How Trump is affecting health around the world

Donald Trump has taken office in the US and immediately turned his attention to dismantling the US position as a world leader in global health. How will actions taken so far affect the health of people around the world? Gavin is joined by co-host Miriam Sabin, North American Executive Editor at The Lancet, and they speak to Dr. Gavin Yamey, lead author of The Lancet's recent Commission on Investing in Health, and Director of the Center for Policy Impact in Global Health at the Duke Global Health Institute.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Gavin: Hello, welcome to The Lancet Voice. It's February 2025 and I'm your host Gavin Cleaver. Today I'm joined on co hosting duties by Miriam Sabin, North American Executive Editor here at The Lancet, and we're talking to Professor Gavin Yamey. Who is the director of the Center for Policy Impact in Global Health at Duke University.

We'll be discussing the recent and shocking changes in U. S. global health policy under President Trump. From sweeping executive orders to a 90 day freeze on foreign aid, we'll explore the severe implications these changes have for global health programs and the potential for disease resurgence around the world.

Join us as we try and make sense of the chaos and confusion of the past few weeks and discuss the challenges and hopes for global health in the years to come. Let's get started.

Professor Gavin Yamey, thank you so much for joining Miriam and I today on the podcast. It's a real pleasure to have you with us. Obviously, you can't get away from the news at the moment about Donald Trump's presidency and his takeover of the US. It's only been a few weeks. It feels like a lot longer than that.

What stands out for you the most in the first couple of weeks of his presidency? 

Gavin Yamey: Well, first of all, thanks so much for having me on the podcast. Uh, I wish it was under happier circumstances. I think the thing that stands out the most for me really is how sort of sudden and severe, uh, and how kind of shocking the changes have been.

Uh, the executive orders have been coming fast and thick. Each new one, you know, at least many of us kind of scrambling to understand the applications. Uh, I think that does seem to be somewhat of a deliberate strategy, right? To, um, shock people into kind of discombobulation so that you're not really sure exactly what's going on.

It's very hard to find information. Many of the federal websites have gone dark, so you can't even get any actual information, even if you, you know, try and find it. Um, and so, certainly for those of us working in the global health arena, the last two weeks have been extraordinarily Uh, unsettling, chaotic, uh, and really quite hard to understand or grasp.

We're in very unprecedented territory. There's really be nothing like this, I think, uh, in, in modern U. S. history. 

Gavin: I sort of have this desire to live in precedented times by this point. Um, what's, in global health terms, what's kind of stood out for you the most in the first couple of weeks? 

Gavin Yamey: Well, it's not even the first couple of weeks, to be honest.

It was day one of the Trump presidency, uh, when he issued a sweeping freeze, a 90 day freeze on all U. S. foreign aid. Well, almost all U. S. foreign aid. There were a few exceptions, uh, military aid for Egypt and Israel, and, um, uh, food assistance, although our colleagues on the ground say there have been major disruptions to food assistance.

So this 90 day freeze Accompanied by, you know, work stop orders. So our colleagues on the ground involved in implementing programs, service delivery, you know, working at NGOs, clinics or doing clinical trials or health research, they got stopped work orders. They were told to down tools, you know, to fire staff, to shut a clinics.

to turn patients away, um, and, you know, that has caused absolute mayhem, uh, as you can imagine. So that's certainly true for global health programming, uh, it's led to interruption of HIV treatment services, for example, malaria control programs, uh, disease control programs targeting MPOCs, Marlborough. Uh, childhood diarrhoea control program.

Oxygen is not being delivered in many parts of the world. Malaria bed nets are sitting in warehouses, not going out to sub Saharan African countries. And all of this interruption and disruption and chaos is, I'm afraid, already causing increased disease transmission. And if you look at, uh, the history of, you know, sudden disruptions to disease control program, We are very, very likely to see major disease, resurgence and sickness and deaths.

Our own center here at Duke has done a lot of research on, uh, you know, the transition of countries out of foreign aid. And when that's done very suddenly and precipitously, you see disease resurgence. So we know that this is going to happen sadly, and it was entirely 

Gavin: avertable. 90 days sounds like quite a short amount of time, doesn't it?

But in these time frames, it's quite, quite a serious interruption. 

Gavin Yamey: Yes. I mean, let's not forget, for example, that if you stop people's antiretroviral therapy, obviously they can become sick. The viral load goes up, uh, transmission, uh, increases as a result. Um, you can interrupt the prevention of mother to child transmission.

And crucially, the longer that you force treatment, the more likely that patients are to develop resistant HIV. So they then can't go back on the same medicines and they have to go on to, you know, more complex and more costly second or third line regimens. You also see potentially rapid malaria resurgence when you stop, uh, malaria control prognosis, when you stop insecticide, um, uh, spraying, when you stop the delivery of these long lasting insecticidal, uh, bed nets, when you stop doing, you know, intermittent presumptive therapy, uh, for children or pregnant women, you can start to see resurgence quite quickly.

And if you look up, you know, some of the cuts. that have happened and some of the reporting, uh, from, you know, on the ground. The Ugandan National Malaria Control Program, as a result of suspending USAID, has had to suspend spraying insecticide into village homes. And they stopped giving out bed nets to pregnant women, uh, and young children.

So we're going to see malaria resurgence, uh, no doubt. And there's also just a tremendous amount of confusion and chaos around the so called wavers. Marco Rubio, Secretary of State who oversees USAID, has been under enormous pressure from HIV activists. from academics, from implementers, from many of us working in the global health, uh, world.

We've been, you know, writing to our senators, um, contacting the state department. He's been under a lot of pressure to at least allow continuing funding for antiretroviral medicines. So he initially issued a waiver last week, but the reality is the language of the waiver was very confusing and it wasn't very specific.

Our colleague in Lower Middle East said they were under stop work orders, this waiver wasn't helping them at all. So a couple of days ago, uh, just last Saturday, he issued a further amendment, uh, trying to clarify that yes, antiretroviral medicine could continue as well as prevention of mother to child transmission services.

Um, but it's still not clear that, you know, these stop work orders have been dissolved. And on the ground, there is still a lot of disruption and chaos and confusion. And of course, the waiver is very limited. And it's temporary, very narrow, doesn't apply to many of the things that I was talking about earlier.

You know, from maternal and child health to malaria to, you know, control of outbreaks like MPOC, Marburg, um, and, uh, it's not the way, you know, it's not the way that you should ever proceed, uh, in, uh, the financing of disease control programs. You should never suddenly switch off the tap. You know, the U. S.

spends around 70 billion a year on aid and around 40 billion of that is through USAID. Uh, a lot of that is for humanitarian assistance and for global health. Global health is about 12 billion of that. The idea that you can suddenly switch off that amount of financing and not the diseases we're serving, people starving, uh, is ludicrous.

You know, countries can't suddenly find 70 billion overnight and that's just not how it works. That's not, you know, how the financing of disease control programs. Uh, works. And so, the effect has really been, you know, quite apocalyptic to be honest. Um, and then if you add in the withdrawal of the US from the WHO, CD staff being banned from, you know, discussions and, uh, contact with the WHO.

The essential dissolution of USAID, USAID staff have been told to stay at home with yellow tape across the office doors, you know, it kind of mind blowingly apocalyptic right now in the humanitarian and global health space, I would say. 

Miriam: So, Professor Iemi, let's, let's dig a little further into the domestic financing landscape.

You know, you had talked about that you've studied for a long time, uh, what, what the outlook is for transition, uh, for countries to take on more and more of their own, um, uh, financing needs for, uh, procurement, for services, for outbreaks. If PEPFAR and if USG funding were to remain frozen, you know, past 90 days or even, uh, or even significantly cut back, um, what do you see as, you know, the outlook and what lower income countries and then lower middle income countries could do, um, and what do you think the donors could do, OECD donor countries, um, to, to also help?

Gavin Yamey: Thank you, Miriam. And that's a great question. And yes, our centre here at Duke, Centre for Policy Impacting Global Health, we have been working with universities and think tanks in six lower middle income countries, Ghana, Kenya, Nigeria, India, Sri Lanka, and Myanmar, to study the transition of lower middle income countries out of foreign aid.

It's also called graduation. Countries are all on the transition journey, and it is absolutely true that, you know, transition is at the heart of decolonizing global health. We all want every country in the world to be able to finance and control and run its own health sector, right? We want a post aid world.

But the reality is, from all the research that we've done and many other scholars have done, transition has to be done. in a very careful way. Donors are supporting the transition process, including the US, by the way. I mean, PEPFAR, if you look at its latest five year strategy, it has sustainability as a central pillar.

So PEPFAR is working with countries to help them gradually increase their own domestic financing and gradually, carefully increase ownership of their own national HIV control program. The key word, I think, there is Gradually, and our research has shown very clearly that if you hurry it, and if you don't do it in a careful, safe, well planned way, you get shocks, and disease resurgence, and chaos, and you particularly see disease resurgence in vulnerable groups.

I mean, I think the best example of this, we did a study on transitions out of HIV programs, and I think the best example of this was if you look at the first wave. of Global Fund Transition, in other words, the first group of countries that lost external support from Global Fund. That was at a time when transition wasn't necessarily being done in a sort of careful planned way.

The Global Fund left Romania precipitously in 2010. There was no plan put in place by the Romanian government to pick up funding of HIV services, particularly for vulnerable groups. And it was. It's absolutely catastrophic what happened. If you look at the prevalence of HIV in people who inject drugs, in 2009, that prevalence was about 1%.

So the year before the Global Fund suddenly leaves, in 2010, the prevalence was 1%. And just four years later, it had risen to 53%. There were no services in place for reaching people who inject drugs, men who have sex with men, um, uh, sex workers and other vulnerable groups. And that's something we have also learned from our research, is that Safe, careful, well planned transition must include a plan for reaching so called key populations or vulnerable groups.

Men who have sex with men, people who use drugs, transgender people, uh, in some places that means refugees, women and children. Very often successful transition taking into account vulnerable groups has involved so called social contracting, where the government contracts with. civil society groups, non governmental organizations, and says, let's make sure service delivery to these groups continues when the donor leaves.

And here, the government says, here is government funding for you, the CSOs or NGOs, to continue to provide prevention and treatment services to those vulnerable groups. And we've seen that in places like Mexico, places like China, where that kind of social contracting was very effective and you didn't then see the HIV prevalence, you know, suddenly rise in these vulnerable groups after donor exit.

Be careful. Planned, well thought out, gradual transition to avoid these kind of shocks. You also asked sort of, you know, what else can the, uh, the rest of the international community do? Obviously, we hope that there are going to be other donors that can step into the breach that can provide emergency financing, uh, to fill this gap.

But again, you 70 billion in aid. is extremely challenging, but you know, all eyes are on, you know, the Europeans, all eyes are on foundations that could potentially step up and, uh, increase their support for humanitarian assistance and for development assistance for help. But again, you know, filling these massive funding gaps, this massive overnight freeze.

It's very challenging. It's a very logistically hard thing to do. Lower Middle East countries right now are reeling and, uh, facing the risk of disease resurgence from this kind of sudden financial unprecedented shock. 

Miriam: The Marco Rubio waiver that you referred to about PEPFAR programs doesn't say explicitly, but appears to suggest that key populations programs in general Also, orphans and vulnerable children programs will not be included.

And as you were saying, you know, this, this is incredibly important for disease transmission, um, particularly in Eastern Europe and, uh, Central Asia where HIV infections, uh, are, are, have been increasing for a period of time, uh, because of, you know, poor legal and policy. Uh, frameworks in a number of countries.

So I guess it also depends on which country is transitioning and how supportive they are of their most vulnerable populations. Right. 

Gavin Yamey: Right. I think that's exactly right. And I think Miriam, we're all trying our best to pass the language of waiver and our understanding, my colleagues here at Duke with, um, you know, deep expertise at PEPFAR.

Um, they agree with your assessment that this memo does not appear to cover a whole range of prevention activities, including prevention with people who inject drugs and orphans and vulnerable children. So here's the thing. I think that we could have a long and very important debate on the pros and cons of foreign aid.

That debate has gone on for decades. I happen to think there's very good research evidence. you know, showing that external assistance has had a demonstrable impact on improving lives and well being. Our estimates that it has saved more than 25 million lives, for example. So I think there's a very strong case to be made that development assistance for health in particular has had an impact.

Although it is not without its own problems, you know, the amount of control, the power that donors have over countries, you know, to shape national priorities, um, you know, there are unintended consequences. There are studies that have shown, for example, that external financing can lead countries to reduce their own Domestic financing of health, so called aid substitution.

So those impacts, those negative impacts, have also been well described. Having said that, I think there is one area, Miriam, that you've already alluded to, where you could argue that donors have been very successful. And that is in ensuring that programming reaches vulnerable groups. So if you are a country that wants global fund funding for your HIV control program, for example, you are required in your proposal to have a plan for reaching key populations, vulnerable populations.

In other words, You know, it's as a requirement of getting your fund, you have to reach the populations that prevention and treatment services. So donors have enormous amount of leverage with their. external assistance to ensure that governments have a plan to reach those populations. When donors leave, when they exit, you know, after they transition or graduate out of aid, that guarantee has gone and that leverage has gone.

And so to my point earlier, I think the key is during the transition process, which typically can take You know, a decade or more, it's the opportunity. There is the time where donors and countries in partnership can have that conversation where donors, you know, are still partnering countries that still have leverage.

To say this transition is going to require a, a transition that includes a plan for reaching new populations. We, uh, you know, we the donor may well be aware that it's a country that has historically marginalize these groups or show them prejudice towards these groups. And that makes it even more important for a plan to be put in place.

And there are now a whole range of so called transition planning tools, transition readiness tools. that pretty much all donors in countries are now using to kind of manage this, you know, decades long or sometimes even more than a decade long process. And that suite of tools, checklists, helps you identify not just the prevalence of the disease, the epidemiology of the disease, how the disease is being transmitted.

the, uh, the financing situation, the country kind of fiscal space, fiscal affairs, but also the human rights environment, and the gender environment, and the status of key population. And those tools will then kind of flag or highlight where there are gaps well ahead. of that day when the donor finally exits and that donor doesn't exit suddenly.

Typically, countries are being asked to spend more and more year on year on year. If you imagine that happening, say over 12 years, the country doesn't then face a sudden cliff, you know, in a dozen years, they've been spending more and more. And during that process, If gaps have been identified around this kind of human rights arena or gender arena, those gaps can then be filled.

The key is that this is done in a very planned, a very sort of conscious, a very orderly way. Uh, to avoid the kinds of, uh, the catastrophes that I mentioned earlier. 

Gavin: You were one of the lead commissioners on the Lancet's Investing in Health Commission, and that looked at how we can reduce premature death by 50 percent by 2050 around the world.

Has anything that's happened in the last two, three weeks kind of changed the assumptions that you had going into that commission? 

Gavin Yamey: That's a great question, Gavin, and it has already arisen. We did a launch of our new large mission on investing in health report, which is called global health 2050. We did a launch at the university of California, San Francisco, and it was in the first week of the Trump presidency.

And you know, the aid freeze had been announced and there was enormous consternation about what that would mean for the future of global health. Um, he had already announced his various picks to lead U. S. health agencies including, you know, his pick for, uh, for Health and Human Services, uh, Secretary, HHS Secretary, RFK Jr.

Arguably the world's most notorious, extreme and dangerous anti vax activist was also an AIDS denialist. And so there was an enormous amount of concern for, you know, the future of global health, future of US public health. And naturally the question arose at this launch, you know, you're talking about countries being able to halve premature death, death before the age of 70, uh, by 2050.

from what we argue would be a pre pandemic 2019 baseline. With all that's happening, you know, in US global health policy, the, uh, you know, sudden shocks to US domestic health, do you still think that is feasible? That is the question, you know, that arose at this launch, uh, a couple of weeks ago. How I approached that when I was asked that question, I was very lucky to give the sort of opening keynote, summarizing the key messages, uh, of the report, was that.

If you take a long term view, you can absolutely make the case that there will always be setbacks, but that the history of global health is a history of progress. In the face of setback. So if you, if you look at the timeline that we're talking about for halving premature mortality, 2019 to 2050, so 31 years or less from 19 70, 37 countries halved their premature mortality in 31 years or less, including seven of the world's, uh, most populous countries.

And those seven countries, by the way, were very different geographically, economically, politically. And they had very different kind of baseline premature mortality rates. And those countries also faced various kind of, you know, political challenges, political vicissitudes. They continued to make progress.

So when we look back historically, and so we imagine the same would be true projecting forward, there are going to be setbacks, but that you can still continue to make progress on premature mortality in the face. of headwinds. If you look at the, uh, Sub Saharan Africa region, and if you look at the rates of, of, uh, premature mortality, those have been steadily decreasing.

The probability of premature death, death before 70. has been steadily decreasing, uh, over the last few decades. It rose at the, at the peak of the HIV AIDS pandemic, and then it started to fall, and actually the rate of fall is now faster than in many other regions in the world. You know, they had a setback, they had a challenge.

And yet they were able, in the face of that challenge, to then continue to make headway and actually to accelerate. What our report shows is that that possible through a focus on the conditions that are the biggest cause of premature death. We identified 15 of those conditions. Eight are infections and maternal and child health conditions.

Seven are non communicable diseases and injuries. and continued investment in research and development. If you look at child mortality, for example, around 80 percent of the decline in child mortality in low and middle income countries from 1970 to 2000 can be explained by the diffusion of new health technology, vaccines, medicine, diagnostics.

And the pipeline right now for global health, for medicine, vaccines, and diagnostics, is incredibly rich. And we anticipate from our own modeling research, from looking at what's in the pipeline, and sort of modeling the likely launchers, that we could see something like 400 or 450 new fools before 2050 that could also have this accelerating effect uh, in reducing premature mortality.

You know, we've got three TB vaccines now, in late stage trials. Last year, we saw, uh, probably the most important HIV breakthrough in a very long time, led to Kapovir, uh, which has an extraordinary impact in preventing HIV transmission. So we can continue to be optimistic on the health technology side.

Again, we have the setbacks, the U. S. age freeze, let's not forget. Uh, doesn't just free services and service delivery and humanitarian aid, it also freezes research and clinical trials, and so, you know, that's undoubtedly a setback, but in the long term. We will overcome those setbacks and we will continue to, uh, see progress, no doubt.

Miriam: Do you think the role and the health of the pharmaceutical companies now, uh, the many startups that now exist and, and foundations might be able to fill some of the gaps that, for example, uh, NIH. held and, and hold still globally as, you know, the world's leading, uh, research institution on the most research dollars.

Gavin Yamey: Well, again, Miriam, the U, the U. S., as you, you just said, is, is the largest public funder of biomedical research. The NIH has been historically extraordinarily, uh, kind of, you know, bipartisan in the support that it receives. NIH has had bipartisan support year on year. As, by the way, has U. S. foreign assistance.

PEPFAR has received extraordinary bilateral support. It was founded by George W. Bush, as was the U. S. president of malaria. initiative. You know, those are two of his signature, uh, achievements, Republican president. And that's why in many ways what's happening right now is unprecedented because you're the N.

I. H. Under fire. Uh, the National Science Foundation under fire, global health, uh, under fire U. S. Assistant global health under fire, pet fire under fire. The present malaria initiative under fire. These have all, you know, traditionally being areas of bipartisan support. So, you know, many of us hope that that support returns.

Uh, we can only hope that this freeze is, you know, temporary. The, you know, domestic, federal spending that, um, Trump put on hold that have been challenged in the courts and that spending had to continue. There is still a lot of uncertainty around whether, you know, grants or uh, research on. What the Trump administration, I guess, would call kind of woke science, whether that research is going to be frozen.

You may have seen yesterday reporting on the national science foundation, federally funded science agency that supports a lot of, um, science research here in the U S the national science foundation is being asked by the Trump administration to review grads. You know, for words like equity, women, gender, um, racism, et cetera.

And, you know, there is a huge amount of fear that our research in the health and scientific arenas that is related to, you know, core concerns, uh, around equity, around, uh, injustice. around, um, you know, racial and, and, and structural causes of illness, uh, or climate change in health around LGBT health. There is great concern that the Trump administration, you know, is going to try and, uh, defund those, those areas.

So. We are all waiting to see how that plays out. The situation right now is really almost minute by minute. You see a headline and you have to sort of kind of try and understand what's going on. You know, uh, whether it's the CDC or USAID or NSF or the Department of Education. Uh, it's really right now just trying to keep up with this kind of firehose of, of bad news um, affecting science and health.

Sure, I hope that other research funders step up to fill those gaps, uh, if there are indeed, you know, gaps in funding critical science research and critical health and biomedical research on inequalities in health. Uh, on climate change and health, on LGBT health, I really hope other funders step into the breach, you know, if there is a breach, um, uh, but again, you know, depending upon the size of the funding gap, that's not going to be easy, immediate, and straightforward, but I would love to see, you know, other funders step up, and I would also love to see universities and research institutes, you know, continue to support their work.

Thanks. And be proud of, you know, those kinds of research. We do a lot of that kind of research here at Duke, and we hope that research will continue. Um, because it's absolutely, you know, central to what we do. If you look at the definition of global health, it has equity at its heart. The idea that you could study global health or be part of the global health.

you know, enterprise, global health landscape and ignore equity is preposterous. You know, it is at the very heart of, uh, of what we do. 

Gavin: I wanted to ask you actually to, to finish up. What, in your opinion, were the kind of the most pronounced effects on global health from the first Trump term? And how does this feel different?

Gavin Yamey: So I think during the first Trump term, my sense is that there continues to be very strong bipartisan support for global health, the arena in which I work. and for NIH. And so for example, Trump said he wanted to cut the NIH budget, but actually during Trump 1. 0, the NIH budget went up. Congress appropriated a larger budget.

Um, it is true that in his final year, Trump withdrew the US from the WHO, but that process requires a year. And so by the time Biden became president, he reversed that decision. So that withdrawal never went through. This time around, He's done it right at the start of his term, and he's gone further by actually instructing officials at CDC to have no communications with WHO.

That seems extraordinarily dangerous to me. This time around, he has issued these extraordinarily extreme, harsh, you know, sudden executive orders and work stop orders that have He immediately led clinics and hospitals and trials, uh, NGOs to down tools, hire people and to stop delivering services and stop doing trials in a way that he didn't before.

I mean, he's using, you know, the power of the pen in this, you know, very extreme and very disruptive way. That feels very different, uh, to the last time. And it feels, unfortunately, as if this sort of bipartisan support. For agencies like NIH, um, and for signature initiatives like PEPFAR or the Present Malaria Initiative.

We don't see that now. We're not seeing Republicans taking to the airwaves and saying, we must do what we can to protect NIH or to protect PEPFAR or PMI. We're just not seeing that this time around. It seems to have sort of cowed the GOP. Uh, into submission. So it, it really does feel extraordinarily different this time around.

Miriam: Just to say, uh, despite the, the hardship and the angst and the confusion that's going on right now, I really appreciated talking to you, uh, today, Professor Yemi, because, you know, Part of what you do is to be a seer into the future. That has been a lot of your work, right? To, to project, to think about what might happen, um, you know, by the time of the SDGs or into 2050.

And I also heard a lot of hope in what you discussed. Um, you know, that, as you said, you know, the progress, um. occurs, even in the face of all this adversity, if we take a long term view. And I'm really, I'm gonna, I'm personally gonna hold on to that, uh, thought and hope that it carries me through. 

Gavin Yamey: I'm delighted that I was able to provide some optimism.

You know, I'm not gonna lie, you know, it is a very difficult time for many of us, you know, working in public health and global health right now. But as you said, progress is possible in the face of challenge. I've been saying that to my students in the last couple of weeks, and I certainly believe that to be true.

And I would also say, you know, to your point about kind of what it is that we do, universities and academics, researchers, we all have a role to play right now. In trying to just lay out the facts using data and evidence and science to say this is what is happening. This is what we are seeing. These are the likely impacts.

You know, we can use the tools of biomedical research and science to say, for example, if you suddenly stop this kind of disease control program, these are the likely effects. And without being partisan, without, you know, getting into the politics. Although that's sometimes difficult, but as much as is possible, we can go forward, continuing to lay out the data, the science, and the evidence, and I think that's going to be an extraordinarily important role for us to play, uh, over the next four years.

Gavin: I completely agree, and it's, um, it's great to strike the note of optimism, but also to talk about, uh, all the, uh, the awful things that are, uh, have been going on the last couple of weeks. So, um, Professor Yemi, thank you, uh, thank you very much for joining us. 

Gavin Yamey: Thanks, Gavin. Thanks, Miriam. Uh, great to speak to you today.

Gavin: Thanks so much for listening to this episode of The Lancet Voice. If you'd like to find out more, you can go to thelancet. com slash multimedia, where you'll find all of our infographics and videos, as well as all of our different podcast offerings. If you're not subscribed to The Lancet Voice, of course, you can subscribe wherever you usually get your podcasts, and we hope to see you again next time.

Thanks for listening.