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keep to a theme of sustainability. We're now moving back to the virtual world with our next speaker joining us all the way from Canada showcasing how truly global global. The speaker speaking cohorts are, uh, so with pleasure. I have lean a row. Who's a resident in obstetrics and gynecology at the University of Alberta. She completed a global surgery fellowship at the Program of Global Surgery and Social Change in Harvard. She holds an MD at the University of Toronto. She holds a masters in public health from the Harvard Teacher in School of Public Health. As you can see, she is very qualified in what she's talking about. Her research focuses currently on equitable access to high quality surgical care and also on the sexual and reproductive services for women globally. So over to her online. Thank you. Good afternoon, everyone. Thank you for having me, um, join your conference today. I'm sorry, Going to be in person, but, uh, so So I'm still really glad to be joining you, Um, guides on line. Um, So I'm going to be talking to you today about global surgery policy and how to incorporate, um, climate change policy into it. Um, as you heard, I am a training, obstetrics and gynecology. Uh, so I am by no means an expert in, um, global surgery policy or in climate change policy. But I'm just going to be talking about some of my experiences at the programming global surgery and social change, uh, working with the rural health organization and with the Ministry of Health of the Pacific Islands, uh, to generate some of this policy. So this is not all my work. This is work where I've been, I've been fortunate enough to be mentored by fantastic people in all of these organizations. Um, so the first thing I'm going to go over is why should you clinician or researcher should be engaging with policymakers. Why do we do it? How and who should we be talking to? Um, and then I'm gonna use the experience of the western Pacific region, um, as a case study on how to develop a global surgery policy. And then I will talk about how the Western Pacific region is incorporating climate change, um, principles into global surgery policy. So the first thing is, why should surgeons and academics engage with policy makers? So here at the bottom. It's a screenshot of a paper that is fantastic. Ongoing some of the what to do and what not to do in order to influence policy when you're coming from an academic point of view. But the main two things are, uh, clinicians engaging policy to have an impact in the real world, meaning in the bigger world, outside of the operating room or outside of your clinic. Um, because they enjoyed finding solutions to complex problems. Um, so, as I'm sure, you know, policy making, um, it's a interdisciplinary Um um, um, interdisciplinary approach that takes a lot of complex issues, uh, to find a solution. So in order to engage people effectively, um, I think when we come from academia and from research and firm clinicians, we need to be able to provide high quality research in order to inform policymakers. Often, policymakers don't have a health background, um, under relying on us in providing a lot of the data that they will then use to guide policies, um, as well, we need to be able to communicate this research. Um, well, for them, um, we need to be able to speak their language so often they might need more data on, um, the economic impact or cost effectiveness and things that for us are obvious because they improve healthcare. But policymakers often need to hear it. Um, in the in the language that they speak, um, as well. We need to understand the policy processes. Who's making the decision at what level when the decisions get made, Uh, so that we can take these opportunities to then, um, influence policymakers, um, and then trying to be accessible and engaging with them routinely. So, um, policy making is a long process is much lower than like, you do a surgery and you're done. This takes years to affect change. Um, and so it's a long term commitment that requires building relationships. Um, this is a picture with Dr Keep Park, the keynote speaker, and we were here together at the Western Pacific Regional office, um, event in Manila, um, with some of the Ministry of Health from the region and the Director General. Um, And as you can see, it can also be a lot of fun to engage with policymakers. So when I talk about policy makers, who am I talking about? So It's a lot of different people. This list is not exhausted, so it could be ministries of health. It could be the World Health Organization. It could be the regional offices or the country office is It could be United Nations agencies, um, things like the Global Surgery Foundation. Which Doctor Park talked a lot about this morning? Uh, World Bank, surgical societies or the leadership in your hospital. So it's pretty much anyone who's making decisions. Um, that can have an impact. Um, on patient care, those are the people that you want to be talking to. So now I'm going to be moving on to, um, talking about the Western Pacific region. So this is the wh office in manila, uh, for the entire Western Pacific region. And I'm going to be talking about, um, some of their progress in the last five years in terms of global surgery. So in 2017, when I joined the programming Global Surgery in social change, one of the exciting, um, events was that the the Western Pacific Regional Group they published regional collection of surgical indicators. So they took the me the six Lancet commission indicators to measure um, surgical system strength. Um, and they collected the data in the Pacific region. So, uh, that's a collection of about 13 countries. Um, and it was an excellent collaborative approach to get this data to be the baseline of what the surgical systems in the Pacific Islands look like. Then, in 2019, um, together with, um, the World Health Organization, we organized a meeting in Dubai. It included, um, ministries of health as well as, uh, policy makers and financial bodies from mostly from Southeast Asia as well as, um, the Western Pacific region. And it was mostly to talk about national surgical obstetrical anesthesia plans or soaps, Um, and how to fund them how to implement them, how to development. Um, so that this was in 2019. And, um, as part of that meeting, um, you can see here some of the Southeast Asia representatives and some of the Western Pacific representatives as well as, um, some of the members from the World Bank. Um, and one of the main take home points from that meeting was that the Western Pacific country representatives agreed to advocate to the ministers of health, um, to ask the w h. O for support for, um, National Surgical plan. Um, development, meaning they wanted this to be official policy in their countries. And they wanted official support from the Ministry of Health as well as the rural or organization. So following this a little bit later on that year, there were two main events. Um, the first one was an official event at the World Health Assembly. And then the second one was the Pacific Health Minister is needing. So at the World Health Assembly, the World Assembly, it's the decision making body of the W H O. Um, it is attended by delegations from all member states, and it usually focuses on a specific health agenda that's prepared by the executive board. So this is the first time that there was, um one of the main events was focused focusing on surgery. Um, and it was led by Pacific Islands, um, from people out Tonga and the Maldives, um, to address the surgical issues faced in their countries. And then a few months later, um, they met at the, uh, Pacific Health Minister meetings, which is a meeting that happens every two years to discuss what the priorities were going to be, um uh, for a region. Now, the interesting thing about the Pacific islands is that many of the ministers of health are actually surgeons. Uh, so for them, it's been a very natural thing to support surgical system strengthening. And so again, you can see here at the bottom. Then again, they are committed as a region to take a collaborative approach to implement a national surgical upset. Like an anesthesia plans, Um, moving on to a few months later in 2019. That was the regional committee meeting, Um, event. So this happened in Manila, which happened to be around the same time that I was being an intern at the World Health Organization. So I got to be very involved in that event, um, and to work with all these ministries. So the regional committee meeting, it's a meeting that happens every year. And what they do is they're they formulate policies, um, to provide oversight for regional programs. They hear progress reports, um, and they revised and endorse new initiatives. Um, they also adopt resolutions as a region, Um, and in this case, because they had a new director general, they were also drafting a white paper to describe the vision for the entire region for the next five years. Um, so in a region that it's so diverse, there's many health priorities. And so it was very important, um, to highlight, um, And to make sure that resolutions were past about surgery to ensure that surgery, um, gets the attention and deserved, um, So the this, um, white paper that described their five year plan that I was talking about is called, uh, it was called for the future towards the healthiest and safest region. Um and so this is just a picture of the surgical events. We had great speakers from Malaysia, Tonga, Fiji and the Philippines, um, as well as from Australia. And, um, by presenting by having this event here, um, they ensure that all the other 47 countries in the region were on board with, um, what they were doing in terms of surgery to make sure that the other countries adopt um, similar policies and plants. So this was their five year plan, and usually they choose for areas to focus on. So, for the region, this on 2019, it was antimicrobial resistance, non communicable diseases and aging climate change in the environment and reaching the unreached. So even though there's not an obvious fit for surgery of Citrus and anesthesia Yeah, in all of it, um, what we were working with the Ministry of Health is how do we ensure that surgery gets highlighted? Um, and that country's commit to advancing surgical, obstetrics and anesthesia care, knowing that these are the priorities that will be, um, that have been already agreed upon. Um, so after extensive discussions with the member states, um, it was decided that they would, um, support countries to create access to save an affordable surgery, um, as part of a systems approach and recognizing that surgery of such an extent anesthesia an essential component of universal healthcare. Um, obviously, the burden of evidence from non communicable diseases and injury many times needs surgical treatment. Um, and so therefore, we were able to make it a priority. When it comes to any CVS and aging, Um, as well, um, innovation is something that the Western Pacific region is focusing on a lot. And so talking about ways, um in which, whether it's medical robots, videoconferencing for education, um, or big data be used to improve surgical care provision and then finally antimicrobial, um, resistance. So the consequences of AM are are catastrophic. And in surgery, we do use quite a lot of, um, antibiotics. Um, and therefore there's a big responsibility to an antimicrobial resistance. So this was another big area in which, um, surgery was found to play an important role for their plan. And so finally, once they decided the priorities and they agreed that surgery was going to be one of the priorities for the entire region, um, it got implemented into the 2020 regional action framework, um, and map for all the member states. Um, to a certain extent, it's, um it involves coming up with strategic action items where the indicators or goals, Um, and it specifies what the country rolls and what the W h. O girls are going to be. Obviously, this took about a year of discussion because all 37 country members have to agree to it. Um, and it had to go through the political process and all the bureaucracy necessary to get it approved. So now that all of that was done, then we could start working on this national surgical obstetrics and anesthesia plans. So the Ministry of Health that were the most interested in reading this were, uh, from Fiji, Cook Island, Vanuatu, Palauan, Tonga and the Royal College, The Royal Australasian College of Surgeons. Um, in Melbourne, Um was very supportive and bringing these five countries together to start the, uh planning. So this is interesting because although many countries in Africa had completed and soap such as Tanzania, Ethiopia, Zambia, um, the Pacific Islands wanted to take a regional approach. Um, part of it is because they are very small island. They have small populations. They have a small surgical work force. So they do have to work together in order to provide, um, surgical care to a population that is very widespread. Um, as well. They have interesting. They have a unique challenges. Uh, climate change affects them a lot. Because of the rising sea levels, these islands are being affected. Um, the most, um as well. The small populations and economies means they have a small economies of scale. They have poor access to global markets again because of the geographic locations. Um, unfortunately, disasters have hit them quite hard. And so pandemic preparedness. Um, it's essential for them when it comes to surgical planning. So when we're having this conversation, it was all about trying to balance scaling of surgical care. Um, so we know that country's low and middle income countries need to scale up surgical care. Um, the Lancet Commission estimated five million people don't have access to care, so we know we need to scale up massively. However, we also know that surgery's research intensive and it contributes to greenhouse emissions. So how do we scale up surgical care without causing even more burden in the environment? Um, so some of the work I'm going to review later has been published. We published in these two papers, the first one is in Lansing planetary health and in the annals of surgery. So if anybody is interested in learning somewhere of the details that I will be talking about, you can find most of, um, this in those two papers. Um, so as it's been talked a lot today, um, climate changes affecting health and is changing the burden of disease. So, for example, rising temperatures are changing. Uh, the obstetric and neonatal burden of disease. So we saw a couple of years ago that changes in vector ecology, um, resulted in increased pathogens, uh, pathogen spread such as cycle, which was a big deal in South America, Central America. Um, and that led to new congenital anomalies that we haven't seen in a long time. Um, as well. We know that neural tube defects have been associated with increasing temperatures. We know that heat waves, forest fires and higher concentrations of pollutions have been associated with preterm birth and adverse neonatal and maternal outcomes as well. We know that with climate change and increasing rates of natural disasters, um, we know that, um, respiratory as well as cardiac events are in the rise. And again, often this we will either lead to increased needing surgery or more complex preoperative care. Um, so I'm sure this audience is probably familiar with the concept of mitigation adaptation strategies, but I just want to highlight them quickly. So mitigations our efforts to reduce greenhouse gases by replacing fossil fuels with renewable energy sources. Well, adaptation strategies are efforts to adjust to climate change, So it's saying it's already happening. How do we adjust? And it's important to know that both are necessary for the health sector, um, to address climate change. Um, so when we're trying to come up with medication and adaptation strategies, we were looking at it at three levels. So the first was, um, at the operating, um, room or the facility level. So that was making, um, use of energy intensive equipment. Um, considered what's the environmental effect when we choose single use versus reusable devices? And I know it's been discussed multiple times today, and I think the bottom line is we need more, um, more studies, and it's going to be very a lot, depending on where you are. Um, we also looked at it at the level of academics and professional associations. So as clinicians, we need to put more pressure on governments, uh, and as well as on our societies to divest themselves with fossil fuels. Uh, and to research, what are the most sustainable, um, practices in order to innovate energy efficient solutions. And then if you do want to go on the policy side and at the national health systems level, um, setting goals in national roadmaps to get to zero emissions. Um, so we had an excellent talked earlier about what Edinburgh is doing so similar examples could be done in a similar initiatives could be taken in different countries, Um, and then again, promoting the role of industry and innovation and public private partnerships. We need new solutions in order to combat climate change when it comes to adaptation strategies. So again, um, in the operating room, a thing that came often in working with the Pacific Islands was the relocation of vulnerable health facilities. So a lot of the health centers and hospitals around in the coastline, uh, they know that they're going to be flooded by the rising PSA levels. So starting by actively relocating a lot of those health facilities and ensuring that all the populations have access to them. Um, developing two kids, um, and again, the green or checklist was mentioned earlier to reduce environmental harms and operating room practices. Um, as well as support, um, clinician response to people that are affected by natural disasters. So we know that you do climate change. We're starting to see more and more, um, disasters. And so we need to be able to mobilize trauma surgeons, orthopedic surgeons, obstetricians, um, to these areas in order to, um so that surgical care is not interrupted in populations that are being affected the most by this. Um, again, we need to put pressure on academia and professional societies to come up with solutions for this, um, and in terms of national health systems, we need to ensure no one is left behind, because we know climate change affects the most vulnerable and the poorest people the most. Um and so we need to make sure that they're included, um, in climate change policies as well as in surgical policies, Um, so that no one is left behind and we need to make sure that green policies and surgical policies are a priority for healthcare systems. Um, so now I just want to talk about how we included some of these medication and adaptation strategies into and soaps. Um, So, uh, when we looked at the end, so framework, it was actually adopted from the world World Health Organization, building blocks from health systems. Um, and so the ends up template that a lot of countries are starting to follow focuses on infrastructure work for service, delivery, financing, information management and governance. Um and so we work with the Pacific island ministers to come up with a way to take each of these blocks and then see how we could incorporate strategies into each of these. Um, so again, with infrastructure relocating vulnerable, um, facilities and rebuilding or building them with environmental practices that our energy efficiency in terms of work force, we know we need to grow our surgical obstetrics and anesthesia. Um, work first and again. We have some excellent talked earlier today on how that's been done by many organizations. Sorry. Did you say something? Okay. I'm sorry. I couldn't hear if you were saying something I couldn't hear. So I'm just going to keep going. Um uh, make sure that surgeons of situations, that anesthesiologist. Okay, so then again, this this figure, it's actually coming from from our papers so you can read into it into more detail so that I can just wrap up in the next few minutes. Um, so again, the struggle that we've been working on with the Pacific Island state is balancing this killing of surgical care. But doing it, um, in a way that, um, fights climate change. So just to finalize, how can you? As a as a trainee in global surgery get involved in policy, whether that's in climate change policy or in global surgery policy or even better, integrating them both. Um, so at the clinical level, we know surgical scale is needed. So we all need to finish our training in, uh, surgical specialties, even though it takes forever. Um, and we can take initiatives again, and many of them have been discussed today on how to have an impact at the operating room level. Um, we need more research. There's a lot of information we don't have. And some of the research posters today were fantastic and highlighting, um, that new information that's coming up so that needs to keep happening because there's still a big gap on how to scale up surgical care in a sustainable manner. And then finally, we need to collaborate. We need to engage with policymakers, um, as they will help us, um, scale up surgical care. And we need to make sure that all of this we're doing it with with climate change mindset in which medication and adaptation, um, measures are taking into account as we scale of surgical care, so that will finish up. I'm happy to take any questions or if you want to send me, send them by email. That's fine, too. Thank you so much. That was really insightful talk. And I think we can all learn a lot about how to be more responsible as surgeons. Uh, I'm thinking about the climate and think about our practice. I'd like to invite the other speakers back onto the stage, and we've got a whole host of questions that we posed. Um, I'm Canadian, and so I cannot say I have been able to put with organization. Um, I have been able to support governments that are more interested, Um, in doing this. So the for example, the Ministry of Health of Fiji is a fantastic, um, advocate and had lots of interested in incorporating surgery into there, um, into their health plans. So as a trainee, I when I when I was doing my research and my policy work, I had the time to go and take a deep dive into the literature provided with the numbers and the analysis that he needed. Um And so it was not pressure that was more like support in somebody that was already willing to do it. They just needed that clinical input or Actonel input. Um, I find as a trainee, it's harder to exert pressure on government. So I would focus more on the next level at your hospital level at your professional association level because we do have more access to that. Um, And if you start with those kind of like levels, by the time you finish your training, you become an attending, um, then you might be ready to then tackle on more national organizations and national governments. Thank you so much. That's a really helpful response. Um, going onto kid. Actually, while you're here, um, some of the work you guys have done. In fact, all the work you guys have done is really incredible. And it's really exciting for me to see. My question would actually be What challenges do you feel like your organization has had in creating and sustaining? Um, sustainable healthcare partnerships. Yeah, And can I just check? You mean sustainable in a general sense rather than climate sustainable. And so I think we I suppose one thing to say is that we don't create the partnerships, the partnerships create themselves, so we and we support the partnerships. Um, I So I think some of my knowledge of that comes through the vet, and some of it comes through my personal experience from leading health partnership in Wales. I think probably a big challenge is, uh is in the cycle of individuals. So you develop a relationship between a few key individuals at each end, and from that the work grows and the plans are made and the and you need those relationships in order to form the equitable partnership. Um, that that will do the best work. And as people move on, the new relationships have to be created. And it's not starting from scratch, Certainly because there's a kind of basis there, but but it definitely affects making plans and communication. Um, and I think probably a lot of that, not the change of individuals. But I think communication is so much easier across continents now that I think that will really help that. What was the original question? What are the challenges? Is that enough? I'll leave it at that, then. Thank you so much. Thank you. Um, And for you, Tim. Last question. Um, there's been a couple of questions, actually, about your echo clave. Um some really has asked specifically, How does the exclave compared to AUTOCLAVING? Is there much? Is there much of a difference in how sterile the instruments are after use? And to add on to that question, Um, there's been a question from Simon asking about whether it's possible to expand this free will innovation use beyond low minimum come healthcare settings into high income countries as well. Thank you for that. So with the sterilization is kind of it's happened or it hasn't happened. Um and, uh, so kind of that's that one. Really. And the great thing about the echo flavors, there's no kind of really moving parts, and it's anyone can use it. So, uh, the other thing is, it's in a It's a normal pressure cooker autoclave, by the way, so you can just put it on a cooker. So I've got sites that if they've got a cooker working, they'll put the pressure cooker on the cooker like they've got an electrical supply. If they haven't, they will use, um, the echo clave. So I think that answers that one, um and, uh, for we designed it, obviously, for low resource environment, where there is minimal or unreliable electricity. Um, we've got sites that grow would, for it kind of thing. Um, it doesn't I would argue it doesn't really have an application in the West. There isn't the actual to claim itself, because the whole point about it, it's just an insulated, fireproof frame. And there's a brochure on our stand over there about it, so it doesn't really have an application. Necessarily in the West. You could just get an electric version of that pressure cooker autoclave. The thing that's interesting about that. Actually, they're They're 40 liters in size. Sounds like an advertising pitch, doesn't it? But so they will take, like, three of our general sets with which you could do a laparotomy with or they'll certainly I think they take two of official sets. Um, which are a bit higher. So, um, but it's it's a very it's kind of a multi fuel stove, really. On that basis. Thank you. Thank you again. Um, this is just a general question to all three of you. Really? Uh, a lot of your works for innovation and about thinking outside the box. What? Our key qualities of a good innovation for you guys Wow, um feels like almost a dragons den type. Uh, question. I think, uh, I think solutions just constantly much simpler than than than than you think, actually. And I think, um, I don't know. I think you've just got to really think I suppose the answer to that is, if you if there's a key thing for me about coming up with an innovation, Um, and you've got things like if you're looking at a brochure, that's the biggest power tool system for orthopedics, which is a really wide drill. Inside, a sterile cover is if you're going to think about a solution. No, I no matter how crazy it seems, say it because I have found in life basically that things that sound crazy actually often have potential if you start to then bring it in. So I suppose if my concept with these things and indeed anything is, suggest it because you just never know where it will go, and if nothing else, it creates a mindset of thinking outside of the box. So that would be my advice. No matter what. No matter how crazy say it. I feel considerably less qualified to answer this. So I'm just going to say a few random things about innovations, really? So I think they need to solve the problem. I think they need to be applicable to the circumstances they used, and it sounds obvious. But I think sometimes people get a little bit like you said about things being simple. People get caught up with new and exciting things that are not either not needed or don't really work where you are. Um, I think ideally they should be cheap wherever there, wherever they're going to be implemented. I mean, why do you want innovation that's going to cost a fortune? You want something that's going to be cheap and easy, don't you? Um, And I think the other thing is just to remember that the ideas for innovations can come from anywhere, and I think that that is one of the great things that can come through global health is that through all the relationships that people have a cross country's, they see different techniques. They see different ways of working that can be applied in a different situation. Um, and I think it's important everyone keeps their eyes open to that. I'm looking at the UK end of the audience, mainly so things that can be brought back to the UK And it applies for people working each other with each other between African and Asian countries and with the high income partners. So I think that's all I can say. Brilliant answer is both of you. Thank you so much for your time and just use a round of applause for both of you.