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In this insightful on-demand teaching session, renowned Pediatric Surgeon, Dr. Yashoda Man, shares her extraordinary international medical experience. With a rich background that ranges from Durban to East London and liaisons with Doctors Without Borders during times of civil unrest and war, Dr. Man enlightens attendees on the role of humanitarian medicine. She particularly offers a detailed perspective on providing healthcare in diverse cultural and geographical contexts, like her experience in Pakistan. Dr. Man's intriguing session also assesses factors like child mortality, GDP, health service quality, and physician distribution across the globe, creating an invaluable learning opportunity for medical professionals. Join in to gain a broad perspective on the global medical landscape and grasp how different elements shape medical services availability.
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"My outreach- Global to local" by Dr Yashoda Manickchund, Paediatric Surgeon, East London, South Africa

Learning objectives

1. At the completion of this session, learners will understand the concept and importance of outreach programs in providing medical services to those who do not have access to them. 2. Learners will gain insight into the specific challenges and considerations of providing medical care in countries experiencing civil unrest or war. 3. By the end of the session, learners will have knowledge about the distribution of physicians worldwide and the disparities that exist, particularly in regions like Africa. 4. Learners will grasp the concept of "humanitarian medicine" and understand how it differs from regular medical practice, particularly concerning disaster response and health care provision in remote areas. 5. The session will enable learners to appreciate and consider the cultural and societal factors that can influence the execution of medical services in diverse settings, using examples from the presenter's experiences in Pakistan.
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Ok. Um, yeah, so that you can try and, um, and, uh, share your screen. Oh, yes. Yeah, she could not control what to do. Ok. Ok. High your sugar, six o'clock and then six o'clock report. Ok. Um, oh, all right. Five. Yes. Yeah. Right. Yeah. Yeah. Yeah. Ok. Good afternoon everybody. Um, uh, today's, uh, speaker, uh, actually doesn't need any introduction, um, to the pediatric surgery team in East London. Um, I thank you, uh, uh, Yashoda for stepping in because we had some last-minute changes to the program. And, uh, and she agreed to share her experience from global to local experience about outreach. So, for those who, uh, are not currently part of pediatric surgery team, uh, doctor man is a consultant, pediatric surgeon for just over three years in East London. She comes from Durban. She, uh, studied and trained in Durban and, um, um, she has worked for more than two years, uh, in various countries with, uh, uh, civil unrest and, and wars, uh, with doctors without borders. And, um, her main area of clinical interest is, uh, pediatric, surgical oncology and laparoscopic surgery. But, uh, this global surgery, global pediatric surgery outreach, pediatric surgery in Africa and um intercountry um sort of collaboration within Africa is very close to her heart. So I think with this introduction, shoulda you can start. Ok. Uh Thank you prof for that intro and uh thank you everyone for giving me this opportunity to share my experience with you all. Um Yes, I think pro summed it up quite nicely. Um I'm gonna talk to you. It's gonna be mostly pictures and because pictures speak 1000 words. So II think you uh will be more entertained by the pictures um than anything else. Um So let me start uh what is outreach? Um So it's defined as an activity of providing services to populations who might not otherwise have access to those services. And you might ask, well, what problem is that for us? And I'll give you a little bit of uh intro on my background. Um I grew up Hindu with the teaching of SEVA, which is um service to humanity and II am proudly made in South Africa, born in Kwazulu, Natal in King Edward Hospital. And I believe in the concept of Ubuntu, which is Ubuntu, Ubuntu Gant which means uh people are people because of people and more simply put, I am because you are and I also grew up with, with teachings of unity and diversity and what better place than South Africa to grow up with these um with in a melting pot of cultures and races and um backgrounds and um to have united against a system of apartheid um and against oppression and segregation. So I grew up thinking that altruism was the most noble of um life purposes and I'm sure all of you would agree with me. And I know our department is very much um from that thing. So, um what is humanitarian medicine? Is there such a thing as humanitarian, humanitarian medicine? Because isn't all medicine, humanitarian? Well, I would say that it is, but there is another faction or another a concept of humanitarian medicine which falls outside our usual scope of medicine in our own countries. And that is battlefield medicine, um emergency teams uh going to disaster situations and that might be um natural or manmade disasters and medical aid to remote areas in countries that cannot afford to provide that, that medical aid uh as well as health education in those areas and helpful marginalized groups in affluent countries. So this is like refugees, for example, in recent times go um presenting in Europe and in the US um who are not uh included in their healthcare. And this is often uh mostly provided by Nongovernmental Organizations. So um this is a cartogram and a cartogram is a diagrammatic representation of data. So uh what you can see here is a map of the world with um diagrammatically um uh showing the population and you can see that India is very fat and so is China it takes up most of the, the, the page because, uh, the screen because, uh, they have the most, uh, population. So this is just an introduction to what a cartogram is. And then I'll follow up with child mortality. And you can see, um, where the increased child mortality is. The Americas are doing pretty well in that respect. But you can see Africa is big and fat and so is India and Southeast Asia, then GDP is almost uh a uh uh an opposite of the last one and uh that makes sense. Um So Europe is nice and fat and so is the US and Japan. Uh but the rest of the world is pretty much nonexistent. And the total spending on healthcare obviously matches this uh GDP map. Uh They also looked at health service quality and they gave a a score uh for essential services out of 72. And interestingly, the the worst of was Sierra Leone uh with half of, of, of that uh score and most of Africa um quite low India is doing and China did pretty well. So coming to the distribution of physicians and I think we are all physicians watching this and um these are pretty old statistics but the ratios and the percentages are are pretty much the same 50% of physicians uh live in territories with less than 1/5 of the world's population and the worst of are served by only 2%. So this is the cartogram of physicians working and I, you can't even see Africa. It's supposed to be that sliver of red, um, where Africa should be. So, um, after my community service II watched, um, or during my community service in 2009, I watched the news and I watched the Haiti earthquake and I thought, well, I'm a qualified doctor now. I would like to go and help. So I joined Medecins Sans Frontier and uh that you'll hear me saying M SFA Lot, which is the French translation of doctors without borders because um that's basically what they call it. It was started in France. Um and they believe in a human, the human right to health care, regardless of race, religion, color or creed or financial cultural uh angiographical context. And this really ran through with my own principles and they seem to be an NGO that represented my beliefs and my um my goals for what I would like to, you know, what, what the, what I would like to achieve. So, and these, I think we can all agree that this is, is, is a basic right? But um it also matters. Um I also don't believe that being poor should uh affect your access to healthcare in any way or what culture you are from. So in, if you are born into a, a Muslim country with Sharia law, that everyone in the world looks down upon, that doesn't mean that you you should not have access to, to adequate healthcare and also the geographical context, if you are born in a place that is quite remote with less infrastructure, it should not affect whether you survive um an illness or not. So, uh once I joined, um MSF, I thought, OK, send me to Haiti. Uh but they didn't do that. So uh I didn't speak French and that was the biggest uh problem. But uh they decided to send me to Pakistan. And if, um, if you guys are aware of the, the relations of India and Pakistan, you know that uh they're not very good, um, since the inception in, in the forties, um, there haven't been very good relations between them. They have an area of Kashmir that they are still fighting over and they have nuclear weapons that they constantly threaten each other with. But anyway, uh I'm just giving you a bit of a background because when I went for the briefing before I went to Pakistan, um that was quite an issue. There was a huge debate about whether they should send me there or not. My name is, it's a very Indian name. I look Indian. Um I'm Hindu, they actually told me to go there and say that I'm Christian because uh they were afraid for my safety. Uh But after much debate and me saying that I was comfortable going, um I went to Pakistan and more specifically, uh this area here which is the northwest frontier province of Khyber, Pashtun. And it's on the, the border with Afghanistan and, uh, uh, between, this is the Fatah, which is the very, uh sign tribal areas which you don't see on this map. But basically it doesn't fall under any country because it's, it's ruled by the, the Taliban and, and extremist groups. Um, so I was somewhere around there in a small town on the border and, oh, this, the Fatah is also the area that Obama was bombing with his drones at the time. So this was a very um neglected area as far as health care was concerned. Uh What people should understand is that it, even though it's a very conservative Muslim area with, um, quite extreme laws and societal um, laws, uh, the people, there are not all extremists and terrorist and they still deserve health care and they were also victims of uh terrorist attacks and they actually needed mass casualty plans. They needed uh, trauma, um assistance in that area because they also suffered from the bombings of these terrorists. So, uh, the other thing I should mention about MSF is that, um, our vulnerability is our, our, our was our safety and we didn't have weapons, our, our hospitals didn't have weapons. We met with both sides of the conflicts. And we, um, they understood that we were there only to provide healthcare and to anyone. So anyone from either side of the, the wall conflict. We did not take any political sides. So this is Tim Gara. Unfortunately, I couldn't take a lot of pictures. I had to be in the car at all times. They were very, uh, tough security regulations for obvious reasons. Um, and we mostly traveled in the cars from the office to the hospital and back to the house. And, um, these were the sites of Pakistan, uh, very deep rural Pakistan. Uh, here you can see Little Gulf. Ok. So a little bit about the past and culture. Uh they're known for their deep religiosity and extreme uh religious behavior. Uh but also of the, of the social uh traditional and family pride and uh every family there had an AK-47 and their pride was very important to them. So they didn't have any problems in uh shooting anyone that didn't, that threatened their family or even someone within the family that threatened the family pride. Um On the opposite side of that, they were very warm and very hospitable. And uh we used to say that Pashtun people made the best friends and the worst enemies because if you were their friend, they would kill for you and if they for your enemy, uh then they would kill you. So it was quite extreme. Um And part of that extremism was the segregation of the sexes. And here you can see ladies with Burca. Um And I think I have another picture here um where society was like this, you didn't see women, they were hidden under Burca. Um And uh, it wasn't only that they were invisible to everyone else. They were also, if you were on the other side of the Bura, which I tried on, you can't really see much. I wondered how they moved around. Uh So definitely without any peripheral percept uh visual uh vision. Um but this was what they were used to and um, it also, it, it, it was very challenging for me, of course, um coming from a Western society to deal with this problem. But it also more than that, it was about how they treated their woman uh which really disturbed me. Uh So 10 days after I arrived in Pakistan, there was a massive flood and maybe some of you can remember that on the news and um it didn't affect gara but it affected the surrounding areas and this is Chakra Bridge. So we were cut off from Peshawar, which is our, which was our uh referral hospital, which made things a bit difficult. And also uh we had to deal with a lot of cholera cholera post the flood. And I say the curse of the flood fairy because that happened 10 days after I got there. And when I went to Thailand on my R and R in between, I also went, I uh there were FLDS there as well. So I became known as the Flood fairy. So this is where I work, it was the, it's the emergency room, you can see our sign, there are no guns and this is our security guard who made sure that that happened. Um And uh the things that we saw mostly trauma, uh it was violent but also accidental. So fair, fair. Um number of road traffic collisions uh as well as cardiac emergencies which are quite rife and medical emergencies, tropical diseases because of the rural area and the cholera outbreak, like I mentioned hepatitis B but HIV wasn't a problem there. So this was the resuscitation area. We had three beds uh where recesses happened and we had an observation area that we could send them to. And this is where I supervised and I supervised for uh Pakistani male uh doctors and a whole team of male and female uh nurses. Uh So what did I do there? I did um a lot of trainings uh with uh in, in regard to triage. This is a picture of one of my triage trainings there. And um I also planned a mass casualty planned for them and we practiced that for in the event of a bombing. There was one bombing when I was there on Christmas day, but it didn't give us many red cases. Um But there were a few before II got there and a few after. Um but it was essential to have a mass casualty plan in readiness for such uh events. Um So I did a lot of trainings and B LS and ACL S ATL S trainings with the nurses and the doctors in, um, the, er, and we had an, er, workshop with all the other, uh, Pakistani projects and, um, basically devising protocols and, and things like that. Um, we also financed investigations, financed investigations because, uh, what happened there was that, uh, the family was responsible for getting drugs and, uh, so buying drugs from outside so that we could give them inside, uh, in the hospital as well as, uh, investigations, uh, weren't paid by the government. So for the d there, so we tried to finance those emergency investigations, especially on our patients, um, to aid in, uh, people who couldn't afford it, getting, getting what they needed. Uh, I also plan an, er, renovation. It wasn't ideal, um, an ideal space, um, but also a primary care unit and an high depends, high dependency unit, which was much needed. Um, and I got support from, um, the nice thing about working with MSF is that if you can, um, if you can, uh, support your request, they are very happy to get the money and help you set up whatever you want to set up. So it was, it was really nice to be able to have that kind of leverage and, um, support. Um, ok, so this was something I saw a lot there, a history of fall from height. Uh, so they were pediatric trauma cases, mostly severe head injuries and a lot of them required ventilatory support. Unfortunately, we didn't have ventilators there and they had to be transferred to Peshawar, which was four hours away. Um And that, uh and during that transit, they would be bagged by a family member or one of the nurses. Um So the problem II thought was that uh there were, there were large groups of Children on the roads on the streets every day, even on rooftops because they were in Muslim countries, they're very um accessible, they're flat rooftops and uh because of the large families, they had less supervision. So the mother was invariably inside nursing a baby while the kids were outside and we can relate to that kind of uh injury here. So the Ubuntu in, in Pakistan was very strong. Um So this is the office that we worked in with national and uh expatriate staff. Um We had a very good relationship with everyone, we had lunch there every day together. Um And I didn't and I can't share a lot of the pictures of the females, but this is how they would cover up. I was less um covered and they understood um they were very accepting of me, very welcoming. Um And this was in the emergency room and uh chai was a big part of our day. Uh It's uh it's like how people drink coffee, uh everything would stop and we would have some chai um and it was a nice team building kind of exercise. Uh Team life is also very important. So this is uh the all the expatriates uh stayed in, in one house and we ate together. Uh We socialized together, we couldn't go anywhere like I mentioned before. So we're very restricted. Uh and we needed to be active also. So we had a badminton court in one of the houses. Um And um yes, we bonded a lot and um it, it was a great experience to be amongst um a global group of people with, with similar aspirations and similar goals. Uh This guy, Rado is a friend of mine who stayed, a friend who's actually now married to a South African guy from uh from the free state. So he's really located here. Ok. So since I handled Pakistan pretty well, um MSI decided that I should go to Iraq next. There was a, a project in Baghdad that I was supposed to go to with an emergency room nurse that we were supposed to stop, but something happened and there was a bombing there. So they scrapped that and they decided to send me to Basra. Basra is in the south of Iraq. And uh there was already a team there. Um and they were doing trainings of nurses and doctors as well, but because of the insecurity of the situation, um they weren't able to go to the emergency room at night and you know, when when they actually could train with, with um actual patients, we weren't really allowed to do that. So it was a very restricted environment, very, very heavy security rules. And I didn't, I wasn't there long uh before uh I was pulled out and before the entire project was closed. So, um it didn't work out the way we had planned. But what I had, what, what was my um saving grace was that I got to go to Amman, which this, this picture here, Amman in Jordan. And I got to visit some historical sites there and to float in the dead sea. So that was nice. OK. Uh Next um MSF kept me in the same group and we, we called it the Kamikaze group. Obvious reasons. They were very insecure regions that were in this group. But the next was Libya and this was an emergency project and it was during the revolution in 2011. So it was during the time of um the rebels uh revolting against Gaddafi. Um So these are some pictures to show you uh what it was like there. Um I was in Benghazi for most of it. Um And Benghazi was the rebel stronghold of the revolution. It was the area where the most uh rebels came from and rebels is, is not the right word because they were educated people, they were people that were just revolting against a very oppressive regime. And II mean, II um Muammar Gaddafi was, was a benevolent dictator. I like to call him because he took care of these people, but he oppressed them and he oppressed their freedoms because if they did speak up against him, they would be killed. And that's what happened in Benghazi. So this is the shellings that from, from uh Gaddafi's uh attack of Benghazi and this is some of the tanks and vehicles that were bombed coming into Benghazi uh to squash the revolution. Um So the people in Benghazi actually um had um support of the international NATO who bombed uh Gaddafi's people coming in and this is just the remnants of this. And there's lots of pictures of the people who died, which is like uh behind here. Um This is the hospital that we supported the Al Juli Hospital. It wasn't very, it wasn't uncommon to see these kind of vehicles with, with guns mounted on them. So the projects I had there, we were a very small team. I was the only medical person and we had a fi uh field co who was in charge of security and a logistician uh who handled everything else, transport and radio and uh setting up of any facility. So I had pretty much free rein to do whatever I thought was needed. So I met with these, this is the the staff of Al Jah Hospital who I met with and I helped them with the mass casualty plan. We did a training and we did a practice which went really well. If anything had to happen in Benghazi, they would go to the Al Jah Hospital. So it is very important for them to have that. Uh This man is Osama. He is a Libyan American who came back during the revolution to help uh because he had left initially because of the oppression of that regime and he came back to help. And um he and another doctor, a Libyan doctor uh purchased some ambulances and this field hospital which they uh themselves out of their own. Um You know, they, they were supported by the doh, but they did this privately. Um and a whole bunch of medical students like this guy um who volunteered themselves to go to the eastern front line, which was in a Dabia and they would drive to the front line where um uh where the wall of the conflict was going on and they would bring back the wall wounded. Um It was a very brave and noble um act that they did and they were taking their lives in their own hands and they, they uh they were very brave and very inspirational. So it was a, it was a pleasure to help them. I did an A LS training with them and we provided them with stuff that they needed. Um And then I was also involved in uh uh I set up a protection against Violence Committee uh together with a local gynecologist um where we trained healthcare workers on sexual gender based violence, which was becoming rife and in any war situation, that's what happens. Um And it, you can imagine in a Muslim country as well. Um It's, it's quite a challenge to get uh people to come forward. And um it's, yeah, it's, it's quite a challenge to seek uh help as well. And this was uh n not uncommon from on my trip from Benghazi to Ajdabiya to see some Camels crossing the road. So with all of that going on, we also needed the team life and to balance uh everything that was, uh, that we had to deal with. Um So it was a team of three which changed every so every few months. And um some of you might recognize Ellen who is the psychologist that we brought in um for the SG B project as well as the wounded and trauma from the, uh from um the PTSD that a lot of people were suffering from. And uh we managed to do a, a team trip to Susa and Aalona which uh beautiful historical sites um that you can actually walk into. It's, it's not like anywhere else in the world. Um ok, so, um getting to Africa or more more specifically Sub Saharan Africa, this is a, a quote from, uh, Fidel, our comrade, Fidel Castro, 100s of thousands of African doctors need to be trained, but nobody worries about it. There's a rich part of the world that only cares about oil, diamonds, minerals, forests, gas, and cheap labor. And um I totally agree with that sentiment. Not that I'm a communist. Um So coming to Africa, um we have the 24% of the wor uh world's burden of disease, but only 3% of the health workers. And um our population is increasing and as I mentioned before, the number of physicians is abysmal. So after I came back from Libya, I told MSF that I would like a nice slow, easy, secure project. And they gave me um the option of going to a malnutrition project in Ethiopia, which I happily took. Um So this is one of the places in Ethiopia. I was, it's um it's very rural, there's no electricity infrastructure, there's no water infrastructure, there's a river um but it's very dry. This was, this is a region in Somaliland which is um on the border with Somalia. So it's a very dry, desert-like region. And um MSF started a a malnutrition project there from nothing basically. So this is the field hospital uh made of tents and um they treated malnourished Children but also emergencies coming from that area. Um The outpatient um malnourished um nutrition project was uh aimed at Children and pregnant women. These are some of our patients and this is Yasmin, my favorite. And uh this is similar to his who is a nurse who became a good friend of mine and this is how we lived. Uh we lived, we stayed in uh these huts or ros we had one each which was nice. And this was our socializing eating area and this was our toilet. So basically, it was a hole in the ground and this was all made by MSF. Uh so that we had somewhere uh to ablute. And uh this was our only um access to clean water which MSF also had to bring in. Um So this was uh was not there initially and um obviously they, they had to bring everything into for uh for the staff and for the running of the hospital. So whenever we have load shedding here or your water stops or anything, just remember there's places like this where people um have to do with what they, with the little they have. Um So once I had enough experience in that malnutrition project, I was sent to another province RC uh where I did an explore um for setting up a new malnutrition project. Um because even though it looks nice and, and green here, uh they still, they, they were suffering from a drought in the season and the next season would mean uh dire insecurity for food uh for that area. Uh Most of the population was very rural. This was a village that we went to um which was in a valley and the nearest health center was hours away by foot and up a mountain. So they were very remote. Um So we decided to do some outreach there and we set up an outreach project going there, but also to support a lot of the health centers in that area. And they went to in Ethiopia also, this was an Emmi, this is similar doing uh coffee ceremony which if uh if you've been to Ethiopia or if you know any Ethiopians, you know, this is quite a, a nice, um very hospitable coffee ceremony that they do for you. Um And um this was my team going into RC. Uh I was the only female, but they made me feel very comfortable and it was quite um pleasant and that's just me. And again, ok, so coming to surgery, uh once I got back from Ethiopia, I decided to, decided to torture myself by um specializing. I, I'm just joking, I decided to go into surgery um and get some surgical experience. So I um actually first II joined um a rural hospital in, in K ZN and, and supported an HIV project that MSF had there. They asked me to do that. So I did that with them. And then I joined the, the pediatric surgery unit in uh Durban. Uh So the global s surgical workforce is even more shocking than the physician, as you can imagine. Uh in Sub Saharan Africa, the 0.5 surgeons per 100,000 people and it's less than 1% the surgeon density of other high-income countries and these are some more shocking statistics to look at this is obviously the developed world and the developing world. Um And yeah, you can see for yourself. Um So I looked at the number of pediatric surgeons and these are just some examples that I put on. Um and South Africa, I think is quite maybe on par with Nigeria, we must have 40 to 50 pediatric surgeons at the moment. Um But you can see there are countries who are in dire in need of support. So once I qualified, um in 2016, I decided I would try more outreach and um I went to support another pediatric surgeon uh B Nandi who was British, but he was in L in Malawi and he needed help and Malawi is not called the warm Heart of Africa for nothing. This is the kind of smile and uh face that and friendly face that you will see everywhere in Malawi. So um Malawi just for a bit of background, Malawi is one of the poorest countries in the world. I think uh *** qualifies as the poorest, but Malawi is second poorest. Um would, you know, uh in terms of money, but population wise, *** is bigger. Um So they don't have money for healthcare. And uh we were in Lilongwe, which is the capital city of Malawi, but the resources there were extremely poor and I'll show you some of what I'm talking about. Um there is a pediatric surgeon called Eric Bogin, uh really remarkable man in um Blate in Malawi. And he, he um serves half of the country but someone needed to be in the longer as well. And that was what Doctor Nandi was doing. So they have tumors for Africa also. And uh they are very late presentations. Uh These Children are coming from rural areas with poor infrastructure often, uh walking from villages and, uh, very far out reaches of areas. Uh, they also have a longer wait for surgery because, uh, they, they aren't surgeons, they aren't facilities to do the surgery and, uh, um, also a lack of resources. So you would be hard pressed to find a bottle of Hibitane in this hospital and I'll show you more of what I mean, but things like consumables like, um, uh, diy pads. We used to reuse multiple times as much as we could because we couldn't just discard it. Um, so that was what we were dealing with there and tumors like this. Um, so just to give you a, a picture of what, what we used to deal with there, um, there was a case of wounds tumor in a three year old girl. Uh, we did the operation in this. Uh, well, first of all, she, she got O vinCRIStine because that's the only thing that was a only drug that was available there. Um, and a Ugandan, uh, uh, onco pediatric oncologist was there. He was a volunteer worker paid by an NGO otherwise there wouldn't be anyone there, of course. And, uh, they also paid for the chemo. So she only got vinCRIStine for a couple of months and had an ultrasound showing that there was some improvement and was planned for surgery. So we did her surgery here, which is actually the burns um, theater. There's light coming in from the windows and this was a light that uh, Doctor Nandy just brought in from his home. It's just a spotlight light, um, not surgical light. And we did the operation there also. Uh, we don't, they don't have anesthetists at all. So, clinical officers who are actually not given medical are trained to give anesthetics there. And, um, they, uh not, obviously not very, um comfortable with Children, which is why they had a longer wait. The pediatric cases, luckily there's a Texas, uh, there's a Texas hospital, Texas Children's Hospital which, um, supports long, um, especially the pediatric, um, department and a pediatric anesthetist came while I was there so that we could do a long list of tumors and p stops and hips all these um, major operations that had been waiting for months. Um So yes, so we, we did the operation there and then this was her transfer, uh, after the operation, she was uh recovered outside there and then we had to take her down three flights of stairs and there is no ICU as you should have guessed, but this is where we were taking her to and this is called the emergency zone. Uh, it is a pediatric resuscitation unit, uh more accurately. Um, and the, um, at the front here there's, there's three resuscitation beds and every time I went there, there was a child, uh a mother crying and a child dying and it was a very busy unit. Um, there were four beds per, uh, four Children per bed um generally, and um it looks like a mess and it looks like chaos, but it was the best place to get uh your POSTOP Children monitored well. And um throughout the night, uh they also had the facial bones as you can see. And team life there, we tried to escape to Lake Malawi. That's Lake Malawi. It's really beautiful and we got some downtime. These are some of the Texan uh pediatricians who I work there. Ok. So what are the challenges to access to surgical care? Uh We talked about some of it already. Uh poor infrastructure, human source resource, um human resource shortages, of course, poor referral systems and um professional isolation like in those areas that I went to and the lack of educational resources. So what can we do? Uh we could train more medical officers, we can try task shifting like the clinical offices in Malawi. Um And we can strengthen our referral systems. Um We also can educate and support rural doctors in those referral systems and uh improve our internet connectivity so that we can have better communication and training. So coming to home, um I my M was done on this on pediatric surgery outreach. I looked at the referrals coming into Durban and the delays in transport and delays in in diagnosis and transport and um how it's related to morbidity and mortality. And obviously, uh not surprisingly, it was stas statistically significant that uh the longer the delay, the higher the mortality. So I identified Nkana as the the district most in need of an outreach program. Um So this is Zulu land actually not in. And then I think you're all recognize from Hadley over there. And this is pro Jordan who is the leader, leading expert in in Rhabdomyosarcoma from America. She was visiting us and we took her on our outreach uh visit. And what we found was district hospitals with very good uh surgical uh operating rooms and facilities and wards that could manage um uncomplicated patients. So, what are the pitfalls of an outreach program? Um You will always get mixed um uh mixed uh receptivity with some people being eu enthusiastic and some people being apathetic and you need partners in the district level to um help you achieve what you need to achieve and sustainability because it needs to continue uh when one person is not there anymore. Uh also the lack of resources and the distance and accessibility and this shows the access problem, which is why the planes are, were, were a good option for us in K ZN. Uh So coming back here to East London, um I started here three years ago and uh we have some outreach. Um we have some arteries going on. So this is uh Queenstown Frontier Hospital that's from Adam Task and you know, these three and is there and uh we do um we try to do a, a clinic uh every month there and which has been halted with COVID. But we hope to take that up again. It improves our, our communication with uh with that uh level and um strengthens our referral system. Um We also uh went to the RA SA conference in 2018 and uh spoke to the clinical offices and the district uh level uh doctors and they really appreciated our presence. They really appreciated our training and showing them uh congenital abnormalities and what to do at their level. It was uh it was quite a good experience and this is Doctor Thomas. We went to MSA in 2018, 2017, 2018. Um to give them a talk on pediatric surgery, outreach, um oncology. Sorry. So what are the ideas going forward? Um I believe that we can, we can uh start the BRICS initiative, which is Brazil, Russia, India, China and South Africa. We already have an economic alliance and I believe uh in the health sector, these middle-income countries in the developing world can act as leaders in the developing world rather than high income countries where most of our protocols, management research is coming from at the moment. So I think a a move in that direction would be beneficial for the developing world. Um Also I think that South Africa and all these countries should act as leaders uh and support the rest of their region. And uh for us that sub Saharan Africa and I've shown you how uh dire the need is. Um So last year I went to the COSA examinations and they trained pediatric surgeons from all over Africa. Uh well, central southern and eastern Africa and this is the group of people um that the examiners from uh different countries. Uh Prola LAU from Oxford University, uh I mean department and this is protein from Malawi BDA from who's the only pediatric surgeon in Mozambique at the moment. Um Agneta from Kenya Feli, and John from Uganda. Um and it's great to meet these people. It's great to have relationships with them and to see uh where we can support each other, especially in the examinations. Uh I was an observer and they passed six new pediatric surgeons from all over Africa, which is gonna make a huge difference in those countries. Um So what are my passing words? Um This is my own little aphorism reaching out to reach in, I think we reach out uh to other people and to mankind in order to reach into ourselves. Um I believe that and philosophy and uh you know, biology even tells us that the outside world is just a reflection of what's going on inside our heads. We are uh we are just the, the outside world is just an interpretation of the sensory perception of uh what happens. So, uh quantum physics is also showing us that the microcosm is affected in the macrocosm and there's a unified field that permeates everything and that fits in very nicely with spirituality and the interconnectedness of all things. And it's, it's now irrefutable with quantum physics proving this. Um So that's my passing word. We should be helping each other and what can we do? We should always ask ourselves what we can do and you might call me an idealist, but then I'll leave you with the words of this guy. OK. OK. Thank you. That's it. Yeah. Yeah, sure. That, that was absolutely fascinating. Amazing, uh interesting enlightening. I'm falling short of adjectives. I'm I'm not flattering you. And uh i it was actually a blessing in disguise that we had to postpone our scheduled talk. And uh you agreed uh on a short notice to give this talk. It uh I think this was long overdue, three years. It was a pretty long time, but uh the time was right now. And uh and uh it is absolutely fascinating that you have not just visited as a tourist but you have gone and um worked in those areas which we only read in, in books and maybe watching movies and in TV series. So, so especially the Northwest frontier province from where Justice the, the girl Malala comes and, and all the areas of Iraq and, and Libya, it's absolutely amazing. And actually that's what makes you whole. And um also I liked, uh the way you presented, it's actually a Masterclass for all the juniors attending this talk, how there should be absolutely minimum words on the slide and you just talk around nice photos and I loved all your photos. So, so thank you very much. And I don't want to take uh too much time. I'm so happy that I could see lots of familiar faces in your uh photographs of Sexa. And uh and we have also contributed a little bit uh uh towards the examiners. Uh Ken Muma, who uh he is uh who is a pediatric surgeon in, in Ja in Kenya. He was our fellow in 2013 and we very fondly remember him and, and he was uh an examiner. So, so I think we have made or we are making a small difference. Uh You and I have spoken informally about this. Uh Our dreams are big, but I think we must always dream big and uh even if 50% of your and my vision comes true, um uh it, it will be a very significant achievement. So, so I think uh we through the Gi CS and the Bricks Alliance and COSA um the pandemic will be over soon, if not in one year, 1.5 years. So we will start that program. Like how Doctor mbaye visited from Dakar Senegal this year, I'm sure if not in 2021 in 2022 we should be able to restart that uh uh that program of uh pediatric surgeons from the rest of Africa coming and spending a few months with us. So I think without, uh, really eating much time, I would like to invite uh Professor Colin Lazarus to just give his thoughts and, and its comments, please. Uh Colin you show that that was an absolutely superb talk and it, it's uh, Testim to uh your courage in going out to places where most of us would not wish to go. And, uh, it's been a remarkable, uh, testimony to what you've done so far with your life. And I just congratulate you for that. So, can I ask you two questions? Ok, because you, I'm sure you just slipped over there. The first is, were you fearful at times? The second one? Well, talk to me about that first and then I'll ask the second. Um, I actually wasn't and I'll tell you why II really, um I had a lot of faith in, in the security that MSF Pro provided. I uh, yeah, II was very, I felt very secure at all times. In fact, I even challenged some of the security rules uh in, in Pakistan and things because I felt so uh welcome. It wasn't always like that. Of course, when I first went, it was a bit of a challenge. The the male doctors and nurses even didn't like the idea of me, but they warmed up to me and II felt quite comfortable and safe because those are the people of that, you know, that area, the same in Libya and those, those are probably the most insecure areas I was in, there was a bombing when I was in Benghazi, but MSF is very quick to react. They, they, um, uh, kept us, uh, kept, kept us under house arrest for a while. They even considered flying us out. But then, you know, everything calmed down. So we, we managed to stay, we even managed to do some traveling, uh, in Libya. So, honestly, I didn't feel, um, I wasn't actually scared in any of those situations, which sounds good. But, uh, but, uh, you know what, uh, my family was scared for me. So they were, um, and, you know, you're so wrapped up in the work and what's going on that, uh, you know, I didn't really think about it in that way. All right. Thank you. And if I may ask the second, yeah, were there times when you worked many days consistently on duty nights and days? Uh, no, II would say no because, um, like I, they, they, uh the MSF is very, very careful not to put too much pressure on you because you're already under a lot of pressure being in this strange place. And, um, so one of the security rules that I broke while I was there, uh, in Pakistan was during, we weren't allowed to go at night. It was only the surgeon and the anesthetist who could go to the hospital at night. And I broke that security rule when I went to help out um in the night during Ramadan because my colleagues who were national staff and from there were fasting. So I felt bad and I wanted to help, but II got reprimanded for that quite severely. And um no, like, like I'm saying, even in Iraq, we couldn't go anywhere at night. There, there were strict security rules so we didn't work through the night. Um At any point. I see. Good. Thank you. OK. Yeah. Uh Th thank you, call it. Uh So I just want to make one minor observation uh this Somali Land. Um uh aren't they now sort of claiming to be a sovereign country? Um uh Because uh there have been delegations from Somaliland uh medical fraternity to uh GI S meetings and even at a and uh II believe they have even started a medical school there. Uh So, so uh was, was that uh had that started happening while you were there? No. Uh So this was in 2011 and they were still part of Ethiopia and Ethiopia has different regions. And um there's like highlands and lowlands and highland, the highlands is, you know, the Addison, all those places. And that's mostly where the uh the governmental organizations and you know, the organ organization of the country or bureaucracy comes from. But there are factions like Somaliland, Somali people in Somaliland, but also the Oromiya and I forget the region name but they, they are, they claim to be marginalized as well by the Ethiopian government. So I can believe that there has been some um you know, unhappiness or discontent and, and need to separate from, from them. Yeah, and just one sort of um comment uh you know, what worked in your favor is that you followed the local culture because uh when you went to um three of these Muslim into inverted commerce countries, you dressed like them and you respected the local culture. So I think that is something. Uh again, we all need to learn, the juniors need to learn that uh we when wherever you are, whether you are in East London or wherever you need to respect the local culture and, and try and sort of behave with respect. So I think that really went into your favor when you show that. Yes, it was very important to assimilate uh culture wise, especially in Pakistan because they, like I said, if they don't like you, they'll kill you. So, I was lucky that they warmed up to me. Yeah. Uh, otherwise I would have been in trouble there. So, and were you, were of the wrong religion there? Wrong religion. Yeah. E even though the bright color but wrong, wrong religion. Yeah. Yeah. Yeah. Yeah. And II didn't bother to lie about that. I mean, it wasn't, it was obvious to everyone so it's better to, I have so many warm stories to share about Pakistan and the people there because everyone assumes that, you know, that part of Pakistan is full of extremists and terrorists and they all believe in this kind of uh you know, violent behavior and you know, a way of getting their way. But the people that I met and I worked with were amazing, wonderful warm people and they were nothing like the Taliban where the Taliban actually does come from there. But uh they were nothing like that. I think that's, that's your talk for next year. You should that? Ok. Uh I need to get uh comments from our two other consultants, 23 consultants. Uh So Sello, I know you had some uh technical problems today. Are you still around, Sello? Is Doctor Macha still around? I don't hear him. Uh Do I? No, Doctor Mala is there? So you want to make any comments, ask any questions? Click on the one you need help. II don't know whether they have left or lost connection. Um Anybody else wants to ask any question, make any comment, either Mia or our junior colleagues or colleagues from outside the department. Yes. Ok. Right. Yes. Yes. Yes. You hear me? Yeah. Yes, yes. Is that Mia? Yes. Yeah. Yeah. Yeah. Please go ahead. Mia. Yeah. Yeah. Uh Yeah, surely, you know, this is also a topic that's quite close to my heart. Um Me coming from Belgium, this is my um coming to South Africa was always because I wanted to go uh abroad with uh MSF and then got stuck here because I met, met my husband. Um um but I'm very happy here and I'm very happy working in the government hospital so that I still have um doing some outreach or sort of like helping the, the needy uh people here. So, yeah, it was very, very to uh to see your slides and hear your, your story. Uh Thanks a lot for that. Yeah. Mhm. Ok. Thanks Mia. We are, we are, we all are delighted that you are stuck in East London until your time. Ok. Ok. I, if there are no comments, I really want to thank ya uh for uh sharing her story, which is most important so that we can know her better and, and sharing her really different experiences which very few of us have ever imagined about um never experienced. And uh this must be quite an inspirational, uh talk to listen to, to to all the juniors it was for me. So we are actually finishing right on 0.6 to two minutes, which is also good. So thank you, everyone. Have a good evening and next week, uh Doctor Marehan will host the meeting and uh and uh it will be on, on stress amongst doctors and how to prevent it and how to look after yourself and your colleagues. So goodnight all.

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