with this family who's going to feed us some pepperoni roll. Woo! We're excited, but thank you for being here on the YouTube, on the vlog, checking out this day out in the country. So, hope you had a good day, YouTube.


The St. Lucia Red Cross is embracing fully its mandate to alleviate the suffering of the most vulnerable whilst promoting human dignity and social inclusion. A special ceremony was held on Wednesday where the St. Lucia Red Cross and the Japanese ambassador signed an agreement under the grant assistance for grassroots human security projects. The government of Japan has committed to providing financial aid to the St. Lucia Red Cross to assist those in need and to procure a special vehicle allowing for wheelchair access. President of the St. Lucia Red Cross, Yubat Yair, explained that the Japanese government has been a reliable and dependable ally and the receipt of this aid will enable the Red Cross to continue fulfilling its mandate. It is important to know that the St. Lucia Red Cross will continue, and I want to re-emphasize this point, will continue not to assist ourselves, but rather to assist the general public. And though this vehicle will be housed here, it belongs to the general public for use. We have been working with people with disabilities for a long time. We have been having youth camps with children with disabilities. And also, we have had challenges when it came to transporting them. Even at the St. Lucia Red Cross headquarters, it was difficult for us to get people with wheelchairs to come up. And of course, we made the effort to ensure that accessibility can be had by such persons. Suffice it to say, this is a continuation in what we hope to achieve in this country. Ambassador of Japan to St. Lucia, His Excellency Tatsuya Iriyama, highlighted the importance of the work done by the St. Lucia Red Cross. I always find my deepest respect to the Red Cross Society for its global role and also for its community-level activities. I trust that the high discipline of the Red Cross Society will enable the procured vehicle under the grant assistance scheme to be utilized most efficiently and effectively. As in the case of our previous assistance projects, this vehicle will become a symbol of our friendship and cooperation between our two countries. Indeed, when the procured vehicle starts its operation, a helping hand to those who are in need will be very satisfied with the investment of about 35,000 US dollars from our own national budget. As a humanitarian and a cooperative value, it worths so much more than its monetary value. Terensia Gilad, Director General of the St. Lucia Red Cross, expressed gratitude to the government and people of Japan. It's about nine months ago I started this process in getting the vehicle. I wish to thank the government and people of Japan for once more putting their trust in the St. Lucia Red Cross. As the president mentioned, this is not the first time that we have gone into a partnership. But it's a second vehicle we are getting and we have also gotten two Japanese volunteers to work with the Red Cross. And we are indeed happy for the government and people of Japan for always coming to our system. The signing ceremony was held on Wednesday 10th March 2021.


There it is. One minute, Bill. That is the best, whatever this is, WC keyway, high security, fancy, best cylinder picked to control. There's that thing. It is locked up. Here's the operating key. And of course, once you've got it to control, you've pwned the lock, and so no need to open it, but if we had, there it is. Mine is not key retaining. So WC keyway best padlock picked to control. Thanks. Have fun and keep it legal.


Welcome to this week's edition of this week in civil engineering, also known as TWICE, a weekly news show focused on providing civil engineering professionals with the most important and relevant industry updates. I am a host for this episode, Luis Duque. I am a practicing structural engineer at Foothills Bridge in Boulder, Colorado. I work doing engineering bridge dismantling retrofitting and temporary structures. I am also the founder of the Engineering Hour Future blog and podcast, where I share my experiences with other students, international students and other young engineers to help them succeed in their careers. You can find all the episodes of this week in civil engineering at TWICE.News, that's TWICE-TWICE.News. Reference to all the news stories covered in this episode will be in the show notes. And if you're watching on YouTube, make sure to subscribe to the TWICE playlist so you don't miss future episodes. Now it's time for what's happening this week in civil engineering. Now it's time for this week's news. You're about to hear excerpts from the stories referenced. Links to all of the full articles can be found at TWICE.News. First, let's cover the biggest breaking news stories from this past week that may affect civil engineering companies and professionals. Firstly, near deadline, Trump signed spending bill with one-year highway transit extension from Tom Ichnowski, ENR.com. A stopgap spending bill was signed on October 1st by President Trump, avoiding for a full year a shutdown of several federal agencies extending to federal highway and transit programs. The Senate passed the bill on a September 30th with an 84 to 10 vote. The continuing resolution, or CR, will continue appropriations through a 72-day period. The construction industry is glad that agencies and their government-wide construction programs will stay operative. The 2015 Fixing America Surface Transportation or FAST Act that was to lapse on September 30th was also extended for a year, giving a lease to off-life to surface transportation programs. The Highway Trust fund got a $13.6 billion boost from the general fund, with the highways getting a $10.4 billion and its transit account $3.2 billion. The technical hitch is that the extension applies to federal highway contract authority but CR limits highway obligations authority spending a 72-day pro-rate share. The real uncertainty will come if Congress was pursuing a 72-day extension of the FAST Act and a 72-day CR. A one-year extension was still a victory. Brian Thurmel, an associate general contractor of America's spokesman, said. However, the extension does not fully meet the expectations of construction and transportation groups, who have been asking for a multi-year highway and transit legislation for a long time. It's unfortunate that the civil engineering construction industry, already burdened with the effects of COVID-19, has also faced the challenges of bureaucratic hurdles as part of our projects. Next up, let's look at the biggest civil engineering stories in the United States. Firstly, ASC salary reports reveal a strong profession, possibly trends. Ben Wappel, news.asc.org. The civil engineering industry reveals strong fundamentals in spite of the pandemic according to the 2020 ASC civil engineering salary report. The annual pretax salary increased to a median of $115,000 in 2019 from $109,000 during the previous year following a five-year trend. The ASC president, K.N. Gunalan, said that while in general the economy had taken a hit, the civil engineering sector continued its services of transportation, roads, bridges, ports and airports. Communication and wastewater systems keeping us connected to the physical world while most of us move our jobs and businesses to the virtual world. It revealed that the civil engineering profession is essential to maintaining public health, safety and quality of life. The demand for the services and skills of civil engineers is showing an upward trend in spite of COVID-19. The article which can be found at news.asc.org goes on to discuss civil engineering salary figures. This is encouraging news to all civil engineers that even in the wake of various disasters, the CE industry as a profession remains strong. Next up, California's first vehicle of cable state crossing debuts, a linchot, enr.com. The Jaldes Mountain Bridge at Long Beach Port has a 2,000 foot long mainspan, 6,400 feet of approach man with a 205 feet vertical clearance. It was built by SFI, the design build team of Scheme Construction. Spain's FCC construction on E-List we build, formerly Salini in Pregilio, using a mobile scaffolding system. It will carry more than 15% of the country's inbound cargo by trucks. California's geologic survey will feed 2074 accelerometers on the on and around the bridge. 49 citizen towers, piles and cabs, 13 sensors will be on the ease approach and 12 at the different depths to measure the ground response. The real-time data will be shared with about 15,000 registered users of the agency's database. The bridge has 30 foot long, 3 feet diameter shock absorbers and joints that can accommodate 6 feet of movement and can withstand any expected earthquake according to Duane Kinaghi, capital of programs executive with the port. There are many different components to this project making an exciting one for civil engineering professionals. EMI is reaching out to the project team members for a potential interview on the civil engineering podcast which can be found at civilengineeringpodcast.com. Next up, B-Doc OK start of $3.8 billion Hampton Roads Bridge tunnel expansion, Jim Parsons, enr.com. The Virginia Department of Transportation has given a go-ahead notice to Hampton Roads Connector Partners, HRCP, a design build joint venture of Dragados, USA, Vinci, Dondin Campanon, Bernard, and Flatiron Construction to start adding twin two-lane tunnels parallel to existing tubes linking Hampton and Norfolk, Virginia. HDR and Mod McDonald are leading designers for the 9.9 mile project which has 14,000 feet of marine bridges. It replaces more than 24 existing bridges and lane additions to sections of I-64. The funds for the progress are coming from regional sales and fuel tax revenue and $200 million will come from agency funds. The tunnel boring machine will begin excavation in 2022. The 45 feet diameter tunnels will be 50 feet deeper than the 7,500 feet long immersed steel tubes which were built in 1957 and 1976. It is one of Virginia's most congested areas with more than 100,000 vehicles a day and power of commercial and naval traffic. It also serves as an excavation route in case of storms. Tunnel constructions of this size and complexity are not often available or studied by civil engineers. It will be interesting to know what design and construction challenges arise during construction. EMI plans to explore this project deeper through our podcast the Geotechnical Engineering Podcast. Now let's take a quick break for the news for this week in civil engineering inspiration. As a very young structural engineer I like to tell all their engineers and even students to continue pursuing their passion and continue pursuing their careers as an engineer and not forget to always be curious always be asking questions and most importantly don't be afraid to make mistakes. As young engineers we think our career and profession needs to be perfect but in reality we need to learn from those mistakes early on in a career and those are the mistakes and the lessons that are going to shape the future of our career. I was able to learn this very early on in my career with volunteering and my own job so I want to give that back to all of you today. Don't forget to always be curious and do not be afraid to make mistakes in your careers. I hope you find that inspirational now let's jump back into the news. Next let's move on to some international news in civil engineering from this past week. First up we're headed to the home of twice co-host Danny Lu. Two billion British pounds needed to keep major London road bridges and tunnels open from Rob Horgan new civil engineer dot com. A transport for London also known as TFL report investment to get London and the UK moving again released recently warns that as in case of Hammersmith bridge many more routes could be shut down in absence of long-term funding. Businesses all over UK will be adversely affected as 90% of all fried use road transport. It warns that several key routes like A40 westway, router high tunnel and gallows corner flyover already face speed and weight restrictions and face closure for major repairs. This is a major barrier to economic recovery. A two billion pound investment from now to 2030 will help renew key road assets. Maintaining safety and renewal of aging assets is a challenge in many locations as they are often reliant upon government funding. The ability to call for and influence funding as well as use funding wisely is certainly a responsibility that falls on several parties but on them is the civil engineering professional is working on these projects which is why our job as civil engineers often goes beyond engineering. Next up over to Southampton sustainable engineering technologies to be advanced in 14 million pound future towns innovation hub southampton.ac.uk. A new high tech innovation center is being built at the University of Southampton Science Park for helping local towns and their businesses address environmental and sustainable challenges for modernization. The future towns innovation hub will have specialist laboratories workshops and facilities for business to collaborate with researchers. Enterprise M3-LEB is supporting this 14 million pound project which will take two years to complete with 3 million pounds from the government's local growth fund and 1.5 million from Research England. This will help towns in the region recover from the economic impact of the pandemic according to Professor Paul Kemp, the innovation director of the future towns innovation hub. Professors Mark Spearing vice president of research enterprise at the University of Southampton said that he looked forward to working with the town and businesses towards innovation to modernize. If all goes well and the project leaves to fulfill its promises it could be a model for future projects of this kind. On that note let's cover a few infrastructure related stories starting with 500 million water infrastructure investment plan for Michigan ChenaRothMlive.com Governor Gretchen Whitmer announced the Michigan clean water on October 1 after decades of underinvestment in Michigan's infrastructure will help protect our public health environment and economy she said. It will be funded from federal dollars for lead service line replacement in low income communities and by bounding authority for water quality protection, general fund from drinking water infrastructure and innovation and various grants for projects like non-lid drinking water infrastructure drinking water asset management correcting combined sewer overflows and removing direct and continuous discharge from raw sewage from surface or groundwater would also support the project. Taxes will not be raised for investment and will provide over 7500 jobs. Mike Sreberg with the National Wildlife Federation and Chuck Lipschrow president of the Michigan Agribusiness Association welcomed the move. Michigan State adopted in July the new PFAS drinking water limit limits for toxic chemicals in Michigan's public drinking water. U.S. Department of Environmental Quality announced another 95 million investment for Michigan communities to borrow money for water infrastructure improvements and $681,000 to the Michigan Water and Environmental Great Lakes energy from voluntary lead testing of drinking water in child care programs. Clean water is a huge worldwide challenge and it is good to see investments like this being made to maintain and improve this precious resource. And last but not least the 284 foot ascent could break mass timber tower height record from Nadine M. Post ENR.com. The world's tallest hybrid mass timber tower ascent is under construction in Milwaukee. Ascent's Jason Korb principal architect for Korb Associates Architects stated that 184 foot tall timber building project framework that was permitted but never built in Portland, Oregon, designing but lever architecture was used for ascent's design. The results of the fire test done for the unbuilt framework funded by a $1.5 million U.S. tall wood building price were also useful. Ascent has a 19-story hybrid timber and concrete structure resting on a six-story reinforced concrete parking podium with post tension slabs. It is a fat L in plan with a full high reinforced concrete core near each end of the leg. Above the podium, there are glue laminated columns and a floor of one-way glue lamp beams with cross-laminated timber framing in the other direction. Ascent got its permits on July 24. Construction was started on August 10 but the joint venture general contractor of Catalyst Construction and CD Smith, the timber framing starts next May and completion is expected by the summer of 2022. Ascent will be four feet higher than the current world's tallest mass timber building near Starnett in Norway. As a structure engineer myself, I appreciate seeing the continued research, development and use of different materials in structural engineering. To wrap up, here's an inspiration quote to motivate you for the rest of your day. What civil engineers do is novel and really matters, but why you do it, it's what's really important. That's from Ronald Berg from our previous episode of the Civil Engineering Podcast. There you have it, that's what's happening this week in Civil Engineering. You can find reference to all the stories mentioned at twice.news and all episodes are also published in video on EMI's YouTube channel at youtube.com slash engineering careers. Remember to subscribe on Apple Podcasts, Spotify or wherever you listen to podcasts and of course on YouTube for the video version. This is Luis Duque signing off. We'll see you next week. In the meantime, go and be the best civil engineering professional you can be.


While their airmen is deployed they wait They work they study they graduate they play they go out to eat They make a turkey for Thanksgiving dinner They celebrate birthdays and holidays they dance they work out They do laundry and mow the lawn and rake leaves and shovel the driveway they cry They go to bed and they wake up counting down the days until their airmen is home But what most people don't realize is that they serve too Because they do all of these things while their airmen is away and that airmen couldn't serve without their support Happy veterans and military families month from the 910th Air Lift Wing and thank you for your support


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Hey guys, how you doing? This is your boy, Rich, and I'm here with a very special breaking news from high times HITM new IPO coming out and Your boy rich has invested in high times.  They told me they would and I'm good I decided to keep my money in I believe in high times and it's because of news like this High times to acquire major cannabis industry trade show organization Big industry show trademark. Look at this thing Are you kidding me? Wow, look at this opportunity here. I think this could be huge. You ready? Look at this. Look at this You guys see this This is big news is breaking news from high times Literally just broke high times to acquire cannabis industry trades trade show or Organization This is the logo called the big industry show. This is their trademark logo Let's click on here and let's read this news Now I invested in high times now remember rich TV live is strictly for education entertainment purposes Always do your due diligence always do your research before you invest in anything We got all the breaking news all the top stock information every single day Absolutely free right here for you for rich TV live You can join the community be a part of our social network be a part of our whatsapp group Be a part of our growing community of people that want to learn about stocks Specifically cannabis stocks, which is our expertise and you can join our secret stock picks group and follow us on all social media Absolutely free and get all the trending news 24 hours a day seven days a week now What is happening with high times you ask this is huge news? High times just keeps getting bigger high times to acquire the big show most recognizable brand in cannabis Announces agreement to acquire big publications and events business into its professional conference portfolio High times the most well-known brand in cannabis today Announce that has entered into an agreement to acquire buyers industry guide. This is huge news What do you think about this news guys? If you like this news smash the like button comment down below remember I Bring you the news and if I win and you win We all win. It's win-win What do you think about this if you like this news smash the like button? I want to know what you guys think The publication and production company responsible for the highly successful Canna conference series the big show This B2B trade show which services the ancillary cannabis community gathers twice annually in Miami and Los Angeles attracts over 10,000 industry guests annually Wow It's huge And they just acquired them the latest acquisition will extend on high times impressive event production business which includes entertainment festivals like the cannabis cup reggae on the river and Industry events like the high times business expo now your more rich is going to be interviewing High times next week It's true. Your boy rich is going to be interviewing high times next week It's mind-boggling. 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I own 363 shares of high times at eleven dollars. Okay It is true. That was my investment at the high times for more than 44 years High Times has been the world's most well-known cannabis brand championing the lifestyle and educating the masses on the benefits of the natural Flower from humble beginnings as a counterculture lifestyle publication High Times has evolved into hosting industry leading events like the cannabis cup Huge love it and I'd love to be there high times You guys are watching this video your boy rich and my members would love to come. Okay to all your events and High Times business summits while providing digital TV and social networks globally distributed merchandise international licensing deals and Millions of fans and supporters across the globe in the world of cannabis high times is the arbiter of Quality wow Wow, wow Huge news Breaking news about high times. What do you guys think about this news? I? Love it. I love high times. I own high times now Remember rich TV live is strictly for education and entertainment purposes. This is a sponsored Video, okay? I am going to be doing videos and advertising for high times I look forward to working with you high times. I wish you guys all the luck and and I hope that the company is a huge success Not just for the stock and because I'm a shareholder and I wanted to go up so I can make money Of course and for everyone that's invested all 15,000 investors worldwide. They're all excited about this new IPO Just like me But because you guys are going to be doing all of the major events for the companies So I'm super excited to be able to hopefully work with you guys and be able to be a part of a lot of those events and Bring that information to the people first because that's what we do here rich TV live We bring you the winners. We bring the news and we bring it to you first So what do you think about this news high times to acquire major cannabis industry trade show? organization the big show I Love it. What do you think comment down below smash that like button share the video everywhere Subscribe hit that bell for notifications. So every single time there's any breaking news 24-7 you can counter your boy rich to give you that news first. It's true And I don't want your money.  I own 363 shares. Let's go champ. Let's go Let's go. Let's go champ. Keep getting bigger keep getting better Your boys out. Peace. Let's go high times