Okay. Well, hello again. Good morning. And we'll get started. So our presentation this hour is on international occupational medicine. We've got two presenters, myself. I'll introduce myself in a second. And then we have Dr. Rob Cantor. We'll be about 20 minutes each, and then we'll leave plenty of time for questions and answers and discussion. So I am Saj Saval, and I'm with the University of Pennsylvania, a medical director for one of their main hospitals, medical director for occupational medicine and employee health, and then also involved with the residency program. And as part of our residency, we have global occupational medicine as part of our curriculum, and we do train on that. So this talk is about comparing and contrasting to the U.S. experience, which is like global occupational health sites, clinics, and then, you know, with some experience from the U.S. and how that can be made more useful for the international workers. Okay. So, okay. Put it the other way around. Sorry. All right, so no disclosures from me or any conflict of interest. I work for the University of Pennsylvania, but obviously the opinions here and the preparation is all mine here. So we'll be talking about, I'll be mostly like comparing like employee health services and then also access to like the general health care in different world areas. And then my colleague Dr. Cantor will be talking more about like the challenges that global medical directors and then the local providers there, they face and how the U.S. based providers, medical directors can help provide better health care to the international workers. So a previous definition by IMF was like developing countries and developed countries and under developed countries, but this definition has been used more, more I guess in the last few years by the World Bank where they have divided into four groups, the countries based on their GNI, the gross national income. And based on that, it's like low income, lower middle, upper middle and high income. And as you can see, about 85% of the world population belongs to the non high income countries and which is like all or most of Central South America, Africa, and then most of the Asian nations. These stats are from ILO and I checked recently, but that's the most recent from 2021, which is of the world population, anybody knows what number are we are at now? Eight. So it's 8.1 billion. So for over 3 billion workers worldwide, two thirds of those workers are employed in unhealthy and unsafe working conditions. And the reasons, lack of resources, awareness and knowledge, accessibility to workplace exposures or occupational hazards, and when we say occupational hazards, we look at like the five main physical, chemical, biohazards, noise, and then radiation. There are almost 3 million deaths which are related to occupational injury and disease every year. That's like 7,500 deaths a day internationally, globally, which is a significant number. And as you can see, like almost half, over half a billion occupational injuries and illnesses every year. Obviously, this is like an estimated number by the International Labor Organization. And like we said, it's only 15% of the world population which has access to essential occupational health services. WHO has this annual, like the leading causes of death globally. And as you can see, the top 10 there, I put occupational deaths there based on the ILO data. And you can see that it's like we are like the top five. All right, so we see that, you know, occupational related deaths are way, way, way up there. And we talked about the, we talked about the access to like occupational health services and those limitations. And then the wide majority of the world working population, you know, lacks that access. Looking at the general health care, your everyday health care, that access is also limited. The Institute of Medicine defines access to health care as the timely use of personal health services to achieve the best health outcomes. Now, to, and then why is that important? Obviously, like preventing disease, managing disease, promoting and maintaining health, and also reducing unnecessary disability, early death. We looked at those numbers in a previous slide. And also to have that health equity for everybody. A lot of that access to or having that health care, it depends on, you know, how you can afford it. So health insurance is one thing, and health insurance is like, they're like different arenas for health insurance. More internationally, it's more like something that's provided by the national authority, like a national health service. So everybody's considered insured, or at least, you know, citizens and residents of that country. Here in the U.S., we are heavily private insurance based. It's not just having the health insurance or the affordability to pay for health care, but it's also like the timely access to it, and also to receive that care or that ability to receive care when a patient is in need. Looking at the private health insurance, like say for in the U.S., this is from, like, from a data, AHCQR, which shows like, so health insurance for those who are age 65 or under, after age 65 or 65 or over, your Medicare kicks in, at least here in the U.S. So here we can see that the private insurance for about 65% of the population, there's still disparities, like even though you have private health insurance, but like it also, the disparities between the different income levels, and like we saw like a couple of slides ago, that is also for the different levels of countries by World Bank, like low income and high income, how that disparity is. Generally, health insurance, and again, this is a private health insurance, the number of uninsured has decreased over the years. If you look at this graph, I have a point or two, good. So this was about the time, like 2010, 2011, when the Affordable Care Act came into place, it was enacted, and then you see a couple of years there, and then it further dropped. So this is very good, and again, this is for age 65 and under, but if we look at globally, it's more than half of the world population is, I don't want to say uninsured, but they lack health coverage. Hundreds of millions, like they spend more than one-tenth of their household incomes as an out-of-pocket expense for health care, and they are either already like in the poor or low income category, or it pushes them further into. So ideally, you know, everybody should have like universal health coverage, which again is when everybody can obtain the health services they need without suffering any financial hardship. But then again, this is just not, like I said earlier, it's not just having that health insurance, it's also like to have that access, to have a proper infrastructure, to have a proper access, a proper availability of health care, and then also like the, having the adequate number of health care personnel for this. Some of the outlying areas, rural areas and outlying areas, even in the high income countries lack that proper access to health care, and I just put some numbers at the very bottom, like where it says 20% of the, this is again globally, 20% children born annually did not get the complete routine immunizations just for the basic preventable disease. So, talking about immunizations, this is, COVID-19 vaccine was started, given in like December, December 2020, and this data is from the World Bank, and as you can see, like in the first 15 months or so, the large variability, significant disparity between the income level of the countries and how they received, there were other things too, availability, accessibility, awareness, acceptance, there were several factors, but overall, you can see there were like big time disparities. So as occupational health services, like globally, like this is from many, many of the high income countries, they have like international sites for one reason or the other, and then they have their occupational health services there for their employees, so how can we use those to provide not only workplace safety and health, but also like the general healthcare? So again, workplaces can be used as areas or channels to not only improve health and workplace safety, but also to provide your basic healthcare needs, at least for the employees and their families. Again, where we practice, this is like two different roads, it's like either your work-related or non-work-related, so non-work-related is usually to send out to your primary care and so forth, but here we are talking about individuals who do not have access to basic healthcare needs and how we can use the occupational health sites for that availability. And then those sites can also collaborate with the local primary care clinics, facilities, helping provide preventive medical care to, again, like I said, like the workers and their families as a whole. So in summary, it's a good 80 to 90 percent of the world's working population lacks essential occupational health services, and then also those populations are deficient in primary health services. That obviously increases your disease burden, not only on the workers, but families as well. And global, these clinics can be used to provide essential healthcare needs for these individuals. And my colleague, Dr. Cantor, he's going to talk about how some of this can be transferred, these services. So, Dr. Cantor, thank you. DR. CANTOR. It's okay. Well, actually, it seems to be displaying fairly well up there, so I think perhaps we'll just try to get started and wing it, and if it doesn't work. Anyway, thank you to Dr. Seville for his perspective. My name is Rob Cantor. I am still confused by this. Yep, it seems to be a little disjointed here. It's not. Okay. Well, if somebody could see if we could fetch the AV person for a little bit of help. In the meantime, I'll just try to get started a little bit. My name is Rob Cantor. I am the Senior Medical Director for Ford Motor Company for Mexico, South America, the Greater China Region, and the International Manufacturing Group, which basically includes India, Thailand, the Middle East, Africa. And I'm also the Global Director of Industrial Hygiene and Occupational Medicine. So I pretty much have all the time zones covered. If this was working, you would see my disclosures. I have no conflicts of interest other than the fact that I do work for Ford Motor Company and I do hold stock in Ford Motor Company. And also, this presentation is based in part on a prior presentation by Dr. Francesca Litto. So thank you, Dr. Litto. I appreciate the assistance with this. Our objective, as displayed by Dr. Savul previously, is to compare the employee health services and access to general health care in different world regions. That was primarily covered by Dr. Savul. Our other objectives are to identify different challenges faced by global medical directors and occupational medicine providers when caring for a global workforce and identifying different challenges faced by global medical directors and medicine providers when taking care of that workforce. And again, I really wish this was working a little better. But I think there are a couple main points here. Cultural sensitivity and cultural competence is very important in this type of role. You need to have an awareness and appreciation of the values, norms, and beliefs of a particular cultural region, ethnic group, or racial group that is not your own. And you have to have a willingness to adapt your behavior to their behavior. You have to meet them halfway in order to work together and achieve our goals. One moment while hopefully we put this back in working order. All right, good. So we appear to be back up and running again. As I was saying, an awareness of the values and norms of the culture and region you're dealing with is extremely important in order to accomplish our goals as a corporate entity and medical department, as well as the goals of the individual and local medical providers and workforce. And you really have to work at developing that cultural competence. I mean, first of all, you have to recognize that there is a difference between your background and what you believe is normal and what your colleagues in the other part of the globe view as normal. You have to learn about it and then you have to adapt and you have to meet them halfway. Just as a couple of examples, when I have case management meetings with Mexico or South America, I do my meetings in Spanish because it's easier for my colleagues to express themselves in Spanish. I have no trouble communicating to them in Spanish, but some of them do have some trouble in English. That's not always possible. I'm not nearly as good at Portuguese and can't really help out too much in Brazil, and I certainly can't speak Chinese, but I've gone to the extent, I've done a lot of research on the cultural background, the history, and tried to understand the mindset of these different locations around the world so I can understand sort of their viewpoint and what they're getting at. The other thing too that I try to do is I don't expect them to bend over backwards for me. I try to meet them on their ground. So if I'm doing a case management meeting with Thailand, it might be one in the morning my time, but I'll do that because it's easier for me to change my schedule than it is for eight people on the other side of the world to change their schedule, and it's just as inconvenient for them. So when you're dealing with international clinics, you have to recognize that it is not your home. You have different views on everything. You have to learn how to communicate, and sometimes that's going to take a very long time. You have to be willing to be very patient, and you have to go into it really as a good observer, a guest. You have to not try to project your beliefs and your values on somebody else. You have to learn from them. Probably another good example here of different values is, I remember when we were trying to hire a medical coordinator for China, and the first candidate that was presented to us was not a doctor of Western medicine, they were actually a doctor of acupuncture. That wasn't going to work for us. We had to explain why that was the case, level set with human resources in China, really explain to them what we needed, and develop a meeting of the minds where we got what we wanted, they got what they wanted. There's still a few gives and takes there. For example, we do carry herbal medicines in the formulary in China that we don't have anywhere in the rest of the world, but that's what the expectation is there. We're fine with that, but we do have a Western-trained doctor who is in there and is able to oversee that for us. So what do you have when you're starting off working with these various clinics around the world? Well, first of all, we have our professional knowledge. We have our skill sets, the clinical knowledge, the understanding of causation, those types of things translate across the globe. Hill's criteria of causation is the same here as it is in anywhere. You have to really have good risk communication skills, though. Using a foreign language, if you know it, is extremely helpful. But what you do need to do is you have to have patience. You do have to have that awareness of the cultures that you're dealing with, as I spoke before. Even now, I've been in this role going on three years, and even now, some of my relationships with some of the people on the ground are just developing to the point where I feel like I'm getting adequate knowledge and communication and feedback from them that I need to make things better. It's just improved drastically in a couple countries just a few months ago, and I've been working on this for years. You can't expect this kind of thing to happen overnight. It will happen, but you have to go in with respect. You have to go in asking questions, and you have to understand what's coming back to you and sort of meet everybody on their ground and not expect them to be on yours. As I said, you are not going to Americanize your colleagues. They're very good at what they do. They're very good at what they do in their regions, and they're the ones that understand what they're dealing with on the ground, not me. So I'm the one that needs the information, not them. I need them just as much, if not more, than they need me. So when you are navigating this, you have a few considerations. You have your company standards, your rules and regulations. Every large corporation has their own standards that are set up. You have to take into consideration the rules and regulations of the U.S. government, at least in my case. We're a U.S.-based company, even though we're global, so everything is viewed a little bit with American viewpoint and American standards, but you also have to take into consideration the local laws, and you have to find that sort of sweet spot in the middle of all that where you can operate, where you're satisfying our government, their government, and the company. Actually, I probably should have put in a fourth oval where you have the cultural norms and standards, and the laws do vary quite a bit in certain places. Just as another example, in Brazil, they have something called e-social, where they, as a government, collect a lot of data electronically. They collect data on entry exams. You have to conduct exit exams when someone is terminated. They collect the data on that. They collect data on what the work description is, chemical exposures. All that is collected by the government, and we have to provide all that data. That's their law. So go into it. Be a curious observer. Don't assume that you know what's best. You probably don't, and it might take some time to figure out what the best thing is, but you'll get there. Just be patient. Look for the program elements. They are different in different parts of the world. We have various types of wellness programs, for example. They are called different things in different regions. They have different approaches that meet the cultural norms in those regions, and develop a strategy with the local stakeholders. You really need to have at least one, if not several, people on the ground who can give you the real information that you're seeking, because many times communication is difficult. You're not necessarily going to get the straight answer. You need to read between the lines. Think about things that aren't being said, and over time hopefully develop at least one. It would be better to have several contacts who will really work with you, and give you the real scoop on what's going on, and what you need to do to get things moving the direction that you want. When you go into it, and I think it's best to really approach this in sort of like a regimented fashion. Think about a framework. What is the same in the country you're dealing with compared to what we're dealing with? Many things are the same, especially clinically, but not necessarily. Think about things that are different. For example, in the United States, we all worry about OSHA recordable injuries. That governs everything. What's a significant injury? In all my regions, that doesn't exist. Determining something that is a work-related injury is determined differently in different regions. It might be the government function. It might be an independent function. For example, in Thailand, we need to send people to the hospitals to have things looked at. But think about what sorts of local resources you have. Your doctors. I certainly recommend that you get a good contact as far as the general counsel to help you deal with legal actions. You can stumble into all sorts of bad areas inadvertently, assuming that the laws are the same in a different country compared to what we have. That just doesn't work. Training and credentialing. That's very different. We're used to the Western world where we have a medical degree, it's an MD, a DO. There's something similar in Europe, but that's not necessarily the case in many parts of the world. And as far as training, residencies here, that's really pretty extensive. In some parts of the world, we might get somebody who gets a certificate in occupational medicine. That's about six months worth of training, if less. So you might need to go in and try and figure out what their base of knowledge really is and augment that with what you know in order to bring them up to speed with what you need. And you're not going to do any better by trying to cycle through different providers either because they're all trained the same. It's going to be up to you to build that. So you have to have different expectations depending on the country that you're dealing with. And it's really important to remember that. And take everything as an individual thing, have patience, build it up, and figure out what you need to do to fill in the holes yourself. Again, unexpected considerations, different ways of determining compensability. As an example, well, you have a Social Security group in Mexico that determines whether or not an injury is compensable, has nothing to do with our OSHA laws. We have something similar in both Brazil and Argentina. And hazards, in India and also in Thailand, we have to carry antivenom in our formulary. Not a normal consideration, but where our facilities are, it's reasonable for somebody to be bitten by a snake and there is no way to get that person to an emergency facility in a fast enough period of time. So we have to have antivenom there. The legal considerations, I mentioned the E-Social in Brazil again. Different medications are available in different parts of the world. Maybe it's the same medication in different doses. That's something you have to consider when you're considering your formulary. You just do the best you can to try to standardize, try as much as you can to get an approximate equivalent medication. But even then, it might not be enough. Because you have to think about things, too, that in different parts of the world, there are different resistances to antibiotics. So you may need to carry a different antibiotic in a different country compared to a third country compared to the U.S. You have to deal with what's going on locally. And again, that's up to your local team and your relationships with those people to tell you about that so you can make that happen. And then there are very specific challenges, too. For example, in South Africa, we have many people on disability because of complications of poorly treated HIV. I don't have that in any other region in the world. But I have many cases that we're dealing with in South Africa because of that. And I don't exactly understand what the basis is for that, why people aren't getting better treatment. But it's just the reality that we have to deal with. And we have to find our way around it. So you do have a lot of assets, a lot of things to help you through this, professional organizations such as AECOM. We do have the international section of AECOM, which, by the way, is sponsoring this event. And also we have an international component of AECOM, which is made up of our members who live in different places around the globe, the CDC and the WHO. The WHO actually has a really good app that can help you stay up to date on different challenges that you may face in different areas around the world. And I probably get three or four updates on that per week. There are journals, and it doesn't necessarily have to be professional journals. I subscribe to some national publications in a few different countries just so I can read up on current events and understand what's going on with people locally and what their concerns and considerations are. And they can be varied. For example, again, in Argentina, they have an enormous inflation rate. And our people down there are very concerned about it. And it really does affect how they respond to certain other challenges and stressors. And then international resources, CIDRAP, the EU, public health resources, research or reach to help with industrial hygiene and toxin Europe, various things like that. So again, I can't stress this enough, patience. You will develop good relationships. You will get the information you need. It just might not be today or tomorrow or next month, but you'll get there. Be an observer. Consciously cultivate self-awareness. What your biases are, where you're coming from culturally, and compare and contrast that to your colleagues across the globe. Ask the questions, and then think about what you haven't asked, because that can be just as important. And as I mentioned, listen for what is not said. Try to read between the lines, because communicating with many cultures is not cut and dry. As Westerners, especially Americans, we tend to be very abrupt and in your face about things. Sometimes that doesn't come off well around the world. But other cultures are not like that, and you need to understand that and try to communicate to them in their, not necessarily their language, but in their approach to things. It's not necessarily just the language. It's how you approach the communications with them. Learn, explore, build your network. The network is important. Eventually you'll get some good colleagues in those regions who are going to be willing to work with you and tell you what you need to know. Ask for advice all the time. Ask for advice. That's really important. And I'm still learning this, and if I'm still doing this in 10, 15 years, I'm still going to be learning. There's so much to know. And just, again, patience. Here are some other resources that can be very helpful for people who are trying to coordinate medical services around the globe, and thank you to everybody. So at this time, if anyone has any questions, that would be great. Also I know we have several of our international colleagues here in the office, so please feel free not only to question, but to tell me what I missed and what I don't know. Teach me. So what else can we do to help practice medicine in your region? Yes, sir? Do you ever hire medical colleagues? No. It's an interesting thought, and I understand why you think that. You know, it would be an interesting way to get perspective on some things, but unfortunately I'm sort of stuck doing my own research and a lot of reading, a lot of research, watching videos on great courses and things like that, trying to figure out different cultures. Is it working? It's working. Can I say a comment on the anthropologist question? Yeah, go ahead. Thank you. Yes, there are times you need an anthropologist. In fact, we did work in DRC, Democratic Republic of Congo. We had an anthropologist because the mining companies were really taking over the villages and the people had to move first out their homes, so then we had to really follow them and find out the issues and report them back to the government. So yeah, there are times you need an anthropologist, but it's not in all cases. But in that case, it was important. I can definitely understand the need for it in certain cases, definitely, if there's some question. Yeah. Thank you. I think this question over here. Hi, you talked about the difference in credentialing of OCDACs or clinicians in different countries. When you seek to train them further, how do you train them? What's your approach? Do you send them to courses, set up your own course? What do you do? A combination of everything. Actually, right now, just as an example, we have this quality improvement program that I've instituted in Mexico, and we have courses on dealing with particular types of injuries every other month with sort of like a question and answer session and like a self-evaluation chart audits, things like that, to help understand what they're doing, why they're doing it, and try to reduce the cases where you don't see them using evidence-based medicine, which happens frequently in other countries. Over time, I think you can provide them some courses. We have some learning apps for the company and things like that, so I hope that answers your question. Yes? So, I'm actually a little bit of a plant, but I wanted to ask a question, maybe, and talk a little bit about, going back to what we saw he was talking about, can you talk a little bit about how we do more care or different care in Mexico? Oh, yes, yes, yes. And thank you. Thank you for bringing that up. That actually really is kind of an important thing. I mean, Saj mentioned that we have the opportunity to provide some additional care. My clinics in Mexico, actually, they're more or less primary care clinics, for the most part. They do some basic OB, they'll treat hypertension, some of the real basic sort of like family practice in addition to occupational medicine, and also, in addition, when it comes to wellness, we have clinical psychologists at each site there as well, and we have a wellness program that use the PHQ-9 as sort of like a screening tool, and they have other things that they do to find some mental illness. We have something similar in Brazil, although there we use the SQR-20 because that's what's mandated by the government. We don't have a psychologist on staff, but we do have a contract psychologist. So we do quite a bit of extra health care in certain regions, and it does vary from place to place, but probably Mexico is the most robust as far as our primary care efforts. You first, and then you. Well, we do have, I'll try to answer this as best I can, and if I'm not answering your question directly, please let me know, I'll try to redirect. But for the most part, we don't really have a lot, personally, in those types of situations. But when things are a little bit questionable, we do have our own corporate standards. We have an extensive list of corporate medical standards that we try to abide by. And even if a country doesn't have necessarily a robust legislation or protections, we follow our standards. For my part, and fortunately, I work for a company that I've never had any pushback on this, but our goal is to improve people's health. And I will never compromise on that. I don't care if it's a country where we could get away with something, we won't do it. So we stick by our standards, and we have that as at least a safety net, a minimum. Does that answer your question? And I'm sorry, there was a question over here. I just saw a little bit of a follow-up on that, because you're also in charge of industrial hygiene, also known as occupational hygiene for the rest of the world. Yes. And the question is, do you do the same type of industrial hygiene monitoring that you do in this country, in Mexico, and other countries? Yes. Yes, we do. And then do you abide by United States standards? Not necessarily, because the standards are different, but we do have minimums that are at least as robust as US standards. So we do have to navigate that. You have REACH in Europe, you have our standards here in the US, and other countries have various other standards. If something is a lesser standard, we will keep it at the very minimum to what our corporate standard is. So even if that's more restrictive in excess of what we can get away with locally, we'll stick by our standards, which are, to your point, at least as stringent as the US. In some cases, it's more stringent, because we also have REACH to deal with. So it's just easier to have one standard applied as peanut butter across the globe than it is to sort of try and tweak and figure out what each individual regulation is. Plus, ultimately, I think that's safer for our workers. Good morning. I would like to know if there's anybody here in the audience that practices in cortisol? Because I have that personal interest, so just in case. No? OK. Thanks. Yeah. Sir? So occupational medicine, when it's practiced here in America, I understand that workers' comp plays a large or fundamental role when it's practiced clinically here. In an international setting, I'm curious to know, what role does workers' comp pay, if at all, internationally, and if not, what equivalent or what are ways to kind of address that? You mean as far as liability? Essentially. OK. There are different ways of dealing with that in different parts of the globe, and that, for the most part, is governed by national laws and regulations. So I can't give you a straight answer, but every country has their own way of dealing with it, and we abide by that. Sir? I have a question about the training. You know how long it takes to be an occupational medicine doctor here in the West. I've been looking around and found, for example, a program in South Africa where you have to be 40 years. You get education. You can't actually get a semester. You can't even go on to get a PhD, but that must really allow you to be more certified in occupational medicine. In the U.S., there's some, you know, it's two years. You know, you have to get an I.E. and the residence is an I.E. So, according to your experience, how long do you think the training should be? I mean, you know, there's so many things you can get in, but... Actually, I will defer on that answer to my colleague, Dr. Savul, who's training residents. Thanks. So, here, I mean, there are different ways, but training is generally two years. And that's after you're done with at least one year of other, like, training, what we call it, the intern year or transitional year. So, that's two years, if you're talking about before certification. I can explain a little bit more to you afterwards. And then, also, it's like an experience base, too. So, if you're not in a residency program, then you should experience. So, there's a way of talking about your province in more detail. Thank you. Any other questions? Go ahead. Just one question. Thank you for your thoughtful review. Regarding cultural awareness and cultural self-awareness, I guess, how do you communicate that to your leadership structure and to other departments? I'm not entirely sure how to answer that. Go for it. Delicately? You know, we can control best what happens in our department. Okay? We have good discussions about it. You know, we try to be cognizant of cultural differences all the time. It is less easy when you're dealing with other departments that also work there that have no interest in that. I think you just take it on a case-by-case basis. I don't know that there's a good answer to that. I honestly don't. Unless you can think of one. I don't know. Well, I guess you could talk about how we got the Austrian concentrators in India during COVID. Oh, yeah. You know, I suppose that is probably a good example. I mean, you can at times show the need for a certain thing, and that's a good example. During COVID, there was a real problem in India with a lack of oxygen supplies, even in the hospitals. So, what we actually did was we imported a bunch of oxygen concentrators for employees who were sick, so they at least had a base form of oxygen as a supplementation. We basically talked to the upper management, demonstrated the need for it, told them what the problem was, and we got the support we needed. Doctor? Do you find that within the corporation, there are different allies that might help you in culture? For example, engineers sometimes regard all people as some kind of robot, and don't appreciate any culture, but are there allies like Human Resources that are actually interested in working with different cultures, and are you able to incorporate them into your approach in different countries? Okay, I'll take a shot at answering that, and Dr. Little, if you have anything to add, please jump in. But I would say yes. You know, to me, it's sort of difficult when it comes to, as you said, engineers that are looking at things from an engineering perspective, but Human Resources have been pretty good. And we have different people who serve as Human Resource Directors in different regions, and those are the people, I think, that can act as our advocates. So, it's important to develop a good relationship with those people as well. In addition, even some people that work at global headquarters have served abroad as an expat worker, and have come back to the U.S., or in some cases are from other places and have come to the U.S. to work. So, they also have a bit of a cultural awareness. I'd have to say our HR department has been a pretty good advocate for that. Would you agree? Actually, I think there's a question there first, then we'll get to you. Was there someone over there? Okay, I guess not. We'll go here. Hello, Doctor. This is my presentation. Thank you very much. I am an occupational physician from Thailand. Oh, welcome. This is my first time speaking with an OEM physician from a foreign company that has invested in Thailand. And I have two questions. From your perspective, what are the three main problems facing OEMs in Thailand? And how can we address and improve them? And the second one is, do foreign companies operating in Thailand need to comply with U.S. regulations? Additionally, for those studying residency course, should we learn about U.S. regulations to better address market needs? Thank you. I think a lot of that depends on the individual company. Rather than worrying so much about U.S. regulations, I think from your perspective, you need to worry about Thai regulations and what the corporate standards are that govern what you do. I think as far as how the U.S. regulations are applied in different areas around the world, I really have no experience in this, but I imagine it probably varies a lot from company to company. So just follow the corporate standards. As far as challenges, I think we have several challenges. And actually, perhaps we should connect and talk about this after, because I definitely have some challenges in Thailand. It's pretty amazing how few occupational injuries are being reported there compared to plants that are building the exact same vehicle in the United States and in South Africa. And I always suspect that there's some sort of cultural difference in the way some of those things are perceived and addressed. I'm not entirely certain. But there are definitely challenges. I don't know necessarily that I have all the answers to that yet. But I'm working on it. So. Thank you. We're right on time. Thanks for your attention. And a special thank you to Dr. Amy Irma, who helped moderate the Q&A session.

international occupational medicine

Dr. Saj Savul

Dr. Rob Cantor

University of Pennsylvania

occupational health experiences

global medical directors

cultural sensitivity

healthcare services internationally

cultural differences