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"Ethics and Paediatric Surgery" Dr Gerhard Botha, Paediatric Surgery, East London + comments and advice by Dr John Sekabira, Uganda



In this knowledge-packed teaching session intended for medical professionals, prominent pediatric surgeons from various parts of the world convene to discuss pressing issues and ethical considerations in the field. Hosting from South Africa, our moderator and members, including experts from Uganda and Canada, provide a broad range of insights. The presentation by Dr. Botha delves into intricate ethical concerns revolving around pediatric surgery, with a keen focus on resource-limited settings. Topics such as resource allocation, scarcity of pediatric ICU beds and the implications on the patients and healthcare workers are scrutinized. Not stopping there, the real-life scenario of varied resource distribution in Africa is addressed, with insightful discussions on the disparities in the availability of pediatric surgeons in different provinces of South Africa, and a comparison with the global situation. The presentation does not only shed light on present issues but also stokes optimism about the future potential increase in the number of pediatric surgeons. The session comes with further thought-provoking discussions after Dr. Botha's insightful presentation. Learn about the ethics of pediatric surgery and understand practical considerations from a broader global perspective by joining this session.
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"Ethics and Paediatric Surgery" Dr Gerhard Botha, Paediatric Surgery, East London + comments and advice by Dr John Sekabira, Uganda. This is the recording of a talk as a part of the Zoom academic meetings of the Department of Paediatric Surgery in East London, South Africa.

Learning objectives

1. Understand the ethical considerations that arise in pediatric surgery, especially in resource limited settings. 2. Explore ways to prioritize resources in a medical environment, considering factors such as the nature of the resources and the needs of the patient. 3. Discover the challenges facing healthcare professionals within low middle-income countries, such as South Africa, and how these challenges impact pediatric surgery. 4. Analyze the distribution of pediatric surgeons within South Africa and discuss potential ways to improve this. 5. Apply the principles of ethics in conducting challenging clinical decisions like ICU bed allocation for critically ill patients.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

Um I have started the record. No. Ok. Uh Carry, can you hear me? Yes, I can prove. Ok, good. Um good afternoon to our colleagues in South Africa. Good evening to Doctor John Seka in Kampala, Uganda. And good morning to my dear friend, Doctor Sheriff Emil in Montreal, Canada, Sherif. I'm keeping my video off because I'm I'm hosting from home. So thank you for joining us. I'm sure I'm sure the home is beautiful ma and but, but that, that's fine. Thank you. Ok. And um uh today's talk uh is quite uh important, complex, ethical considerations in the practice of pediatric surgery. And uh the presenter is Doctor Botha who is uh a medical officer that is a junior trainee in our department. And in the future, he intends to become a pediatric surgeon. We are uh so honored and happy and proud that we have Doctor John Seira as our guest today. Couldn't have got any, any um um any um uh uh guest better than John because uh in 2015, John was one of the three pediatric surgeons in Uganda and the population of Uganda is, is about 30 million or, or 40 million if I'm John May correct me. So at that time, there were about 20 million Children in Uganda and he was one of the three pediatric surgeons there. And um and he trained in Uganda also in the UK and he has got a very strong connection to our country because he trained for over two years uh with professor in Durban in South Africa. Uh John is a very humble man. What I've come to know of him. He will never say any a lot at all, never say much about his work. But he is um probably a founding member of COSA that is the College of East African Surgeons. Um ee East African Surgeons. He is also a board member of Global Initiative in Children's Surgery and he has strong ties with pediatric surgical associations in the West. Sorry, those who do not know about John, I urge them to read this scientific publication in the journal of pediatric surgery. And that was Au Greenwood lecture which John was invited. He was the first speaker or or person who delivered this lecture. And this describes John's remarkable and inspirational story from internship to becoming a pediatric surgeon in Uganda. And I know recently John and his hospital um have received um a state of the art pediatric operation theater from the kids or RR and from our beloved Scotland. And um so without much delay, I will invite now doctor both to do his presentation after that we will advise Doctor Seira and then we have stalwarts here who will give their opinions after uh Doctor John has finished his talk. So carry, I stopped sharing and you can start sharing. Thank you pro um let me just get that out of the way. There we go. Can you see my slide? Yeah, we can see it and you can, you can start now. Thank you. Welcome all. Um I will be talking about ethical considerations in the practice of pediatric surgery. Um You'll be especially focusing on uh resource limited settings, looking at resource allocation, lack of pu beds and the implications for both patients and the healthcare workers. Um So let's start off with what are ethics. Well, at its simplest, it's a system of moral principles and perceptions about what is right versus wrong. These principles affect how we make decisions and are concerned with what is good for individuals as well as society. Talking about resource allocation. This is aiming to do the most with what is available. This becomes a problem once demand exceeds supply, which is something we frequently experience. So how do we decide on who gets what a few important considerations are that we need real time information. We need to know what is available as well as what is needed. Um To allocate resources, we need to know what has the highest priority. A simple example being that when limited theater time is available, an emergency procedure would certainly take preference over elective one. We also need to know the nature of the resource itself as this can play a major role in distribution as well as how we go about solving problems. Is it something that we can easily purchase if the budget allows or is it something such as experienced senior clinicians that cannot just be bought as the need arises? So firstly, let me just mention that we um work at two hospitals fre Hospital as well as the Syria Mako Hospital. Um They're located 25 kilometers apart and eastern cape. Sorry, what do we have? Um Talking about our resources, we are fortunate to have the expertise of five consultants, three registrars as well as five medical officers and a dedicated secretary in our department. Together, this team caters to O PD visits, ward rounds, surgical emergencies and all the service provision and academic needs of our department. We are also very reliant on all of the nursing staff at both hospitals at fair. We have two dedicated theater days, a specialized pediatric theater with access to an anesthetic consultant with theater time for emergency cases. 24 7, 365 days of the year as the need arises. Um The majority of our emergency work is done at free hospital. We have access to a combined pediatric and neonatal intensive care unit with seven beds shared between ourselves, pediatrics, cardiothoracic neurosurgery, and even occasionally orthopedic surgery. A general ward with only six beds in our cubicle, but we frequently overflow. Um Just recently, we've had 15 patients in the ward and we have a single burns ward that is shared between adult male and female patients as well as the Children. Um where we have beds for four Children at a time at Cecilia Makuwa Hospital. We have access to a 12 bedded neonatal ICU two full days theater lists per week with anesthetic consult consultant available one of these days um emergency theater time as the need arises. But this is only during working hours, seven beds in a burn ward and a spacious general ward. Most of the emergency conditions and acute conditions are treated at free hospital um as the patients get closer monitoring and this is where we are after hours. This slide gives a summary of what is going on in our department. These are actually the stats from last month between the two hospitals, we attend to almost 300 0 PD visits. More than 100 and 60 admissions to our general board, 13 patients were admitted um with burns, all of which were large percentages mostly more than 20% and a total of 90 theater cases with more than 30 of these being um emergency cases and the majority of them being done at free hospital. Talking a bit broader what does Africa need? Although Africa has only 11% of the world's population, it has been found to bear 25% of the global burden of disease. Multiple factors contribute to this high burden of disease from ende endemic po poverty to poor literacy. South Africa is a low middle-income country. One of the countries with the widest income gap, a population of approximately 60 million with only 12% of these having medical aid. The tax base is made up of 14 to 15% of this population. And a study done by um P research Africa. Research collaboration presented in 2018 showed that the 30 day mortality of patients in Sub Saharan Africa was 10%. As compared to 0.7% in high income countries. We need to focus on what counts. Um So often focus has been placed on the prevention and treatment of infectious diseases rather than uh that of trauma or surgical diseases in Children. Surgery remains an important part of basic healthcare even though it's frequently considered to have a high cost and limited availability due to the need of trained staff and expensive equipment. However, Goslin et al performed a costeffective analysis um to evaluate the cost and disability adjusted life years saved by the provision of surgical services to Children in a rural hospital in Sierra Leone. And he found that um there was a positive effect compared to that of other healthcare interventions. South Africa needs to remain attractive um to newly qualified surgeons. Many South African doctors immigrant, it was estimated that approximately 50% of South African trained doctors had immigrated in May of this year, eight new pediatric surgeons qualified. However, there were only three posts available in the state sector. Thus, five of these newly qualified doctors will be forced to go into private practice. Increasing the surgeons attending to this 12% of the population with medical aids. Thus, while we still have three provinces without any pediatric surgeons, the following information is from a review article that was published in the journal of pediatric surgery in 2018. Um it focuses on the pediatric surgery, surge and density in South Africa. It found that there were 2.6 pediatric surgeons per million of the uninsured population under 14 years versus 9.4 per million for the insured population under 14 years. That's just shy of four times the amount per million. This highlights the socioeconomic maldistribution of pediatric surgical workforce in South Africa. We also fall short of the international recommendation of one pediatric surgeon per 500,000 of the population and this will serve to pay our pediatric surge surgeons per million of the 0 to 14 year old age group. It's almost ridiculous when comparing it to the high density of pediatric surgeons in the United States of America. But we are very fortunate compared to one of our BRICS countries, India with more than double the amount of pediatric surgeons per million um than they have. And even more fortunate if you compare to one of our neighboring countries, Mozambique that has no pediatric surgeons. Here's just a graphical representation of um the amount of pediatric surgeons in South Africa per province. Um As you can see, we have quite a geographically limited distribution with Gauteng having by far the majority of 15 Kwazulu, Natal, Western cape, Eastern Cape and Limpopo are all close to each other with um eight and seven and then the free state has two. Whereas Mpumalanga, Northwest and Northern Cape do not have any at this time. This slide um looks at the workforce distribution of um pediatric surgeons in South Africa. It shows specialists, medical officers and registrars, medical officers and registrars work solely in the public sector. However, in 2018, it was noted that of the specialists, 40% worked in the public sector, 20% worked in the private sector and 38% worked in both. This slide does give us some hope for the future. Looking at the high number of registrars and the high number of specialists. Um It's hopeful that the number of pediatric surgeons will be increasing next. Moving on to our um topic of lack of ICU beds. Now ICU bed is unlike any other bed in the hospital. Um if your patient needs close monitoring, um their strength of strength staff attending to them, it's one of the best places for a sick child to be before or after a major operation. But this idea level of care cannot be offered in unlimited quantity. At Frey Hospital. As mentioned, we have seven of these potentially lifesaving spaces available. They are the only beds that can house ventilated patients as well as patients requiring inotropic support. We frequently must postpone theater cases while waiting for a bed to open up and we are also very reliant on these beds. Um and do not have any high care beds in either general or burn wards. Let us discuss a case. I had to deal with recent one night when I was on duty, I received a call from one of our referral hospitals more than 100 kilometers away from fre there. Um at the hospital, there was a single medical office in the emergency unit trying to attend to the needs of a mother and two Children involved in the shack fire. This hospital does not even have as much as a dial a flow to control the rate of intravenous fluid administration. Both Children were reported to have sustained more than 50% flame bones also involving their faces with potential inhalation injury. What was needed? Well, we needed two P ICU beds for two patients who were likely shocked and potentially will need ventilation. But what was available? We only had one possible mover out of ICU to the ward. So just looking at the literature, um the following information is from a retrospective cohort study that was done on patients younger than 10 years admitted to the pediatric burns ICU at Chris Hani Baragwanath Academic Hospital all the way from January 2013 to December of 2017. It was done by one of the recently qualified pediatric surgeons. Chris Hani Baraga is a very fortunate institution in that they have a pediatric burns ICU. And this study showed um the mortality of patients that were direct admissions versus those patients that were transferred in. As you can see, it was less than 20% in direct admissions to transfers. More than about 50%. This table shows um some information regarding the different types of admissions, that different mechanisms of injury. We can see that um flame burns were the second most common mode of injury. And that patients transferred in with flame burns had a very high mortality, 31%. So from this, we can know that patients with flame burns affecting more than 40% of the total body surface area were at a higher risk of mortality. So mechanism of injury, total body surface area and type of remission all seem to play a role in um prognosis. And in terms of these, all of our patients who are at the worst prognosis. So my question to you tonight is what would the ethical thing be to do? What would you have done in this situation? What could we have done? And then just to tell you what we did do in the end, so we tried our best with what was available at the time. The dilemma was whether the two Children were salvageable um in our setup or not in our setup, burns more than 35 to 40% total body surface area are nonsalvageable. These two patients were initially managed at the referral hospital and all necessary advice was offered to the referring doctor after exposure of the wounds. The following day, we found that the burns when calculated with 32 and 23%. Thus both salvageable. Um As soon as we had one bed open up, we had transferred the child with 23% we had collected because they had a better chance of survival and continued management at free hospital. Um As far as I was knowing before going on leave, we were trying to get the other sibling transferred as well. So what are the implications of this for our patients? Um Implications can vary greatly. Um, a delay in elective surgery can be quite the inconvenience. But for a patient needing emergency procedure, procedure delay can be the difference between life and death. We need to prioritize um who gets treated next. Um For our parents, they tend to understand when smaller Children or emergencies need to be operated before elective cases. However, during this time, many of our elective cases have been postponed. Parents do get frustrated with this. However, we do our best to do open explanations um telling them the reasons why this does help our doctor patient relationship, even though they may not be happy, at least they understand what are the implications for us. Well, healthcare workers can find themselves feeling guilty for something. They do not always have control over in such a case as the last big dilemma, all of us will do our best to save both patients. But when unable to do so, feelings of guilt would be common, whatever we choose, we will be doing something wrong it feels like. And this is a genuine moral dilemma. We get frustrated by the limitations of the resources at our disposal. We get angry for the situation so we get it and then after this, we get sad. So in conclusion, Africa is a young continent with 50% of people being young. One of the poorest in resource allocation for healthcare. We have critical shortage, shortages of both human and consumable resources and surgeries is getting neglected um in pediatric surgery even more. So being the orphan child of surgery, some of the solutions we have is that we have the universal healthcare in South Africa or the plan we need to train specialists, we need to recruit them and we need to retain them. Make South Africa attractive option, especially the state sector, get some doctors into those three provinces that do not have um pediatric surgeons yet. And on a global level, we have the global initiative in children's surgery, which we are proud to say that one of our senior staff members is a board member of. These are just some of my references. Ok. Thank you very much. Thank, thank you very much. That was an excellent summary and uh you have stated the case very nicely. And thank you for presenting even when you are on leave and you are more than 7, 800 kilometers away from East London. But that's the beauty of the technology. So the car well done. If you can stop sharing, then I will uh invite doctor Seira uh uh John, you can share your screen. And uh while John is, is uh sharing, trying to share a screen how things are related that um II sort of uh had to do introspection when I read John's story. Uh and John will tell his story uh himself that we in South Africa, we always keep complaining and uh that we have limited resources. So there are countries which are in Africa who have almost nothing. And uh so I think we just need to have the perspective when we say limitation of resources, it's a relative term. So John, please go ahead. Welcome again. I hear me and we thank you for that Yanda for introduction. And that I'm actually humbled. What I wanted to say is when I go to this, talking about this topic, when I go to this invitation, I was uh wondering what I'm going to talk about. Sorry. Oh, I'm failing to move on the cast. I sorry. Uh my talk is going to go like this. I'm going to have an overview of pediatric surgery in Uganda, some challenges and the two successes. And then I will try to go an overview of medical ethics, uh which will also include the aspects of pediatric surgery. As you know, Uganda, a low, a low income country and the population distribution of uh as you can see if you compare Uganda and the US, our population is very young. We have Children uh below 15 years, they constitute almost 50% of the population. So you can find as a doctor in the high in in his introduction mentioned, you find that the burden of conditions to treat with a four on those who manage Children and the pediatric surgery being one of the specialties, managing child, child childhood conditions, either we get the biggest brand of treating these Children, these patients. Uh as you can see from that picture, you got the Children below 14 years, the Children below 14 years constitute 20 million. And the current entry, we have six pediatric surgeons. So if you consider the US standards, that is the absa standard which was pass some time back, uh which recommends one pediatric pediatric surgeon every 100,000 Children, then you would need 200 pediatric surgeons at this moment. So it means we have a deficit of 194. And that is a similar scenario when you consider other African countries. And if you can see USA has a population of Children built for 10 years, which is 61 million. And how many pediatric surgeons do they have? 1000? 250? So they need 610. So they have a aplas and when you talk about ethics of equity, I think you should be blaming United States because they should be giving, distributing this pediatric surgeons to other countries. And I need and I think it is similar scenario plays in when you consider other co developed countries, they probably have a excess of pediatric surgeons, uh not an center when we started this program of training pediatric surgeons on the picture on the right, you can see graduates of pediatric surgeons, as you mentioned in pre not until recently, did not have a single pediatric surgeons, but now in 2016, they managed to get one pediatric surgeons graduating and through. And so is Rwanda just go there as on 2016, right? So you can see the effort is ongoing. But I think we have a very long way to go because at that rate, if we just go graduate one or two, how many years do you need to graduate enough pediatrics to meet the demand? I think it can take us so many 100s of years. So we needed to find out ways of how we can even train and train and train more pediatric surgeons so that our population does not continue suffering. Currently, most of the surgeries are being done by general surgeons in general hospitals. And as you can imagine, sometimes the outcome and is not good as I'm going to show you the subsequent pictures. Sorry. Uh In that picture, you can see the trainees, the pediatric surgery. Uh some are now since qualified, but these are an ongoing program. Some of them who are not training and we have a big number of collaborators passed all over the world who have been helping us in this training program. Some are in the US, some in Canada. And so these have been very no, this is picture is not ex exhaustive. We have so many who have not been included in this picture. But thanks to this, ladies and gentlemen, we have managed to start a training program which has managed to scale up our so to scar up the output of pediatric surgery as the most of the literature written and most of our addresses, the challenges of pediatric surgery are enormous in that picture. You can imagine the people waiting to see just in a one day clinic. How many those patients are waiting to me to see probably one doctor and they can turn up in the 100s on a single day. And when you talk about ethics and equity and uh by now and all that, how can that doctor see all these patients and they continue being ethical. So, so there are some of the challenges which pediatric surgeons can meet and you, you may see what day, every day. This is the picture which always plays out. So really it is so it's a big challenge. So another picture, another scenario which comes out is lack of resources and infrastructure. So some of the challenges we face not until recently before the coming of we or and he the renovations of fo just a few years ago. This is to be the picture in our, we call it like a nursery where our babies used to be nursed. In the picture, you can see how they are being bumped together in small cos I don't know whether you can see my casta and then the tubing to supply oxygen connecting the wire connections between the tubing so that could deliver oxygen. And this picture you could see fluid is being titrated in syringes because we didn't have infusion pumps so that you could give Children fluid so that you can get treatment. And this was tiring and this could be done by one nurse who would be wedding through a population of like 50 babies in NASA. So you can imagine what kind of quality of care would that be? And another of lack of infrastructure, this picture rates the warming could have instead of a baby losing temperature. I think you can see here if you can see my car. This was like a electric warmer, which was connected to, connected to electricity. And then a baby is wrapped in cotton so that it can preserve the heat. And this was like in a way so that you keep warm for surgical babies. And this used to be the picture and you can see the warmer gloves scenario. We need to put water in the warm gloves before you can start on the surgery, you put it on, on a warmer and then you put, you put the under the blood, the bed, the the shes so that you could warm the baby and so that they go through the surgery. And so that by the time you finish these babies, I know hypothermic and the consequences of hypothermia can be devastating. Uh The issue of anesthesia has also been trying to anesthesia because as you can imagine, you can't do self surgery without having safe anesthesia. It also embarked on a program to start stimulate young doctor to start training as pediatric anesthesiologist. So far, we have two ladies who are already pre ok, three who have already and the gentleman doctor who have already finished training in the pediatric surgery by pediatric anesthesiology. This has been done in a collaboration with the universities in one of them training in Cape Town, another one University of British Columbia and the others are also training and it's ongoing so that we can also improve the safety of our Children during surgery. Uh This picture, I took to show some rural hospital whereby some of the Children can uh being operated. This is one of the hospital you can see the infrastructure of the hospitals. This hospital we are building in 19 fifties probably and probably they have nothing to show that you can safely treat a child safely and they survive. And here in this picture, you could see the congestion in the water. And so really such pictures are still going on you. In the previous slide, I talked about complications which can take place when, which can ensue when those Children are being treated by general surgeons. We can't avoid it because most of the Children are being treated by general colleagues, you know, surgeons. But as you can imagine, this is like a stenotic colostomy which was placed probably f friends. And after that, then they have to come to us and then we have to visit and do all these corrective surgery then proper replace co co you get a lot of colostomy prolapses. And you can imagine after opening up, you can see a childhood delayed presentations and have this has rather a child. After like this, this tumor, you open up and you find this bowel which like a cat and you have to decide what you are going to do whether to resect this bowel because probably it will never function or not. Some of these like you can get a tinea or you can with colostomies and you have a was band because of the rugs they use to tie the colostomy. And this one is like an unknown operation which child presents with a colostomy and he has incisions all over the place and on the abdomen. And you wonder what your, what your next steps are going to be. So such Children are very many. Another baby challenge is a presentation and this should because of lack of appropriate care. The Children when you come like this one with drugs presents at nine years. So you have to find a way of treating these Children. And this one, the child has never gone to school and comes to you and your daughter making decisions how you are going to today. These are some of the presenters chart comes with has pranks and you have to deal with it. Some of them you f support. So part of the bowel the Coron in the bucket because even if you put a replace across to me, such colony will never come back to a normal size so that it can function properly. Uh We have challenges of some of the conditions we get especially in managing in your neck and not until we used to have high mortality of for Children, for example, with gastrosis, as you can see in one of the papers which we published in page 16, which one of our by then it was a, a resident surgeon being surgical residence by then they own that. You said there was only one child surviving out of the cohort of 47 patients. So you could see the high mortality rate. So managing a neon with the surgical conditions was very challenging. Another chance challenging condition is of late presentation is getting tumors which present very late. You can see in that slide, a child who present with a tumor very emaciated. But I remember, ok, even when we were in Durban, South Africa with professor, we could see such Children coming to Durban. So probably this picture is not exclusively so, but I think when it comes to Uganda, we just get such Children very many. And when you think about if you can never do any primary surgery, I think this one is going to be, it can't be thought about that. You can end up doing primary surgery like Americans do. So these Children are supposed to be optimized and improve their nutrition as a given you chemotherapy. And probably that is the only way you can probably save them improve outcome. I talked about the high mortality rate of uh vass cases. This paper shows one of the efforts by one of the our colleagues in one of the hospitals where a pediatric surgeon is done. That is by trying innovative ways of trying to reduce reduce mortality due to gastrosis. So they managed in a period of two years to reduce mortality by 50%. And newspaper was published in a general pediatric surgeon. And you can see this picture. This is a surgery. Now, she's a pediatric surgeon. High interest started when she was, when she was doing surgical residency. That is the one who published the paper of the high mortality, which was almost 90 90%. But she went ahead and took it upon herself to see that improvement of morality, mortality for gass cases is observed. And right now we have tried to reduce mortality for vaso cases to reasonable numbers which are a comparative to other parts of South Africa. And we still, of course, has a have a backlog of, we still have a backlog of pediatric surgical conditions. And as you can see between the VLA, that's where we have pediatric surgeons. They basically we they we do, most of our cases are emergencies. So what happened to an active rectal condition like a Children will probably they are, they are the ones who are wishing in the areas are not access appropriate corrective surgery. And this probably goes on for rectum malformations and hash plan which requires surgical procedures and these Children end up probably missing out on correcting their surgery early enough to improve their outcomes. Uh This was one of the papers which we published back in 2014, which was showing the animate ate and for neonatal surgical disease and the burden of surgical conditions in the neonatal surgical conditions. And as you can see, most of the but then if you consider ectal malformation, the only need is around around 20%. So the only need constitutes, if you consider that is, constitutes the biggest percent of the di is, I don't know, anat need is just so and this plays out with any for hashtags and when to consider s cases, the need the way hand and even for other condition like atresia and so is fas so you can find the burden of neato surgical conditions is high even in our country. So this slide should try to show you some of the cholesterol treatment when we have treated it successfully. And we go on the Joing and as you can state there that takes the day. So there is more for an individual to improvise so that these Children, you can survive. Some of the Children who survive has come back and we try to rejoice with their parents and this keeps us probably our moods and keeps our spirits high much longer ago. You could hardly see it. We track. So five kids are surviving but we have started coming back in the clinics and when you review them, you have to take pictures so that you celebrate as a team. And even Children, mothers with gastro cases come back and we consider it as AAA small success and some of the Children come back and they have already started to go to school. So those are the few success stories. We are having now Children in our practice and with the collaboration, we don't forget his such work, we have continued publishing in some of the his high impact des so we continue show him what, how work. Not until recently, we started the emb event starting doing complex surgeries. We started the pioneering in a similar condition. Like initially, this picture shows the con T which came with the anorectal formation. Of course, they had no an open. And initially you had to place Colo as the initial step. And later on, they went, they have five separation successful. And so that one was uh our uh some of our success stories. And then I mentioned sometimes the enthusiasm of the individuals I can show you a picture. What takes, for example, what you used to take to a child, a child who had, for example, sore survive this child. We had to take an atic machine which you can see here in the picture you can see this was the or I think in 1992 tomorrow, we had it now to close the theater and we took the baby to ventilate in a small ni which we improvised and we might save this baby. And in this picture on the right, you can see also a baby. So it took us as it could be hard, hard to make a uterus of doctors that including anesthesiologist, surgeons. So that we are the one who who the baby through the night and so that this baby could also survive. So that is enthusiasm for the doctors which they take so that such babies can survive. And this is just recently a complex. Now we started the breathing complex. Yeah, con separation. This is a picture before we started doing the babies working on the baby. This is a team assembled together in the or together a picture with the parents. And we went back to like a 20 a 20 hour operation of this joint which we are doing at lower back. And that included even separating the nerves of the sac and the quina and the two parts, we had it to work together with orthopedic surgeons, neurosurgeons to do the who we are doing the intraoperative neuromonitoring and we successfully separated these things. So and so these are some of the success stories we have been handling and we tried to bring together all stakeholders who have been helping us. In that paper. I showed you the who are a little bit what? In 2019, we had a conference which had tried to chat with how we can I improve pediatric surgery for pediatric surgical services in the country. And the outcome proceedings of this meeting, we have published in the surgery of 2020. You're welcome. And in a way for me to get the suffering of Children even in the upcountry hospitals where people cannot access the center like in, in places where we have only two centers. We have a pediatric surgery. We start, we started doing outreach surgical camps. And this one, we do them in collaboration with colleagues from North America who bring the resources, resources like sutures and a and a and a drugs and even the other supplies so that we go at the camp in a hospital sometimes even in this hospital so that we can correct some of the surgical surgical conditions for Children who cannot access the the center. And that way we can reduce the backlog. And also, as I mentioned earlier, some of these Children are being treated by our colleague, general surgeons. Sometimes we live in medical. So we tend to have skills transfer so that this local clinicians can start gaining confidence and in preaching in some of these conditions and started by doing radio announcements and make screening even. And then we call our international colleagues and we start him back in one, usually a a week long surgical camps. And we have successfully carried out several surgical camps. And this slide, you can see the conditions we have treated in the different surgical camps. We have had, this was a slide of up, but since then, we haven't carried out anymore. But of course, now with the COVID, everything has slowed it down. But that way, we have managed to reduce much of the backlog of the surgical conditions even in the low area. And you can see as a devo these are some of the in the local press as this um 60 Children with the with the anorectal formation. We are and medical conditions we are treated in one who come in the areas and also part of quality improvement. We can we had to hold workshops about pediatric surgical emergencies. And this one was in a rural referral hospital in Mbarara where our pediatric surgical colleagues are working. And this also help to improve the the the outcome of Children with surgical conditions. Um Not until recently, we started, we started, actually, I can probably say that kids ago are started in Uganda because this was a charity, 10 Scottish charity organizations which started as a foundation. We started you with collaborating with professor Youngster whom you know, know, and because he comes from Scotland, he was a, he was by then a body chair of Arch Foundation. And so we started funds, collecting funds from there. And indeed they built the first pediatric surgeon hospital in Kampala. And from then we started the work and showing that it can work. And so the economic benefit for which we published a paper which came out in 2018. And this has been having a very big impact, which showed that investing a dollar in Children services can improve the survival and save the first that disability yesterday, if like for example, just investing $1 another $60. And this has been having a very big impact and from then, or a was born because c was first the CEO of foundation and because then it me up to two or, and of course, we are the first beneficiary of the kids and they built the first, the, the first two theaters, one in, in Barra and another in. But as a to now they have refurbished the three theater suits in the Molabo National referrals. And really this has gone way improve the surgical outcome of our Children because now we have Walmart, we have a very dedicated theater teams. So and of course, working in a very good conditions, working condition, it is very stimulating to the staff. So thanks to Por, we have managed to improve the surgical outcome of in the not only in Uganda, but as you can imagine these kids or has gone to view these theaters in other sites as I talk now they are in Zambia, pick up more theaters for Children. I thought they have done it even in West Africa, Nigeria, Ivory Coast, Chicana. So it has done a lot as far as improving in the world. Of course, I now going back to what about medical ethics? Doctor Bosa mm Men has been mentioned in all of these things, what I wanted to talk about. But as I want to say that doctors, they deal with a variety of ethical issues and the commonest I can mention when you such literature and in our practice is the challenges we meet and withholding treatment to meet organizational budget. And this plays very well in our resource limited settings. For example, our budgets are always limited. Can you scale up? For example, like that surgery I showed separating coned dreams. So when you have a social location, it means one surgery is going to consume almost the entire budget of the surgical, pediatric surgical services. So you have to we where to go. So unless you get support from elsewhere, some of these conditions and the treatment can be with so that you meet the organization and demand. And another big elephant in the house is accepting money from the pharmaceutical for the and the device manufacturers. This is sometimes can be unethical but we have to do it because there is no way you can go away without getting support from pharmaceutical companies. But this way sometimes they can sway you doing, getting only their supply from their devices. But I think this can be cannot sometimes cannot be avoided. The other thing which is not very common. I think getting rheumatical involved with the patient. So, but sometimes when these pains are very vulnerable, coming from poor back ground, sometimes they can be really vulnerable and can, if someone is not ethical, a doctor can get rhematic involved. Another common challenge is covering up mistakes because when you are walking up limited, limited settings, mistakes are likely to occur from way from preoperative care intraoperative because you are improvising and some of these mistakes can be covered up, which sometimes is very unethical and repeat reporting, unethical impaired colleagues. This can be challenging because if you are very few and how can you go on reporting colleagues though? It means when you report to them, you can end up being picked by the law and this can have dire consequences to future care of these Children. Then the other condition. Another scenario is cherry picking patients. Of course, when you have so many people demanding for surgery and so many Children, for example, a as I mentioned, you have to start picking up where you feel like the probably the prognosis is the best. So like where are Children where prognosis is worse? You might end up not like not uh they di not divided today neglecting with them, which is very unethical. And another thing is practicing defensive medicine to avoid the malpractice. This can be very real and also reaching patient confidentiality. For example, those babies that is right, which I showed you whereby so many Children are lining up to see one doctor. Sometimes when you have two doctors in one room, there is no way you can keep confidentiality. Like patients might be even hearing the stories of of one another. These are the basic values of medical ethics. Patients have a right to determine their own health care. But in a resource limited countries, I don't think that these patients have very much right to determine their own health care. But as we are realizing it now the society is becoming enlightened and we are having a middle class which is coming up, some of them do read a lot about on the internet. So they might have but even then you are supposed to excise autonomy. But most of the time this cannot be real in our setting. Then another value is justice, thereby distributing the benefits and the burdens of care across society. I don't think that one also can be realized very well in resource limited countries. Another one is doing good for the patient. I think this one, in fact, with medical workers support to have this and another normal which is making sure that we don't hurt your patients. But these are the values values which I talked about the medical school. But there are so many other values which is consider truth taking, truth telling is very important. Uh You are supposed to tell the patients the truth about their conditions and what you are supposed to do and what can be able to do. You don't want to tell your patients that you can do something which you can, which I have never done that will not to be ethical. And of course, you are supposed to be transparent and the most important thing we are supposed to show him respect for the patients and the families I mentioned earlier that it was uh the previous slide that some of these patients are coming from poor families, but that knows, does not stop you from respecting even the core values of this patient of that are the interest of these patients and even their values. For example, they have can have religious values, they can have beliefs who are supposed to be respecting all of these aspects. Uh Most of the time is ethics can, ethics can be seen to be very prescri prescriptive and telling you what you cannot do and what you can do. But if, if you practice it properly, it can be free and it can make you affirm you that you are doing the right thing when you go through the proper difficult thought process, uh maybe some of the tips, how you can remain ethical, even in poor resource settings, you are supposed to listen locally, however busy you are so that you learn the facts about the child, the child's condition so that you don't rush into making the decisions when you have not listened to the entire story and this listening and you are supposed to gather all what happens around because for example, like treating an electro malformations, you are supposed to know all the circumstances surrounding in the family, everything because that's the only way you can successfully treat these Children and you are supported, communicate effectively. And so that you provide all the necessary effects to the patients and relatives and you are supposed to be thankful so that you win the confidentiality of these patients. So that because if these patients do lose confidence in you, you can never treat their conditions, but you is trying to find time to explore all of the issues. And even if you are over being over by your work and always is trying to pass to pass responsibility to other qualified caregiver so that you are not overwhelming the blood work. Because if that happens, you are going to get burned out and you are not start becoming unethical and you might not be able to explore all the ethical issues surrounding the conditions you are treating and you will support respective values, as I said, and that to resolve with the patients, there are so many conflicting situations in the practice of pediatric surgery. Uh some of the patients can refuse treating to your treatment and you might, you can be faced by expecting a autonomy of the patient. Why you are considering what is the best of the patient. And so that one can be a very best case scenario, another circumstances which can be a conflicting like as I said, a doctor, you might be just fine, for example, not to accept to see all the patients because you are going to run out. But that means you are going to deny medical care the patients, but you are supposed to be careful because if you are going to let in every patient you are, you comes in to get treatment, you might start to becoming unethical. You don't listen to their stories, you rush out and you make rush decisions. So it's better, you divide your time, you divide your clinics so that you can practice. Typically by the treating the patients. There are other issues like uh you know, our societies have a lot of religious background. So you are supposed to consider all of these. And for example, you have to understand the ethics, what is the difference between the ethics and the morality? Because whereas morality that is basically values, which are the here to basically be and systematic point of conduct, medical ethics is the r value and the reason. So you are supposed to reason out when he was making such decisions when you are treating these patients and morality is what they r on such authority like a Bible. And for example, political persuasions, whereas medical ethics is flexible because it on set of solutions and it's based on the fact. So, but because our societies get all these beliefs and the morality issues inter sometimes it can be difficult to where you are with when you are treating these patients. And then you have another issue like uh addressing medi medical ethics and the law, usually medical ethics have different standards from the law and the law always created by legislators and they may not share the same values and reasoning as for eee ethics for physicians. And this for example, or I can give you an example an example when for example, a doctor decided to treat it deep premature. Whereas consider they can say that uh by the low demand that you are supposed to treat everyone, but the doctor can think that and this premature cannot probably make it. And so you are supposed to find a way between the law and the ethics. But I think you are, the ethics should take precedence over the low so that you can practice it. Can thank you for listening. I will come with your comments. Thank you. Uh John, thank you very, very much. I really appreciate what you have shared and I'm almost speechless. And uh uh my respect for you has multiplied 10 times while listening to your talk. Um what you have shown us uh is actually the way forward for us because uh uh you uh the amount of research output you have shown and you, you're not talking anecdotally, you have proven most of the things what you preach, what you advise, you have proven it by scientific research and with such a limited resources, with low income country like Uganda with a huge population. So few pediatric surgeons you have established systematically and you have shown if there is a will, there is a way and you have also proven that in Africa, we don't sit and cry, we find local solutions for local problems. So Thank you again. We have um colleagues who are joining from various places in the world. So I just invite co one by one and maybe uh Doctor Emil may need to go to operating theater. So I'll invite uh Doctor Sheriff Emil uh to, to give his comments. And I think please let us keep comments short uh at the most two minutes each expert. So Sheriff, please go ahead. Yeah, thanks me and II. Uh I am on call and I actually have Doctor Fabio Olo. You might see him here. He's a Brazilian pediatric surgeon who also works in a very low resource area and he's with us for some time here in Montreal. So Fabio has been watching with me as well. Um I just wanna echo what you said about John. I've always been completely fascinated by his work and, and John, your, the last part of your presentation I have to say is applicable to any setting, whether it's low resource, medium resource or high resource. I think that fundamental set of ethics you laid out is really universal and the same issues are the issues we deal with here. Um I guess the one thing II would have liked to maybe hear a little bit about is and II think you've, you've set up some great uh models and examples of how a North South collaboration can, can actually occur without surgical adventurism. Um But I think from, you know, the other, the other consultants here from Africa I II would actually like to hear a little bit of your views on how surgeons from our parts of the world can potentially uh collaborate. Uh uh uh Thank you, Sheriff. Um I will invite uh Professor Headley uh to, to comment because Professor Headley um uh has practiced for many decades in Durban. Uh but he knows the situation in Africa inside out and, and properly. Please comment. Yeah. Uh thanks me. Um I would like to uh share Doctor Emil's um uh plaudits for, for what John has achieved in you again. I think he's done a, a fantastic job. I would uh whilst acknowledging the, the positive pediatric surgeons that Doctor Botha and uh Doctor Secker are referred to. I think we're missing a trick. I think we're forgetting that pediatric surgery is a team sport and that training more pediatric surgeons and leaving them out there on their own is not gonna help anybody want iota. And what we've got to do is we've got to incorporate the training of our anesthetic teams, our intensive care unit teams and particularly our nursing staff and we've got to take them along the uh the road with us. The other thing I'd like to say is that a lot of what we do is not exactly rocket scientist as you know, a pediatrics you don't need, you don't need 10 years of training to be able to drain an abcess. Um and I think that, or make a colostomy or take out an appendix. Um This is the sort of thing um that we could train medical officers to do or even people who are not doctors as they are doing in, in Malawi where you trained as a nonphysician, uh pediatric surgeon with a limited range of uh procedures that you get, but I had a limited range of procedures that I could do. Um So I don't think that that's in any way. Uh demeaning bye. Third point that I'd like to make is that it's incumbent upon us working in Africa with these limited resources to vary our surgical techniques. There's no point in an ESTIM, a judge Atresia and expecting to keep the child alive on TBN when you've got no TBN. Mm. So we've got to change our surgical strategy. Make an anastomosis, make a bishop who put a transanastomotic feeding to you to do, do something that gets us over this hurdle of re relying upon a resource that we don't have. Um And so I think that we need to look and instead of just aping what they're doing in the developed world, we've got to look at the strategies and match our strategies to the resources available. And the last thing I'd like to support your point uh me and that is that it is unethical to practice pediatric surgery without reviewing your results and publishing your results so that we can all learn So I think that at, at a very basic level, it's unethical to practice without doing research. Thanks. Uh Thank you properly. And uh when John was presenting um uh his, his initial experience before uh the kids or um arrived uh uh in, in um, in Uganda, I just remembered my good old days uh in, in Pune, in India and in Mumbai in India while I was training in general surgery and in pediatric surgery and then working again in general surgery, uh looking after Children, we had no surgical intensive care units, we had no TPN. And as John said, we managed to make survive newborns with esophageal atresia and aromatic hernia in female surgical ward. Uh with a dedicated team of doctors who uh bag masked the babies for 48 hours a a at a stretch. So, so um I'm so blessed that uh then subsequently, I could spend time in Glasgow and in South Africa, I mean, uh we really cannot complain about lack of resources. So that is that is really what John has opened my eyes once again. Um Is Doctor Harper still here? Doctor Harper is a pediatrician and a neonatologist and he's head of the department of pediatrics at the Frere Hospital. I saw him initially if uh Kim is here, Kim, can you unmute yourself and give comments or has Doctor Harper left? Um maybe he has left. So if I don't see Doctor Harper, can I then invite Doctor Nulla Majola, who is our consultant pediatric surgeon to give his comments, please, Doctor Majola. Thanks Pa. Um Just wanna echo uh just our gratitude to John for his um great talk and just to opening our eyes um to what we are really complaining about is much worse with what they have um in other countries. So we are blessed in that sense and just to head out as well, just for uh a great talk, just to get us through to discussing such um topics at L. So that's all. Thank you. Um Before I invite Doctor Mataya, I just like to openly um sort of share a request with uh my, my dear friend, uh Doctor Emil that um uh we will uh communicate privately about establishing a link between uh Montreal and East London and South Africa. And uh we will see uh how uh uh your trainees can come and spend at least a month or six weeks as an observer in East London and how we can get one of our trainees to spend say four weeks in your department. So I think that will be mutually beneficial, not only for those uh respective trainees, but also for uh the growth of our department. So we will communicate uh privately. And uh now I'll invite Doctor Seu Bacha. Doctor Bacha is our, another pediatric surgical consultant. And the interesting thing is um during his training uh as a pediatric surgeon, he has actually done his master's in pediatric surgery on um a gastroschisis in the eastern Cape. And uh I think his comments will be quite valuable. So, Doctor B uh thanks for uh thanks for the talk and uh thanks John as well for um giving us your insight and uh and giving us your point of view as to how things are actually in, in the rest of Africa. I think what's important as well. What you were just highlighting now uh prof is how uh what's important in the way forward in training. Uh new pediatric surgeons. It's not just a interprovincial or interdepartment uh communication or transfer of training uh fellows registers, but intercontinental if possible. Because what you actually see in South Africa, it's very dynamic where you can be in one part of South Africa and you will think you're in the middle of Europe, then you're in another part of, of South Africa and you think you're in the middle of some jungle somewhere. So it shows how diverse even in a country is and how um a firm supporter of actually allowing um trainees to actually experience um training in other facilities. Um not only just to gain experience from um that specific facility, but also to see how other parts of the country are functioning and ultimately how the rest of the world is functioning because you can't live in your own little bubble. And believe that um how you are functioning is how the rest of the country or how the rest of the world is, you need to actually be out there and see um what's actually happening. So um these kind of collaborations actually improve pediatric surgery. They spark interest. Um not necessarily in the individual who's in pediatric surgery, but on the other people around them who actually they interact with um to see passion and to see dedication um that one person has. And as pro was saying that um it requires a lot of work. It's not just one pediatric surgeon placed in the middle of nowhere who will all of a sudden bring change. Um lots of elements um have to come into play lots of ingredients to make the the cake called a good functioning uh pediatric surgery. But ultimately, let me just last words. Um I think it's volt might be mistaken. He said um the perfect is the enemy of good. And that actually that phrase of saying stems very well because we try to be perfect. Um try to give the best to every patient which we should. But when we are in resource limited uh areas, you find that as John was saying, you can literally exhaust a fund of the whole department on one child. And when we're in pediatric surgery, like in our setting where we are not the only ones who are um catered to an ICU if our child is in ICU and is found to have a poor prognosis. They are already blocking a bed for 10 other pediatric patients with uh croup or upper area obstruction or whatever pathology it is um from entry, entry into the ICU and getting a, a short period of intensive care and having a good outcome. So it's one of these things where you have to kind of weigh, um not necessarily that you are already putting the patient on a bed note and saying you are a nonstarter, we're not gonna do anything but weigh your options. Um If you have 10 beds, icu ventilated beds and you have 20 patients that all need the bed, you have to literally say, um look at the prognosis, look at the outcome of each patient and be able to cater to all of them. If we had 1020 beds for these 20 patients, fair enough, everyone gets a bed. But in reality, which is what we see in South Africa and definitely in the rest of Africa and maybe even in the first world, you have to make uh difficult choices and it's experiencing and seeing how other facility centers function that you can actually make a good informed decision other than reading what you all can do. Um It's via experience and via communication and all these factors that you can actually be a holistic uh pediatric surgeon and um try to do your best. Yeah, that's all prof thanks th thank you, sir. Very, very wise words that our country is such a mix uh which is very interesting mix of, of, yeah, you correctly said Europe and, and middle of nowhere. But, but um I'm actually encouraging one of our trainees in the future when that trainee completes to uh if possible go to one of those three provinces where there is no pediatric surgeon. So we tried our best. So before uh I think uh it's time to conclude the meeting, John, please unmute yourself and uh final words from you and John before you say your final words, um I give you an open invitation to visit East London in South Africa. Um when the COVID nonsense is over, we can privately communicate and we would love to have you for at least a couple of days uh in East London. So let's talk maybe 2022 2023. So John final word from you. Uh Thank you doctor. Thank you for allowing for this opportunity to present at this meeting. Maybe what I can reiterate is that the ethical decisions can never be avoided whenever doctors or surgeons or like pediatric surgeons make any clinical decisions. We are invariably or in a today making an unethical decisions. So in all our practice there is always medical ethics. Mm Thank you and thank you for listening to me. Thank you, John. Thank you very much and thank you to all the attendees for their contribution. Um The meeting is recorded so I will post the link uh to the Google Drive um in about half an hour to 45 minutes. The next week's meeting will be open only to the staff of our department. And so we will meet the rest of the uh attendees and delegates in two weeks time on a Tuesday evening. Thank you all have a good evening. Good morning, wherever you are. Good night, John. Thank you. See you. Good night. Thank you. Bye bye bye bye bye.