Spotlight on Mental Health: Physical and mental health

Sophia Davis, Senior Editor of The Lancet Psychiatry, is joined by Laura Fischer, Sarah Garfinkel, and Simon Rosenbaum to talk about how physical and mental health are interlinked, from the connections between mental and physical health conditions, to the physiological and neurobiological mechanisms involved in mental health and ill health, and to mental health interventions that are integrating the body within them. 

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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.

Sophia: Hello and welcome to The Lancet Voice and to one of the podcasts on mental health as part of The Lancet's 200th anniversary. It is June 2023 and I'm Sophia Davis, Senior Editor at Lancet Psychiatry, and we are going to be talking today about the interplay between mental and physical health. And I'm joined by Laura Fisher, Sarah Garfinkel, and Simon Rosenbaum, who I'll ask to introduce themselves to you in a moment.

So we're going to focus today on how research is increasingly showing how much physical and mental health are interlinked, from the connections between mental and physical health conditions to physiological and neurobiological mechanisms at play in mental health or mental illness. And to how various mental health interventions are trying to involve the body.

Let's start at the big picture of mental and physical health conditions. And I wanted to start with you, Simon. Could you introduce yourself for us, first of all? 

Simon: Hi Soph, thanks so much for having me. My name is Simon Rosenbaum. I'm an exercise physiologist by background. I'm currently an associate professor in the discipline of psychiatry and mental health at UNSW Sydney on unceded Gadigal lands here in Australia.

Sophia: Yeah, so starting with the big picture, I know you were involved, Simon, in the Lancet Psychiatry Commission on protecting the physical health of people with mental illness. Could you tell us about the physical health of people with mental health diagnoses and what kind of disparities there are there and what's driving that?

Simon: Sure. So, I mean, in short, we know that mental illness is associated with High rates of cardiovascular disease, obesity, diabetes up to 1. 2 to 2 times higher risk compared to the general population. We know there's a gap in life expectancy for men around 10 years, for women around 7 years, just for having a mental illness.

And some of the drivers behind that, and this was identified in the commission and I'll just acknowledge Dr. Joe Firth from Manchester University who led that, that Lancet commission did a great job. Part of that was identifying the factors, as you said, so some of those modifiable factors. Risk factors, but also other sections looking at the interplay between psychiatric medications and physical health and some of the impact there.

In terms of those modifiable factors, we looked at things like physical activity and diet and smoking. But I think it's really important that when we think about those modifiable risk factors, we look through the lens of, of social exclusion and poverty. And too often we hear that we just say, well, this is an individual.

You know, if we just choose to eat better or we choose to exercise, it's going to be better, but it's just not that easy. So I think, you know, what's really clear from the evidence is that our services What we're providing through those services have to match the needs of the individual to address those, those modifiable risk factors.

Sophia: Yeah, that's a really good point that it's, can be interesting to think about, oh, physical mental health, how are they involved, but it has to always involve thinking through a social lens and cultural factors and, you know, social structural factors are always involved and make it complicated to understand what's going on, but we need to try.

I know you've worked a lot. interventions related to mental health, Simon. But before we get to the topic of what we can do, I want to zoom in a bit more on processes within the body. So so Sarah, let's come to you. Could you introduce yourself? 

Sarah: Hi, I'm Sarah Garfinkel. I'm a professor of clinical and effective neuroscience at the Institute of Cognitive Neuroscience, UCL in London.

Sophia: I really like the way that you describe the brain and body as being Intrinsically and dynamically coupled, such a nice phrase. And I'm fascinated by your work on interoception. Could you talk about how body signals influence how we think and feel and Tell us what 

Sarah: interoception actually is.

Exteroception is sensing the outside world, and that's through senses such as vision, audition, whereas interoception is sensing inner bodily signals. And my work and others delineates interoception across all different hierarchical levels. So you can have the afferent signals themselves, the signals in the body that communicate to the brain.

You can have the neural processing of these signals. You can have Also individual differences in how precise people can monitor and sense these signals. And then you can also look at higher order measures, such as how people interpret the signals, their attention and bias to the signals as well. And then we can test interception using all of these different levels to see how they map on to emotion and cognition.

For example, we do know that emotion is embodied. What gives sort of the emotional, the feeling states of it all and how it differs from cold cognition are bodily changes. And so interception has been linked for many years, really going all the way back to William Jameson before as being very guided and influenced by the sensing of the signals.

Sophia: And you found that the sensing of those signals differs between different people and sort of maps onto. How you might classify their mental health. 

Sarah: Yeah, I find it so fascinating to bring people into the lab and see how accurate they are at sensing the bodily signals, because there are massive individual differences in this.

Some people are incredibly accurate and some people really, really find it very hard. But then what I think is. Another interesting insight into interception and how it differs from extraception is that people often don't know how accurate they are about the body. So some people can think, Oh, I'm so accurate.

And then you bring them to the lab and you test them and they really, they, they have poor accuracy. They often feel overwhelmed by bodily sensations. So they feel they're sort of bombarded with them, but they don't have precision into them. And also the neurocircuitry in the brain picking up on these signals.

doesn't maybe have quite the same precise mapping either. And you do get these vast differences in, in how people can do this. And it seems to map a little on mental health and neurodevelopmental conditions. So a lot of my work is with people who are autistic who often have difficulties understanding how.

They feel in terms of their emotion, they're often overwhelmed by anxiety and my work and others show they can have poor precision into these signals at times. 

Sophia: So interoception, as you've said, it's happening unconsciously in our sort of unconscious processing of signals from the body, as well as through our awareness and our interpretation.

And Laura, you're working more directly in this area of body awareness and embodied learning. So let's come to you. Could you introduce yourself? 

Laura: I'm Laura. I'm the founder and CEO of Traumascapes, which is a survivor led organization dedicated to addressing trauma through arts and sciences. Like 

Sophia: all three of you, your work combines a focus on research with interventions.

Could you start by telling us how you see the body as being central to mental health, particularly in relation to trauma? 

Laura: I mean, we know that more and more studies show how the body is central to how we understand ourselves, how we. Interact with others, how we react to threats, how we process and store memories, and generally how we function.

So the body is inevitably key to our understanding of mental health as a whole. But it's particularly important when we understand trauma to, to look at this through the lens of the body. Because trauma unfolds in the body. Under traumatic circumstances, the stress response system is overwhelmed, which then disrupts the memory system.

which means that traumatic memories are unprocessed and stored in the body as fragmented sensory and emotional traces. Essentially, trauma continues to play out in the body in present time, and it influences how we feel, how we think, how we act, how we interact. The body is not only where trauma plays out, but where healing also takes place.

To heal from trauma, we need to rebuild. Internal and relational safety. And we can do this through, through the body. We can learn to. Really understands the languages of the body and learn from them and work with them to rehome ourselves and reconnect to ourselves and reconnect to others. 

Sophia: So 

Laura: we have, we have 

Sophia: your three different perspectives on the body that all sort of interact with each other in a way on different levels of understanding.

You've already brought up Laura, the idea of healing and what we can do and how the body can be a site of healing. Healing or learning or change. So let's turn to interventions. What are we going to do with all of these ideas that are around? Simon, you've worked and I'll just, I'm just going to disclose here that I'm an avid, very avid runner and have played a lot of sports during my life.

And so I'm very excited by work to do with physical activity. Now, Simon, you've worked with a whole range of. Physical activity and exercise interventions. What are some of the ones that you see as being effective for working with different kinds of mental health needs? 

Simon: In short, the ones that people enjoy would be where I'd start.

So we've got very solid evidence that the type of exercise doesn't seem to matter. It's really about. And finding an activity that a person enjoys that then they become autonomously motivated towards and they're willing to do. So we've worked with, you know, I've worked with a range of groups, trauma affected groups or trauma exposed.

So veterans, emergency service workers, and more recently with, with people affected by forced displacement. And when we think then about the, the transcultural applicability of exercise and sport, I think we, We're reluctant to talk about specific interventions, and thinking about what fits with the communities that we're working with, and what do they have available, and what do they have access to, and what can be used.

And I think there's some exciting work happening around the contextual factors of physical activity. So what we're talking about there is, is it done outside? Is it done with friends? Those sorts of factors that we know are so critical to actually helping people find that enjoyment and find that thing that they want to do.

You know, but we know from the evidence that, that the notion something is better than nothing. You know, I think it's very clear that if we actually can help the most unwell, the most affected, the most disadvantaged, those that don't have access to services, those that are the most sedentary, if we can help them do something, that's where we can really see a really significant impact and improvement.

So it's really when, you know, for me, my interest now is, is around systems and how can we actually embed these sorts of interventions within mental health services and mental health systems, and I think some exciting stuff is around the, the future workforce and what does the future mental health workforce look like.

You know, we talk a lot about integrating physical and mental health services together, but actually what are we, what are we doing around training around our undergraduate, postgraduate level to actually integrate and bring these. You know, I can give you one quick example of some work that we're doing with the Olympic Refuge Foundation in, in conflict affected settings training the mental health workforce in sport and physical activity, and then training the local sport and physical activity workforce in, in psychological first aid and basic principles of, of mental health skills to actually bring those workforces together, create those referral pathways and allow for those local school.

Local types of activity and culturally appropriate forms of activity to actually happen and to take place. 

Sophia: That's such a good point that it's the bridging between those services or contexts that's so important in encouraging things to actually happen and change. It's really interesting that you say that enjoyment seems to be the key factor.

But that sort of brings up what, what do you think is really going on there in the way that physical activity or exercise is affecting mental health? 

Simon: I think it depends on, on, on the individual and that point in time, but I think there's some really interesting Work and if we think about exercise, are we are we thinking about a patient who is in bed who is severely unwell?

Or are we thinking about someone who's who's who's functioning well? But you know is using exercise as part of their maintenance. I think there's different There's different mechanisms taking place at different points in time, there's different systems that we're impacting, there's different biological, social, psychological mechanisms that I think at different points in time, they all play a role.

So you know, I think possibly Sarah and Laura might be better placed to answer some of the, the, the biological stuff that's happening. But for me, I think there's a lot of. stuff around providing routine, the social support, providing meaning, providing purpose, particularly in, in, in socially disadvantaged or socially excluded communities.

I think there's a lot of stuff there that, that, that activity and movement can, can harness and can offer that we're not capitalizing on in terms of the health benefits enough. 

Sophia: It just shows how interlinked it all is. Cause you're saying, okay, well it nevermind the exact physiological processes.

There's also these psychological and social processes that are really interesting, like meaning. Or like the social interaction, how important that is. There's all these different levels that we must be attending to. Talking about this more neurobiological level, Sarah, I've been really intrigued by some of this work within the interoception area on these novel interventions like heart rate monitoring and flotation tanks.

Can you tell us a bit about some of these new interventions from Insights? It's a really 

Sarah: exciting time, I think, where we're neurobiology of interception and how it may also help with different treatments. So you mentioned flotation tanks, it's lovely work happening by Saibh Khalsa and Justin Feinstein looking at flotation tanks and when you go into a flotation tank as you may know, it's, it's a bit like sensory deprivation, so it's dark, it's silent, so you have all the other sort of.

extraceptive senses dulled down. And it's fascinating because your interception sense suddenly becomes very sort of precise and that starts to sort of dominate. And it's a very good way of getting people in touch with the, this interceptive processing and it's, it's informative to see that this then can lead to profound reductions in anxiety, increases in relaxation.

And the flotation tank itself is providing the context for interceptive precision by sort of upregulating this interceptive processing. And we can see based on other interventions that there's something special about interceptive precision that may actually be helpful. So we've also undertaken.

taken a clinical trial to teach autistic individuals who are anxious to be more precise with their heart. So this heart rate monitoring you talk about, and we do very simple exercises with them. to help them feel their heartbeat more precisely. We just get them to sort of jump up and down.

It's actually similar to Simon. We do very light exercises with them, but this actually helps them feel their heartbeat more strongly. We then give them feedback about what their heart is doing and they learn to be more precise with their hearts. We can also scan their brains before and after and see that this is associated with changes in connectivity in the brain.

So insular is an area that's involved in the sensing of internal bodily sensations. And we see greater connectivity between the insular and the ventromedial prefrontal cortex, an area involved in control. So there's something now about this precision into the body being linked with better control and potential regulation of the body.

And through. this intraceptor training with the heart, we can see marked reductions in anxiety, which we've now unblinded the follow up data that lasts for one year and is, is making a so called using a sort of predefined threshold, a third of autistic adults recover from their anxiety, which has strikingly high results when you think this is potentially also quite a hard to treat population.

Sophia: And also when you think that it's fairly simple in its concept, just monitoring the heart rate. 

Sarah: Yeah, I think that's right. It is, it's such a simple behavioral intervention. And yet it has these. consequences in the brain. And it also seemed to generalize. We need to do formal research to look into it, but it seemed to generalize where they also felt they could monitor when they were hungry and not hungry better.

They were able to use the bathroom more accurately as well. It seemed to have some sort of general. bodily awareness as well, that was helpful in other types of functioning as well, which might have broad implications for physical health too if you start to understand and process your body with more precision.

Sophia: I've talked to you about this before, about where the borders are between what's interoception and what's not. And so the definition of interoception that you use, if I'm right, is more to do with like organ functioning, right? I'm, I'm curious also about the other ways that we perceive our body. So we had talked about this on another occasion about how we also perceive how we hold our bodies, like say the tension in our bodies and things like that.

That might go more into the territory of Laura, what your, what the type of bodily awareness that you might be focused on. So can, can we come to you now again, Laura, and can you. Talk with us about some of the body based interventions or healing that you've been involved with and, and what you see is 

Sarah: key to developing those.

It's fascinating to hear from Sarah about interception. And yes, you're right. There's a, an interesting line between the two or an area of blur of opportunity. So what, where, where I work is a survivor led creative approaches to healing. So at Traumas Keeps We. We look at healing as something that is as an approach that is survivor led, creative, embodied, and relational.

We, we do this through various strands of work, but one key intervention that I've been working on for, for a while now that is still being developed iteratively by survivors taking part, but it's a trauma focused movement language. which is an embodied process of co creating internal and relational healing and empowerment.

And it's built on two foundations, the neurobiology of trauma that is common to all survivors, and the experience of trauma that is unique to each. So it's really looking at a space in between the two where We can approach healing in a way that's led by survivors, but is based on evidence and our understanding of the neurobiology of trauma.

The key principles to, to this intervention, and generally to answer your question, some of the key principles to this work that I believe are important a survivor led approach because power and agency are key to, to healing trauma. We need to be able to reclaim the power that was taken from us.

And also because healing is something that I believe it's internal to survivors or to everyone. It's an internal capacity. The solution isn't externally located. So having that agency is core. Then another principle I would say is critically being body based because, as I mentioned before, trauma is held in the body and also because healing must be experienced and felt.

It can't just be talked through or thought through. It's also creative because creativity is the enabler of redistributing power and working with the body. And creativity offers a position of not knowing and of exploration, which creates a space for what could be to emerge. And the last principle is that this work is relational because healing is both internal and relational, and healing is a co created experience.

Those are, I guess, conceptual pillars to, to, to this work, but it's quite connected to, to, to the work on interception and to the, the ability to reconnect to our internal signals. Both I would say both the, the organs. You know, the heart rate, for example, can tell us a lot, as well as what you were mentioning, Sophia, that comes a bit beyond that, which is, for example, the tensions in the body, because all of those languages will tell us where we are at in the moment and how we're feeling.

Those are often the very signals that trauma survivors are disconnected from. There's that disconnection from the body as a result of trauma. So being able to connect to these, understand them, is the first step to then being able to work with them and transform them into processing trauma and moving beyond it.

Sophia: Connecting to the body, it's a phrase that sort of resonates with me there, as well as like healing being integral to the body, like we have, we have these healing capacities, incredible healing capacities within us that we can attempt to tap into. Because you're all working in this field, but in different ways.

Do any of you have any questions for each other or any comments on what you've said so far? 

Sarah: It's really interesting to hear Laura speak because it was actually working with individuals with PTSD that really highlighted the importance of the body. And that's when I retrained in autonomic neuroscience to learn about how the body and brain were coupled together.

Because when I trying to understand fear in the brain, which is typically what was done in the neuroscience of post traumatic stress disorder. Actually, you have all of these body hyper arousal responses that just seem to be such a big part of the story that wasn't being integrated in the neuroscience of PTSD.

And because you do have this fascinating constant interplay between what the brain's doing and what the body's doing. The body can be a route which shapes neural processing and also a route through interventions such as Simon's doing with exercise. And it's, I think it's really exciting to hear everyone speak together about their individual routes, which really are sort of supporting this idea about the body being a key driver and a key and exciting method for intervention for different conditions.

Simon: One question I might have is just around how do we actually scale these interventions? How can we get more people getting access to body based intervention? Yeah, I'm interested. We're in different countries, but if there's any any thoughts on what the priority is and how we can actually achieve that.

Sophia: Yeah, that's a big question. I mean you don't, you already partly answered it yourself when you had said about Trying to have people in physical arenas being trained in mental health and people in mental health arenas having physical Some kind of physical training, which I think has to be some kind of first step.

But what do you two think? 

Sarah: I wonder if there is a bit of a shift in the zeitgeist of it that will drive it from the people themselves so I think maybe before body based interventions or things that worked on the body were maybe seen as not sort of not the scientific ways of doing it, but actually it's through basic science and work which is mapping out these body brain connections at the sort of science foundation to these body interventions.

And if we can describe how exercise changes, cardiovascular parameters, coupling with brain inflammation as well as other. body based interventions and how they are also changing these neural substrates, then actually it might drive the scientific basis, which in turn will facilitate funding implementation and greater scaling through the scientific foundation.

That's my head. So just talking more to change this and publishing more of 

Sophia: the landscape and all of that. It's always difficult to know what a zeitgeist is doing, but from, it seems to me also as though there is a bit of a shift happening that there is more interest in, in this, in the whole, you know, body brain or mind body and trying to look at the different ways that they're interacting, which is partly why I wanted to do this.

Have this conversation. So it does sound, it does seem like there is a bit of a shift in awareness and then, yeah, hopefully that affects all those different levels that you mentioned. What about you, Laura, do you have any thoughts on how to scale all of this up? I 

Sarah: mean, I agree with all that has been said.

Yeah, I do feel there's, there's a growing interest both in the scientific community and in the, in the general public. And I am keen to see more work being driven by communities themselves as, as well. Obviously what we do is, is survivor led, but but, but not only not only that, just generally people leading, taking the lead in, in, in what they need and what response they need.

And I like what. That Simon put the emphasis on doing what people enjoy because at the end of the day, health is, is to support our, our, our enjoyment, our enjoyment of life, right? So though we, though I do feel we should develop new interventions that are specific to responding to mental health needs and trauma in my case.

I think it's, it's a case of just allowing space for people to, to, to be able to do what they enjoy and support their health and well being and whatever that means. And so there is space for non clinical work to, and then actually science to be led by that rather than the other way around. So it'd be good if we could sort of meet in the middle, maybe not even in the middle of a new space entirely.

Yeah, community led science and science led community work and something entirely different as well. 

Simon: Just to link, I think, what Sarah and Laura said, so, I mean, Laura, I completely agree about the co design. I think we have the answers. What we don't know is actually what do communities need to access what we know works, and I think there's so much exciting work happening around real, genuine co design of interventions.

We've just finished a project with refugee women here in Australia. You know, co designing essentially a physical activity space around what they want. And there's things that came up in that that we would never even thought of, things like childcare, for example, that are actually the key barriers.

And unless we address that, they can't come. But one of the things, you know, Sarah, that you mentioned around the, the, the evidence base. And I, you know, I absolutely agree. But I think we also need to acknowledge that, that it's. Ultimately, the motivational aspects and providing the support and the resources to help people to be able to engage in these sorts of interventions is so tricky.

And I think we've still got, at least here in Australia, a lot more work to do around actually funding these resources appropriately so that They're, they're treated like the, the treatment is and people are actually supported and facilitated to access them, not just expected to go and have the individual will to go and, and, and participate.

Sophia: Yeah. I think that's a really important point. It's not all on the individual to, to get up and motivate themselves to go out and do something. That's not the position that everybody's has access. Like you said, there's a lot of barriers in what, from childcare to all sorts of other things. Does anyone have any other points from, that have arisen 

Sarah: through the conversation?

I'm just curious as to how we, we bring all this together, because clearly we do very similar work, but also very different work and it would feel so strong to bring those different strands of work together. I can see it, I can visualize it, I can almost touch it, but how, how do we make that happen?

Because I think a lot of. The issues when we become so specialised as we become more isolated. How do we connect these different strands of work together? Maybe we should organise a conference. 

Sophia: Or, going along the line of what we've just said of how it doesn't need to necessarily be serious. It needs to be enjoyable.

Maybe we should just organise a group activity. 

Sarah: This is what I think is so, it's an excellent point. Because science is all from the neurobiological mechanisms. to working with individuals to help shape their therapeutic intervention to large scale implementation. And that's actually through all of these different levels, do you get the real shifts and impacts?

And I think it's through, yeah, collaborations with the scientific community that makes sure we don't get stuck in our own level and that we keep the conversations and. Dynamic shifts between them to make sure that things things progress because there's so much great research out there But we really need to bring it Into the world to also make a difference.

So that's not answering how we can do it 

Simon: I mean a first step for me I see is around treatment guidelines and you know, I think very often they're very focused on on symptoms and so a lot of the, the work around functional recovery or, or these sorts of interventions that we're talking about, I think are often excluded which means that, you know, at least what I've seen over time, and it is changing, but the sort of recognition within, in mainstream, whether it's like psychology or psychiatry, the recognition of these sorts of approaches, I think is not necessarily there.

There's an evidence base, but that evidence base sits separately, and it's not being used or, or, or applied. So I think, you know, I really, I like your point about it all coming together, and Laura, I totally agree. I think there is so much, there's so much synergy and, and, but how that actually, the different disciplines and the different worlds.

An example, I was, I was saying offline, but like the Latin American Mental Health Physiotherapy Network, for example, are doing this great work around these sorts of interventions. You know, and I think that there's a lot that we have to learn from them as well in thinking about How we can actually incorporate some of that knowledge into the work that we're doing as well.

Sophia: What do you mean that guidelines are just focused on symptoms mainly, and so that this, this type of work doesn't tend to be included? 

Simon: Well, I think, for example, if we look at the evidence around deteriorating physical health associated with mental illness you know, it's very clear. We've got, you know, really strong data that physical health deteriorates over time.

And I think there's a real opportunity for these sorts of interventions to act as a safety net. And to catch people before the, the mental health symptoms deteriorate so much, and if we think about, you know, we keep talking about the burden on the mental health system, and we need more mental health professionals, and absolutely we do, but in the meantime we have these sorts of physical health interventions or somatic interventions, body focused interventions that could be used in the meantime, and it might be not.

Not, not in every case, but in some cases it might alter the trajectory of the illness itself. And, and I think there's a real opportunity there that we're just not seeing because of the separation of these workforces. 

Sarah: But I also want to go on to a really positive point, which is the strides that we are making.

And I do think that. It's such an exciting time where we're opening up the scientific understanding as well, as well as the therapeutic potential for body based interventions, which as Simon points out can be fun, can be engaging, can be less invasive. And I do think that This is a wonderful time for mental health science where we are understanding these dynamic relationships between the body and brain and we can use this to fuel and also ultimately make more precise different interventions because the more we understand the neurobiology of these different types of interventions and how they work, the more that we can augment them, shape the therapy to target the mechanism.

The more we can do personalized therapy, match the type of therapy to the type of mechanisms that need to be changed. And there is a world opening up of these body based interventions where I don't think we've made the strides that we would have hoped with conditions like schizophrenia in the past.

That's traditionally been seen as a very brain centric disorder, but with new focus on bodily inflammation, there's also really fascinating work looking at cardiac effects that happen in individuals prior to them getting a diagnosis of schizophrenia. That actually we're starting to see that things that we just assumed were all brain based may also have a bodily basis and a world is opening up for more possibilities.

Sophia: I think that's a really good, a really good point to see the, the opening up of different possibilities and then in, in the end, that helps you to have different options to provide to people because people's preference and coming back to enjoyment is so important. So to, to be able to look at pharmacological pathways, psychological pathways.

More body based pathways and others for people to be able to choose from perhaps, and to mix in different ways when that's appropriate and guided opens up more possibilities. Well, maybe that's a nice positive note to end on about the positive signs of opening up or the steps happening in this area. So then we'll finish there.

Thank you all again, massively for making the time from different time zones and in your schedules for, for talking with me about this topic and to the listeners, you can find a collection of articles in our 200th anniversary mental health spotlight online now at thelancet. com. So yeah, thank you all again, Simon, Sarah, Laura, for joining me and thanks to everyone for listening to this episode of The Lancet Voice, which you can subscribe to wherever you get your podcasts.

Gavin: Thanks so much for joining us for this episode of The Lancet Voice. This podcast will be marking the Lancet's 200th anniversary throughout 2023 by focusing on the spotlight with lots of different guest hosts from across the Lancet group. Remember to subscribe if you haven't already and we'll see you back here soon.

Thanks so much for listening.