This session discusses the challenges and unmet needs as regards surgery in low and middle income countries. With the introduction of the Lancet Commission on Global Surgery in 2012, six indicators were identified to monitor access to timely, quality, and affordable surgical care for everyone. Speaker Dr. E.G. Lambert, who works at Ahmadu Bello University Teaching Hospital in Zaria Nigeria, will discuss these challenges and provide workable solutions to them. This course is also beneficial to medical professionals as they will overview topics such as improving insurance coverage, incentivizing surgeons to work in rural areas, and upgrading healthcare centres. Join this interactive set-up to understand global needs and sort of care, and then later on to learn about technology designed for low resource settings.
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Join us for Modules 2 and 3 of our Global Frugal Innovation Skills course!

Module 2: Understanding the unmet global surgical need.

o   Gain an understanding of the lack of global surgical care

o   Describe the challenges faced by LMIC surgeons and patients

o   Market research and appraisal of existing solutions

Module 3: Technology design for low-resource settings

o  Describe participatory and context-specific design principles

o  Understand how to develop sustainable technologies

o  Learn how to collaborate across disciplines

o  Technology transfer principles in global health

Learning objectives

Learning Objectives: 1. Participants will be able to describe the concept of global surgery and its components. 2. Participants will be able to identify the challenges of global surgery in low and middle income countries. 3. Participants will be able to list the six indicators used to monitor access to surgery. 4. Participants will be able to explain the potential solutions to global surgery in low and middle income countries. 5. Participants will be able to identify incentives for surgical personnel to work in rural areas.
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Computer generated transcript

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

By a very good afternoon, everyone. My name is Jean. I am the secretary and I'm an anesthetic creditor are in the UK. And joining us say we also have Jen Man UK guess stock anaesthetic representative. And uh so we are going to the uh brain um uh understanding are not global needs and sort of care, which is module to for the Frugal Innovations course today. And then later at four o'clock, we will do module three, which is technology designed for low resource settings for that. Further do I'm going to introduce to you our very first speaker who were very proud to present his doctor E G Lambert, who's a senior registrar in plastics and reconstructive surgery. He works at the Ahmadu Bello University Teaching Hospital in Zaria Nigeria. Lambert is also our guest of International surgical rep. So over to you, Lambert. All right. Thank you so much then. Um I'm very grateful to be here to talk to us today about the challenges and on meth needs um as regards surgery, um lower middle income countries. Um I reside in Nigeria were also work and um these challenges um cut across um West Africa sub Saharan Africa and also other law on middle income countries. Um for by way of introduction, I mean 2015, um 1015 the Lancet um commission on Global Surgery um identified the fact that um um surgeries have been relegated to the background. Um First of all, sorry, um we came to understand the challenges of um global surgical care. We also um see how we can appreciate the challenges faced um in low and middle income countries. Then we also attempt to identify some workable solutions to these problems. Um Like I said earlier, um in 2015, the Lancet Commission on Global Surgery um discovered that surgery has been relegated to the background um in the discuss regarding public health. Um So they met and then they came up with the concept of global surgery and global surgery is basically, um has to do with the study and practice of improving access to timely quality and affordable um surgical care for everyone. Um That's just what global surgery is all about and that's what got suck also helps to propagate. Um I don't know whether my slides are moving. I since I'm seen, I seem to uh to get um some sluggish um reaction over here. Um Sorry about that. Um Global surgery is essentially like I said, what it seems to do is to ensure that everyone has access to timely quality and affordable um surgical, I'm kid. Um an estimated five billion people globally don't have access to quality and affordable um surgical interventions um from statistics that we have gathered. And then because of this, um the last committee had to define certain criteria that had to be met before we can say that um there's access to um surgical um care. Um Let me see if I can turn off my camera. I don't know why my slides are not moving, but I'm sorry about that. Okay. So sorry. My slide seems to be stuck on a slight tree, John, is it moving at your end? And my slides moving? You're muting. I'm sorry, looking mistake. Can you get me? We can hear you. Um But how about this? You send your power 0.15 to presentation going on and you can upload it in a moment but you can keep going with what you've got. Okay, but just a couple of minutes now. So everyone who's listening so numb, but you just send your Power 0.2 Gene. Um And then we'll sort it into a PDF and then we'll get onto the main stage. Let me do that. The problem is that all right? That's good while we're waiting. Welcome everyone. I see that we've got a lot of people around. We've got people from Kenya, we've got people from Lebanon, Uganda. Um and Ireland um in case you have missed out, we've also got a chat box on the side. Um The plan is we've got three very esteemed speakers today. So there'll be 15 minutes um for the first talk, then 15 minutes for a second talk, 15 minutes for the last talk. And at the very end, we will do um the question and answer. I've got my own questions, but ob obviously the best questions comes from the audience. So, um you're more than welcome um to ask some questions. Now, I'm really sorry that this has been um, rescheduled, but hopefully everyone is gonna enjoy today. Um As you can see, Lambert's got some very snazzy slides um for everything else as well. So that's all right. Um You know, I've sensed them. I don't know if you've received. Yeah. So why is this is going on Lambert? Um I think Genes received it. So probably you can go on. So where we left office about the Lancet Commission in 2013 if I'm not wrong. Um And then you can carry on from there. All right. Um So do I need to stop sharing my, my slides? Gene? Yeah, or it's all right. Um Stop. So I've, I've stopped showing my slides. So, can you see this? No. Yes, thank you. Thank you. So, do you want here? All right. Thank you very much. Yes. So, as I was saying, um, the last Health Commission on Global Surgery, um, not notice the fact that surgery had been relegated to the background, um, when discussing public health. Um, they definitely came up with the concept of global surgery, which is basically trying to make um surgery affordable and accessible to everyone. Um Globally. Um Next slide please. Yes. Uh and in this um aim to achieve global surgery, the lower and middle income countries are not left out. And then it was also discovered that an estimated five billion people globally lack access to quality and lifesaving um surgical interventions. Um Next like this. Yeah. So as a result of this, um the committee decided that they would define um six indicators that will be used to monitor access surgery um for everyone. And one of them is access to timely an essential surgery where they look where they can start. The fact that um at least people should be able to access a facility where the bellwether procedures can be carried out within two hours or where they live. Um They also looked at the workforce density and they proposed that um at least um there should be 20 surgical, personal bit surgery and aesthetics of ophthetic physicians per 100,000 population by 2030. And then um for the surgical volume, um they proposed that uh the numbers should be increased to at least 5000 procedures, uh 100,000 population by 2030. And also they look to reduce perioperative mortality as much as possible by 2030. And they also aims to protect against improv improvisation, expend expenditure to stop people from spending so much out of pockets that will leave them um, broke and impoverished study. And so these are some of the indicators that were proposed by the committee um to help achieve um global surgery. So let's look at the challenges um, and the unmet needs that will face and low a million compounds. One of them is um socioeconomic challenges and, well, we'll see that poverty's um, arrive in most L M Icees and statistics have it that um at least about 2040% of population in Nigeria um live below the poverty line as a as a 2019. And this number has increased drastically over time. Um Therefore, people have to pay, people find it difficult to pay out of pocket um for um their surgeon, surgical needs um due to poverty. Another issue there is health insurance, um low and middle income countries find it um find it difficult um covering most of the population when it comes to insurance. And in Nigeria, just 5% of the population have health insurance. Hence, you have a large majority of the population. Um how they have to pay out of pocket to access um surgical care. Because of this. They have to resort to pour authorities like traditional healers, traditional bone uh setters and traditional better attendance. Um living them with more mobility and increasing the mortality. Next slide, please. Um A second challenge that we have discovered also is um timeliness of care. People are not able to access timely care because they don't live near this. The facilities that can provide this bellwether procedures also scored that road networks are quite poor. So um accessing these facilities actually difficult and even where they're d central networks, transport facilities, ambulance facilities are not readily available to move them from their point of emergencies to the point um of care. And also um call center facilities. Network services also make it difficult to um call for help when emergencies arrives. Next leg, please. Um Another challenge is the workforce density in lower middle income countries which whether there is in drought of surgical personnel um in these countries as a result of um immigration for greener pastures better be and better working environment. Also discovered that um younger doctors are not um wanting to choose surgery or aesthetics as their core specialty. They prefer to do public health and some other um easier specialties because essentially the pay is the same across board. And also those who have chosen to work as surgeons um suffer from born hours because of the increased workload next life, please. Um Also discovered that there's lack of political will from leaders in these countries. Um They don't want to invest in healthcare because they find probably better alternatives abroad. So the results to health capitalism and where they can meet their um surgical needs and they also don't have uh fit in the system to solve their problems. Hence, the um seek care abroad. Next slide, please. Another challenge. And uh we've discovered is that um most of the surgical instruments reduced and the consumables are not manufactured in our countries. We have to import them. Um Also our, our equipment's spare parts, imaging materials are also not locally sourced. And since we have to buy these things from high income countries, we also grapple, grapple with rising exchange rates. And so the Mahdi exchange with the more difficult it is um to source um foreign exchange to buy this material. So this material are not readily um available um for surgery. Okay, next like this. Um So these are some of the challenges that we have faced and there are workable solutions that to these challenges that we have identified. One of them is improving um insurance coverage um for Nigeria. Well, we're looking to um see how the national health insurance scheme can cover um much of the population s tried those in dural areas that don't have to pay out of pockets for um surgical care. Um On, on that solution is to upgrade the facilities in neural areas um from primary healthcare centres to even secondary healthcare centers where the bellwether procedures can be performed. Um This has actually started in some states across the country and also in West Africa. Um these facets have been upgraded um also looking to incentivize um surgeons to agreed to work in the royal areas. Um The right areas are not exactly attractive for surgeons because of poor power supply poor living conditions. But then we can make this place is conducive and attractive for surgeons to work. Um where I work the hospital where I work, we've started it, we usually send residents surgeons to um do a one month traditional neural areas to both gain experience and also provide surgical care for the population. Um Also we also increase um surgical workforce by encouraging younger doctors to do such as a specialty because of um the shortage of surgical stuff that we have, then we can also continue to engage our leaders. It's not a one off thing. We have to keep doing it because the more we do it, um they're more likely that they're going to understand that um surgical care um is needed in countries and eventually they will respond to us and then not forgetting global interventions uh from organizations that could come in to also assist in carrying out. So um surgeries to ease the surgical body, for example, um small chain is um an opposition that has come into Nigeria and other um low and middle income countries to pioneer free clear flip and palate surgeries and other organizations are also coming in from time to time and this is easing the body um of this of surgical care in um these countries. Next slide, please. Um the solutions to these challenges and and are made needs that we face in your middle income countries are not far fetched. And um it is obvious that gas out is one of the bodies that at the forefront of championing these solutions with the workshops and the trainings um that actually being organized as well as interactions between high um train insurgents in high income countries and also um in low and middle income countries. And thank you very much for listening. Um Have you have a good afternoon? Okay. Thank you so much, Linda much. And you were enlightening for all of us here and we'll keep the, keep the questions coming guys and we'll tackle all the questions at the end when we have all three speakers online. So next up, I'm just gonna start presenting, I'm gonna share my next slide. So next up, I'm going to introduce to your doctor Finger Cut Chiro, who is our guest talk International obs and gaining representative and she's also a senior registrar at the Ahmadu Bello University Teaching Hospital in Zaria Nigeria. So just give me the Chantix. It's green. Missed it. Yeah. Yeah. Uh huh. Okay. Uh huh. Okay. Sweeter. Can you hear this? Fever? Am I audible? Yes, you are over to you. Good day, everyone. Um I'm actually pleased to be a speaker at this forum to just highlight some of the challenges faced with. So to care in any Mrs and I'll be coming from an obstetric perspective. Okay. So next slide, okay. This will be the outlined for this presentation next slide. Okay. So um conditions that are actually are mean able to surgical obstetric trauma and anesthesia. Quite significant. However, they are largely underestimated source of uh global boarding of diseases because the focus initially Australian and um eyes is the base on communicable diseases where by vaccines where um vaccine coverage was improved in L M is is which are seen to a drastic reduction in communicable disease. However, no communicable disease of which most of the conditions are been able to sorta careful on that have actually been underestimated. And then um the largest one med meat, meat for. So take a A coin L M I C is where the poorest one sort of the world's population received only um 3.5% of the surgical procedures contacted globally. Now for us to have like a proper so take care. It requires a side energy between all pillars of the health care system, including infrastructure foundations like uh as basic as having um the minimum standard for a structure bit standard structure for theater, for the labor ward, constant running water and electricity. Then human resources also another important pillar to ensure. So talking because apart from skilled health workers, there has to be a proportional description of health workers among all regions in order to actually ensure universal cooperate and then equipment, the thought pillar. Because even if you have skilled resources kill human resources, you have infrastructure without equipment to work with and there will definitely not be an adequate attack it. Uh next slide please. So um basically for obstetric care, you know, the hallmark of uh obstetric case actually to ensure a safe modern and a safe baby. And then usually the best indicator to ascertain and the quality of obstetric care is actually maternal mobility, maternal mortality and then severe maternal morbidity. So that's why the concept of an essential obstetric care actually came about which is actually the basic minimum that either a primary health center or other secondary facilities should have put in place now to ensure a positive pregnancy outcome. So the essential obstetric has been better into two. We have the basic emergency, obstetric and newborn care in which it's actually focused on primary health center, which are usually where uh which are usually uh centers actually found in the most remote of places is shedding LMS is and it ensures that administrate antibiotics are into returning drugs and compulsin. It's uh there should be uh skills form on a level of class center and over the routine products of conception after a miscarriage or abortion. And then there should be provisions for assisted vaginal deliveries and basic unitary cessation. Once 100 facilities, in addition to all these basic emergency of citrical new banker should actually be able to perform abdominal. So just like senior section have a safe drug transition and permission to fourth to care for sick and no better tweet newborns now, these are just the minimum standard that have been put in place and actually ensure that at least people in L M, especially in the most remote and most neural bases in L M. I actually have the basic minimum of etiquette now to ensure a positive pregnancy outcome next slide next night. Okay. So now focusing on barriers to obstetric care in L M I C S. Well, according to the sustainable development goal, 31 of the targets is actually to reduce global maternal mortality ratio, less than 70 per 100,000 live births by 2023. However, between 2020 20 the global mortality ratio has declined by 34% which is just about one third of the 6.4% and order in debt to actually achieve this S D G. Now, most of this reduction improvement in maternal mortality ratio has actually been from developing countries. Well, this stagnation even decline has actually been in developing countries of which LMS is make a lab trunk. So now they're according to wh you for every maternal date and for every life threatening complication, it's actually a story behind and it's our duty to actually understand the lessons from that story so that we can actually avoid such outcome. Next slide, next slide. So now this is a map map showing um just the burden of maternal mortality ratio as I said earlier for STD tree is expected that by 2030 which have less than 8500 like. But so you're looking at this map if you can see Africa, right? I think in all regions in Africa, there's actually no country that has a maternal mortality should less than 8500 live apart from Egypt. And then you can see countries like Nigeria like Imuran actually having more than 566 per 100,000 like, but that's just to show you the actual distribution of this burden of this maternal debt burden in the world, which is actually been focused on L M I C is like in Africa like the Middle East, next like okay. So now generally when we're talking about barriers, obstetric care, we can actually relate it. Like I said earlier, the Hallmark is actually see them maternal morbidity and maternal that you can relate it um due to to the phases of maternal daily. I'm sure most of us are familiar with the three phases of the leg of maternal deaths. We have the first delay which is this lay in decision to seek care for whichever problem or complication. And then the second delay is actually the delay in identifying and reaching the medical facility. The top delay is actually the delay in received of adequate and appropriate treatment. Now, the there are factors that actually directly or indirectly influence each of these days. I have the social cultural factors which directly affect decisions even recognize and seek here for any obstetrical problem. And then we have a delay uh factors affecting accessibility of facilities which actually has an indirect influence on decision to secure and a direct influence on identifying an itch in the medical facility. And then we have the type of quality of care which also has an indirect influence on delay in decision to seek here and also a direct influence on delay in receiving adequate and appropriate treatment. Next lied. So now for this social economic and uh you know, previous slide for the social economic and cultural factors that actually affect of Tetrick it that might lead to maternal morbidity or mortality. We have the high poverty index. Doctor Lambert has already highlighted us about the burden of how many percentage of people actually below the poverty index and then it has increasing constantly. So now when we with with very poor people, you know, even if you recognize that you have a problem and then you're not thinking of how am I going to afford this care actually delay, you can actually deciding to actually re spend sick for health. Now there's poor health seeking behaviors which is actually a direct correlation to either our social cultural um social cultural factors showing in this environment. Now, there are some people that actually don't believe in going to hospital to seek for help. Even if they have the money, there are people that actually need permission from their spouses to go ask for help. There's people that actually don't believe in actually giving birth in the hospital and then they just do home deliveries be it's whether in hygienic and unhygienic areas. So these poor health can behavior actually contributes significantly to this um maternal morbidity. Now, unhealthy cultural practice, like I said earlier, also decision not with the hospital decision to get better at home decision um practice that you have to take permission from your spouse is the lack of health insurance is actually a very big body because we all know that medical care is actually expensive and just very few can actually pay out of pocket. Now, when you have about less than 10% of the whole population actually accessing health insurance, it's going to pose a big problem because even if you have a problem in it, I have to go to hospital, you can't afford it. There's no health insurance might actually think twice before going to the hospital. Then high levels of unemployed women. Like I said, the whole mark of upset your care is just to give is to ensure safe, modern and a safe baby, right? So now when you have an empowered women, women that really don't have money, women, they need to take permission from spouses or for families to seek for help, even when they have complications, it's like um it's actually a very big problem. And then it actually the day in either seeking here help or even the day and get into the facility. Now, various accessing medical facilities. We have four road network actually for people that actually in the most remote oral areas in these countries. Right. There are some people that they are um wherever they are, there's actually no road networks even need to uh the closes or still next to them. So that cause hospitals and family several kilometers away. And there's actually no road network to actually there. So I actually have have to enter like maybe Keanu actually get to a landed hospital. So it's actually a very big problem in some areas. Now, even if there's a proper road network, transportation is actually a problem because hardly do you get to see 24 hours transportation in some of these places, right? And then if you have a problem in the night and then you are no mobile and then there's no public transportation to take you to the nearest hospital. So it actually put a delay in actually reaching the medical facility. Now, insecurity, we've been having uh increasing rates of insecurity in our environment training, minimize this instability here and there. Now when I was growing up, like even in the middle of the night, it's everywhere where you'll see people walking out in the middle of the night because everywhere was it. But now of recent times, once it's like nine pm, you see everybody in there was nobody really wants to go out at night because of care, fear of so many things kidnapped, I'm robbers. So now if you have a problem in the middle of the night, even if you decide to go to the hospital, right, you might actually think to have. I actually am I said actually leave in the middle of the night with the hospital which will actually indirectly pulse that the league in actually reaching their facility. Now, I've had this proportional distribution of health facilities. It's it has been recommended that according to the W H O that for every 500,000 people, it should be about four facilities that can cater to a group of 500,000 people. But now there are some areas I used to get to see more than 500,000 people in a particular local government and then you're not have really a dissenters facility cater to them. So that means that and then you might not see some urban areas that have like congestion of different caters of health facilities be tertiary, secondary primary health facilities. So there's actually disproportionate distribution of health facilities in some of these areas. And then poor coverage is directly linked to disproportionate decision of health facilities. When you have poor coverage of health facilities across the uh across the region across the country, and it will actually lead to barriers in accessing medical facility next light next night. Okay. So for the quality of care, right, I'll just portray the point that doctor number had made. Well, there's lack of uh adequate number of well trained health professionals because of the high turnover, immigration here and there, even the high turnover among skilled workers, even within the country. Right. There are some, yeah, she's condi a states that have uh that most health workers would like to walk there. And then there are some states that have actually have a high turnover of health workers. So you might have a well trained professionals, but then the numbers might actually be very little. So it's the quality of the Toviaz cannot be compared to areas that actually have a large number of well trained skilled professionals. Discretionary distribution of schoolwork has actually pose a problem because most of the skilled workers, we have actually concentrated in the urban areas. Then the rule remote areas where you actually have these problems where these these obstructive problems are actually predominant. You might get just once killed, health worker in uh covering a large local government of a large region, which is definitely not enough health financing challenges. Now the health finance is not just for the patient as as to the health insurance also health financing. It's a big problem because when you look at the budget, the health budget of some of these lme's and you compared to the health budget of some of the developed countries, you can actually see a very marked difference. Now, there is no health system that can try without adequate health budget to finance the hospitals and all be it's little coming from the government bit coming from the private sectors. So poor health financing to the hospitals actually put uh problems these and then sculpt resources like doctor A Gyn mentioned earlier about the equipment to use. And it can it will surprise that even in some of the tertiary hospitals, some of the basic equipment that are like routine in some developing countries actually like very scarce even in tertiary hospitals and most minimizes next slide. So I'll just talk about some of my personal experiences. Um Last two weeks, I was in Jigawa State and then um let me talk about infrastructure. Yeah. Right. So I was in a hospital that is supposed to be a tertiary hospital and then we had night problems for the two weeks that I was there. So we had emergency cases and then you know that you need to actually operate on this woman and then, you know, have problems like there's no constant life supply and you need to look for back up and then the backup that is not already available. So now there's actually a skilled personality to do whatever needs to be done for the future. But then there's actually an infrastructural problem. Right. So now my experiences incanus, it, I've worked in so many centers in Kaduna sit tertiary secondary hospitals and in each of these places actually have peculiarities while some secondary actually have problems with adequate manpower, adequate skilled personnel because most of them are concentrated in tertiary hospitals. That's a long time. The test trackers told actually they have the skilled manpower. Sometimes even the equipments used to work with is actually a problem. So it's just uh to portrait the point that they're, there needs to be a sign that there needs to be in harmony in the infrastructure, the human resources and then the equipment now to ensure adequate obstetric. Here. Next bike. So um what are the strategies that have been put in place to actually ensure uh adequate obstetric care? So, like I said earlier, the early focus was on infectious diseases. However, just like Doctor E G said, the Lancet Commission and Global Score to introduce a framework of the National Surgical Obstetric anaesthesia planning. And then this framework actually offered a systematic approach, strengthen health system. Now, initially, most of this approach tension health extension in L A, prices were from primary volunteer work from like developed countries or from non non governmental organizations, but then it's actually not sustainable. So that's why this framework actually came to place that to ensure that is a national framework that will ensure uh straightening of health systems in L M is is now this framework actually covered than six domains. However, this framework is still faced with challenges because the national framework post proposed and then each country is actually supposed to modify it based on their own identified needs. But then we still have challenges of developing a framework of implementing the framework. And then even after implementation, calm commitment in the framework itself. And then there's also problems of indicator collections also financing the framework and then regionalization amongst other problems identified next slide. Okay. So now these are the six um these are the six domains for the framework, infrastructure, workforce, service delivery, financing, information management, and governor. So each country's actually supposed to walk towards developing their own framework, identifying their own challenges, I'm putting things in place. So the the focus on on one part of the female for a country might not be where another country might actually focus on depending on their own identified deficit or however, it's important that all of these domains are putting the police are being considered not to ensure global and surgical obstetric anaesthesia. Okay. Okay. Next slide. So this is a map showing some of the country's a few countries that have actually developed and implemented their framework like uh Utopia, Nigeria, Senegal, Tanzania, Zambia, Rwanda. It actually um personalized the framework and actually have implemented yeah, framework ivor we still have challenges of commitment to this framework while countries like Pakistan are still in place of develop India on framework. So next slide. So now apart from that, like I said earlier, the idea of that framework was just to move from a place of voluntary or mission based. Uh So tuck it to like a national framework for so Turkey, however, we cannot, you know the rule that key players and NGOS have played a have played in actually improving obstetric care in Lme's. Yeah, Ngos like the Clinton Health Access initiative. My so part final share governmental organizations like UNICEF U N F P A W H U which have actually uh actually champion campaigns that many targeted and that is targeted to improve human resources and also to ensure adequate equipments also in these regions. And then these NGOS and organizations do not actually working and actually collaborate with ministries of health, with healthcare agencies. Another governmental organizations not to ensure that they actually put things in place. Now, each country had their own peculiarities. So depending on the identified challenge from the country, these these players actually come into play and collaborate with the ministry is not actually tackled that challenges. So personally, like Nigeria, I know that one of these engines actually championed uh programs like train on essential obstetric care trainings on essential in case if abortion you need postpartum contraception and even community based distribution of family planning. Now another strategy one that I actually looked personally because in as much as you want to like help people, you actually have to ensure that every person can actually afford mate. Okay, that's a home, a copy it right. So now the National Health Insurance Act of the National Nigerian National Head Insurance after I was just signed actually has in one of its do mean actually has a rule, it actually considered indigent people, vulnerable people, like under five unemployed people, very elderly people, very poor people. So that in as much as they cannot afford to, to get an insurance scheme, the federal government is actually supposed to like uh sponsor, like paying something into their own insurance, you know, to be able to keep it up for the needs of these indigent people. And then the beautiful part about this National Health Insurance Act now that has been scientist that for default has also be it's the practitioners or be it off to actually turn out is for default that just in order to ensure that this National Health Insurance actually actually uh it's actually successful. So hopefully it does not, I said it doesn't have been implemented, but hopefully in Nigeria it should be implemented. And then I think um we should be able to see at least an improvement in in how people access obstructed care and medical care generally. So generally, um I've just highlighted some of the challenges and barriers that we've identified um towards assessing ulcer to care in L M Icees. And then it's important that courses like this is important that we are aware of these challenges. It's important that we are aware of the strategies that have been put in place. And it's important that we actually bring storm on solutions naturally to help and these LM is actually catch up with developing countries in ensuring and general global obstetric care. So, thank you. Next slide. These are my references. Thank you. Thank you so much. Thank you know, it's super are crazy. We so removed three speakers for, for this second. And unfortunately, our first speaker, uh Doctor Maria causing this true history going to a game. So you might just move on to question and answer session uh for our two speakers. So for a favor and uh representing as you can see as a favor and uh lender if you can just pop your cameras and microphones on again, we can see uh all our audience joining us from all over the world. We're really excited to hear from you. Please let us know if you think questions. Uh uh huh. Okay. I might just take some correctly flashes. You guys don't mind. Um A very thorough talk. Um Thank you very much everyone. Um So my first question is a bit of an imaginary question uh line. So if time my niece were at least this is a question. Um What would be your first priority? You as just as Dr favor, Doctor Lambert, what will be your first party you wanted to come all the efforts into if we get that question? Okay. Yes, I, I had, I had the last part of the question but the first part's I didn't really get this. Can you come in? Uh time power, money resources for, in a problem, let's say we have an imaginary funder that's gonna come. Um and say because you're in the front line, I will trust you and put all my efforts into one thing. So where would, where would you want to meet? Where would you want to sort the um ethnic? Okay. Um Thank you very much John. Uh I think human, human resources is human resources. They would be priority because no matter how much money you have, no matter how much equipment you have, no matter how much instruments you have. If you don't have the manpower to get things done, all those resources, all those equipment would just be a waste. One of the major problems we are facing now, like I said, it's workforce. Um Currently um we we uh when I started residency were about 20 registrars in the department of surgery. Currently, there are just four registry department of surgery. So people are immigrating in their numbers and it's not just here, it's across the board. So human resource is very, very important. Thank you. Okay. So thank you Jan for the question. Um Personally, I think I don't think there's a right or wrong answer for your question because it kind of depends on where you're coming from. Like I said, each region actually have their own popularity, right? Yeah, we actually work in the same century. Doctor 80 and even in my own department actually have that challenge. We have more of senior residents now compared to junior residents, right? Because they have not been like employment for a couple of years to actually augment junior residents that have moved to senior resident sick. But then there are some regions that you cannot be talking about workforce when you don't actually even have like an infrastructure. Like I said, there are some regions I have to travel several kilometers from. So I think the game if you actually have a lot of money to come and if you, I will not just commentary that okay. This is where you that form on its face that actually have to do a grassroots analysis because the problem that you might have in Syria, right is different from a parent that you might have in maybe gabby local government because they don't even have hospitals or they might not have adequate hospice even cater. So even if you do Humenik sources, so where will those people? So I think different regions with your own challenges and that is why that framework was actually built in. If they're supposed to personalize it, find out your own popularity at that point and then know where to channel your energy you're starting from. That's right. Every, every place has their own unique situation even within a big, big country that I think is resonates with all of us in all different places. Um There are a couple of questions here. I'm not sure I'm getting the right hand of mistake, but I will try um, first when I just want to go with Ola Toyo or do or last one said amazing presentation. However, the whole healthcare structure in Nigeria needs needs to be changed as well as active engagement with government for doctor retention and utility insurance. And I think that's what do you think about that, um, that comment, um They say there, there needs to be active engagement with the government or doctor retention and utility of insurance and countries or your thoughts about that, that the idea. Yes. Um Holiday. Oh, thank you very much. You're absolutely right. Um The structures, but when the foundation of the structure has a problem, the entire structure is bound to before tea or eventually collapse. Uh So we have to really dig deep into the roots of this matter and begin to take healthcare seriously. Um The truth of the matter is that our leaders have not really taken healthcare seriously. Um That's why you have uh them traveling to seek healthcare abroad and things. They find that these things that the goods look for outside can be done here. And um like I said, the engagement will not just happen once we are doing it, we are working on it. Additional resident doctors, the Medical Association's, we keep going to them, we keep engaging them using both the currents and the stick approach. And at some point they listen to us, they do some intervention, some point it done. But then the back is definitely going to be one di di uh, we'll continue the engagement on the issue of insurance. Um, I think we've come a long way actually as a 10 years ago or 15 years ago, almost nobody was insured, health wise, everybody was paying out of pocket. But now, um, once your civil servants, you're entitled to health insurance, at least to a certain extent. And then even for those who are not civil servant, those who are not government workers, there is a particular arrangements for them where they can pay um little contributions. And then they also captured um in the health insurance scheme and education also plays a role because some people don't really know about the availability of these insurance packages. So they are just the believing that um nothing is there for them. So it also falls on us as practitioners to reach out to these people and tell them ok, their packages like it's available for you. Um You can pace to be taken as a community into a particular fund. And then when there's a health crisis is a surgeon, surgical crisis and ophthetic problem from that fund, it can be used to take care of you and you don't need to pay out of pockets. Thank you so much Lamberg for highlighting um the positive changes that have already been happening and we hope we'll continue to happen. And improve. Um I just had one quick question for favor and I, I picked up on your presentation about, um, sort of cultural beliefs and uh certain cultural practices that might not be, let's see, that might prevent women from seeking healthcare, uh, you know, in, in labor or in antenatal period. I just wonder if you're aware of any say, innovative ways in which may be, the community has, maybe the secondary care components have sort of reached out into the community because that's where, you know, a lot of things that affect outcomes in secondary care actually start from the community. So are you aware of any innovative ways that maybe we can or maybe that is already going on instead of reaching out to the community to kind of change or challenge these um cultural beliefs? Okay. Thank you Gene for that question. Yeah. So I think I totally missed it in my presentation. So, um you know, like I said, some people actually don't believe in going to the hospital. Some people actually have to take a chance, go to the hospital. So one of the ways in which the government has actually tried to help that is actually to drink traditional birth attendant because there are people that are not skilled, there are no well trained that actually go to this, that in their communities actually take deliveries and then do all sorts. And then by the time the patient is actually coming to the hospital, you know, they have like severe complications. Right. So one of the ways that it, there was actually to train traditional birth attendant, they have been campaign driving workshop to train them just for them to actually have the basic minimum skills, actually be able to conduct a norm mail delivery and then to actually be able to detect any complications that they will know that. Okay. Now, right now there's actually a problem. So because we need to identify a problem before you can even know what to do. So they've been trained, you know that to identify the problem and then appropriate referral systems, right? And then, and that's where one of the, that I think that's one of the things that brought up about the popularity of miserable store in our environment that everybody even in the mail and lose the use of these post online environment. Because like that was one of the quickest of the topics that uh this traditional but attendance could actually used to prevent hospital. You might, this is a major killer of pregnant two main environment, right? So they've been trained on that which are very easy taking a delivery because most of these women actually deliver industrial areas are actually those are very high priority. So they are prone to retry it. To me, they are prone to postpartum hemorrhage. So they maintain to actually administer miSOPROStol. And then even when they're inside the ministry, miss a post All right and announce they're okay. They're still an issue or they still see signs, they don't know how to refer them. And they've actually, and they've actually been linked to like, hospitals closed by, to them. Now, another way they say I was actually involved in this training. There was a couple of years back in which we actually trained community base distributors because there's some, uh, some in some seconds there, there's adversion to use of contraception, right? So, but you know, when you're coming as a health worker, you're just trying to like put the gospel of contraception, another space family and then prevent conditions that comes with two frequent child birds, right? They might not actually listen to you, but then when you're not hearing this from like people in their community, you know, they might tend to give a listening here. So a couple of years back, I think it was championed by Clinton Health Access initiative, community distributors for control. We actually trained at least for the basic conception like barrier methods of contraception and all and even the natural methods of contraception. So that it will go door to though like talk to these women enlighten them, tell them about the importance of contraception that it's not like I'm telling you to give breath for at least space, your Children, right? So these are some of the ways that they try to like reach out to reach out to many industrial areas. Cute we have just one there should, should we just do a little more, but I'm trying to suss out the annals questions but, you know, feel free to jump in if I'm interpreting it wrong. Um So they're now choke, um which we have met in Uganda is a Cameroonian Meniscus. So she was talking about, what about, I suppose in the place of an unmet need discussion. What about the place of law responsibility when there's a def so I think it's talking about medical negligence, the infrastructure of malpractice and error and how and it's insect on your met need. So I suppose um whether it has a place um first and if so what, what we're gonna do about it and how we make it um to suit your met need and that's what I can try cost about sets up. So I suppose that's the question to the speakers. So what your thoughts about that? All right. Thank you, you know, um for, for negligence and practice. Um Yes, it happens. We're not going to deny that it doesn't happen. It happens, but for, for where we are currently, Nigeria have the Medical and Dental Council um that has recently launched a campaign against them negligence and errors. Um In the past, um patient's didn't know their rights. Patient didn't understand that they had the right to certain things. They had the right to be treated. They had the right to refuse treatments. They had the rights to whoever they wanted um to treat them. But then with the passage of the Patient's Rights Act um by the National Assembly, um Patient's have begun, begun to understand that yes, um they have the rights to appropriate and timely treatment. So in the event of event of negligence, um there are bodies that um this can be reported to and addressed and eventually the case will be taken to the Medical and Dental Council of Nigeria where the case to be reviewed and um the offending practitioner um adequately reprimanded. And we've had a lot of cases like that um licenses withdrawn, um license is suspended. And the like, so yes, we've worked on that tremendously and um negligence has just ically reduced. I hope that answers the question. And if I may just add some things about the negligee, I think um you know, for you to even know that there's some as a patient coming from a patient perspective, for a patient actually even know that uh something went wrong. You have to be self aware, right? So like when you have patient's are ignorant, when you have patient's that like have low education, like it's actually going to be difficult for that patient even know that I should, I actually deserve a better care competitive. So I think that's one of the things that actually brings about like the law, like most people just in this environment, actually, we're limited from that prosthetic perspective. So you have a woman that actually a family that actually suffered maternal debt, right? And they just accept like coaching his job, the window of God, it's just meant to happen right now. In most cases, the problem is not actually from the hospital, medical negligence, right? But there's some instances that he has the hospital or the health workers should have done better, especially inserting especially in this hospitals in quotes because there are so many buildings that enabled hospitals that are actually no hospitals, right? So actually in those settings, so they just accept it like that. But I think it continues education. The first thing that a patient need to know there, right? They need to know that it deserves better, right? And then we as health workers actually need to do better. And after that, it's actually going to be quite difficult actually. Um I really don't know how to put it right? Or because in as much as you want to help a patient yet, you know that this patient deserves better, right? For your handicap because probably I need this patient access I C U K. And then at this point time, the center that there's no I C U K. So will you call it negligence kind of? But then it's not on me because I can only do, I can only provide kid extent that I can provide. So how do you actually defend this? So I really don't, there's like a disparity and then they're like blurry lines in order in which you can actually say outside it is negligent is not negligent. But most of the, most of the cases I've actually seen about medical legal issues actually in like well established hospitals. I know that basically because as we have that establishments that, that almost have all standard facilities, almost actually private facilities. So those are the places that I know that. And as you see like a couple of cases and then obviously patient that patronized those places actually have the funds. Actually, we'll learn it actually exposed to the new their rights. And I know this is something that they actually voice that and actually seek for health or justice. Uh mhm. Thank you so much favor and thank you to Lambert's. Well, thank you to the both of you for giving us your time today and for highlighting unmet needs and hopefully, you know, throughout the rest of the course, we'll we'll come up with more ideas, strategies to, to deal with these problems and move forward in a positive manner. Uh I'm going to move straight onto module three, which is about technology designed for low resource settings. And we're very, very pleased to have with us, uh Professor P Coma and June Maudette who's joining us from Kenya believe uh to talk to us about uh this topic. So without further to, I'm going to introduce proper peak comma first, who's a professor of Health Engineering leading the healthcare Metronic Research group at the University of Needs. His research concerns the development of sensing and automation technology with application to address global health challenges with a particular focus on underrepresented groups and conditions. So, and I'm going to uh hand over to pigs first and put your slides on life now. Uh Perfect. Thank you very much Jeanne. Excellent. Can I advancing myself jean or do I need to ask you? You have to ask me to say no problem, no problem at all. Thank you for this. Well, thank you very much for the invitation to speak to you today and I'm really pleased to be joined by June. Hopefully, between the two of us, we'll get some nice kind of complimentary messages out to everyone. Uh So yeah, thank you very much for the invitation. Um Just as a brief background. Um uh my backgrounds in Mecca Tronics, the subject which looks at the integration of electronic computing and mechanical engineering. And during my phd, I was involved in applying that to healthcare. So, first of all, looking at rehabilitation and then I was interested in surgery. Um and more and more, I've kind of grown into the idea of applying these skills to look at the inequity and provision of surgery and surgical technology across the world. So that's the kind of the, the Angula I'm coming from um my presentation today. I will um next slide please. Gene I will share with you three lessons I've learned and just draw on a couple well, three case studies um hopefully to highlight the points um that I'd like to make. Um and then I'll be very interested to kind of hear from you about any questions. So here, I've got this idealized representation of innovation um that can be applied particularly in the healthcare domain. So you start off with a particular challenge and you move through these two phases where you develop ideas, uh you refine them according to kind of user requirements. So this might be your clinical healthcare team, you clearly define the problem, you test it and then suddenly you find yourself with a solution. So we often see diagrams like this which kind of represent and portray this this innovation process that we'd like to go through. Um I guess the message that I'm going to sort of talk to today is that that process is rarely as straightforward as we see here. Um And there's kind of lots of ups and downs. Um And it's important to understand where the challenges might lay uh next slide, please. So the first case study is actually some a project where I started off in surgery and surgical technologies. Uh And this involves the development of a device we call the IAP the intraabdominal platform. So the concept came from a surgeon that we worked with and the idea was to provide a structure that could be used in keyhole surgery. In particular, laproscopic surgery, where you inflate the abdominal cavity with gas and then you use instruments that are inserted through incisions in the abdominal wall to perform surgical operations, particularly things like the liver or the kidneys which lie in the abdominal cavity. So the idea was we could provide a structure with which the surgeons could use um to retract tissues to. So that enables them to kind of expose underlying tissues and, and to conduct their operations. The idea was that it would help reduce the dependence on numbers of assistants who would typically kind of have to do this manually um and give more flexibility to the to the lead surgeon. So we thought it's a wonderful idea. And we set off on a on our way to develop a solution and engineer something next slide please. And we assembled a good team. Um and we went through a whole range of prototypes. So we understood the kind of the size we kind of looked at things like the anatomy and the typical size of the abdominal cavity, the kind of loads we might be having to lift. So how heavy is a liver, how we're going to retract tissues, how we're going to hook them and pin them on this device? And we went through lots of different iterations that you can see there, the design slowly changing over time. And we went all the way from a system that was designed to be reusable to something that was single use. Um We've got various bits of funding along the way. So we're very pleased with how the project was progressing. We had some uh good investment and then we started to have sort of commercial interest in the project, which ultimately is what we'd like as, as engineers, we'd like to design things that can go into the real world and actually have an impact. So next slide, please, we were asked to kind of illustrate the uh the system and how it would be used in real life. So we uh leads have access to a really good anatomy department and we could do categoric simulation. So using cadavers, um in particular ones that have what we call like a soft fix, you can simulate a, a surgical procedure. So that's what you can see here, some images and stills from videos where we use the device uh to retract issues. So we were increasingly pleased with the way it was panning out, we thought, right, we have a system, we've designed it, we think we have some I P here, some intellectual property and we have commercial interests. So it all seems to be going very nicely. And then next slide, please, we produced this final system. Um and you can see here, I've kind of represented um what they sometimes call kind of the hype cycle. So as you go through this period of innovation, you come up with concepts, you rapidly develop kind of prototypes, you test them. And then we found ourselves with of user feedback redesign. So we went through this iterative process, produce the final design. And then at the point where we thought it was all done, actually, the companies that were involved, asked lots more feedback and they asked in particular from a range of surgeons. So we had our key surgeon had been informing the design. But as we got a broader set of opinions coming through, we found that there was a real diversity in surgical opinion. So we designed a system that very well met the needs of perhaps one or two surgeons. Actually, if you looked at, if you took a step back and took that more holistic view, we found that the surgeons in this area tended to do things quite differently in style. And a lot of them didn't really see the same need for a device like this as perhaps our lead champion surgeon are advocate. So we were left in an awkward position where we designed a system that we were very pleased with it worked. But actually, we should have taken this step right at the start to get this broad kind of consensus, a greater understanding of what the clinical need was. We thought we understood it and we had a good viewpoint, but that was limited and it was very focused on one or two individuals. So my lesson here is that it's very important not to design a solution that doesn't have a real clinical need. It's an easy thing to do for us as engineers. If we think we have a particular understanding of a clinical view point, we're not trained as medics, we're not trained as surgeons. So we may think we understand it and go off and do our thing. Um But is it very important for us to kind of keep working closely with clinical uh experts to guide the process and not to rely on just one or two individuals, but to try and get a broad view of uh the clinical case. So that's my first lesson to make sure that you work with a broad range of people and you really understand the clinical need. Okay. Um The second, sorry, the next slide um brings up the second case study. Um So the last one you'll notice is essentially a failure. Um I guess we have to accept our failures and you know, learn from them. And that's absolutely what I did in that project. It was a really good learning opportunity despite the fact that it didn't come to an outcome that we might have anticipated at the start. This is a slightly different narrative, a situation that we nobody in the world wanted to find themselves in. But with the advent of COVID, um we were faced with shortages of respiratory equipment all around the world. So in the UK Um There was a real need for oxygen efficient respiratory support devices. Um We were running out of oxygen in hospitals, in particular when, when they described as those waves, uh the capacity just wasn't within our hospital infrastructure to supply the numbers of patient's that we anticipated. So we worked with the teaching hospitals locally at Leeds. Uh and they were particularly interested in looking at provisions for, for patient's who weren't critically ill but could become. So if they didn't receive some um some support earlier on. And in particular, they were looking at a form of um respiratory support called CPAP. So a continuous positive airway pressure. So uh systems which can uh not act like a ventilator but just provide enough positive pressure to open the lungs and then supplementary oxygen is introduced uh to help that person's health. Next slide, please. So we were interested in developing a system um working closely with the teaching hospitals during the COVID pandemic. Um They had uh identified that there was this a sleep apnea machine which could produced, could be using the CPAP device and it was fairly low cost. So we were looking to see what we could do, what we could engineer. You can see a mapping there where we've kind of worked with the healthcare professionals are teaching hospitals to understand the range of different solutions that are out there with mapped how efficient they are in terms of the use of oxygen and how complex they are. And we saw that there was a real gap there. So the sleep apnea machines that you can see one is called the Nippy, the Nippy three plus um a relatively oxygen efficient, but they are fairly complex. They have a lot of extraneous functionality that they don't really need. So if we need to produce them quickly or at volume, they weren't particularly useful. So what we were trying to address is that bottom quadrant there that you can see uh the resource light section. So again, this is a real case in point that we had to work very, very closely with a range of disciplines. So healthcare professionals, but also a range of technical staff from our teaching hospitals. Uh And we rapidly kind of came to the conclusion that what we could do is develop a system specifically to deliver CPAP and to remove a lot of the unnecessary functionality that was in something like the nippy three, the CPAP sleep Apnea machines. And in doing so, we could make this efficient and also low cost. So we could hopefully react quickly and deliver these systems where they needed to be uh next slide, please. And we were really pleased, we kind of produced this system. Um We were, I guess just behind the curve in the UK because it turns out that the the anticipated kind of peak demand never quite hit the peak that we anticipated. So uh there wasn't a need for these systems in the UK. But we demonstrated in safety tests and working with our clinical partners that these systems could produce equivalent care, uh equivalent performance to CPAP machines like the nippy that I showed you in the previous slide, but a fraction of the cost and they were very, very easy to use. Um So this could have been the end of the story, but actually, we felt that there was really kind of virtue here and we didn't want to just look inwardly. We like to kind of look globally and think, well, how else can this be of use? We can't be the only people who have kind of the need for this kind of system. Um And through some of the links we have at the teaching hospitals were introduced to a fantastic group uh of researchers and clinicians at Mango Hospital in Uganda. Next slide please. And they happen to be interested in looking at respiratory support uh and testing new systems. And we had a long discussion with them about what we could do and how we could collaborate together. And the interesting thing here is that we were able to um run a safety study at Mingo Hospital. So Mingo worked with us and they ran a study with healthy volunteers that Mango Hospital and they were interested to see how this technology might work in their context. Obviously, the context, the environment is very different from the UK the set of resources, they have a different uh even things like the physical environment. So they reported lots of ingress of fine dust that we wouldn't really get in the UK far to dump here. But they would often get kind of dust, things that would be pulled into the fans. So we work with them and their biomedical engineers as well as their clinical teams to understand how this technology might be of use uh in their context. And um then the COVID wave hit uh the Ugandan um sort of nation and it went across and we were uh in this position where actually the team at Mingo had a range of these CPAP devices that we call levy. Um And they were forced to use them in emergency use cases uh with real patient's. So it was a really strange position to be in. But the wonderful thing here is that they're biomedical engineering team um innovated themselves and use these systems. You can see some of them. They're so Rachel was one of the lead engineers, biomedical engineers who really helped kind of innovate, took the the unit system that we had the levee system uh and hooked it up in such a way with their, with their infrastructure, they could actually support and care for people with COVID and they did, they did so successfully throughout their kind of their peak wave until things stabilized again. And this was something that we could never have foreseen. So my message here is that firstly, that understanding the local clinical needs of very important, there's no way that we could have had any idea about those local clinical needs unless we'd worked with Mango. And they were the experts in their particular area in their particular context. So they were able to take a piece of technology and use it in a way that we haven't anticipated because they were flexible uh and they could react to local conditions uh and their local kind of challenges. So it shows you that sometimes you have to be kind of uh you have to show ingenuity, but having that understanding of the local environment is absolutely crucial in doing so. So that's why we need to work not just across disciplines but across uh national borders as well. Because as an engineer from the UK, there's no way I could appreciate the kind of demands and the challenges that they were facing in Uganda. Um So, working across those borders is absolutely fundamental. Okay. Next slide please. And my last case study uh so this looks at a system we've been developing um for gas interplay Shin list laproscopic surgery, which is a bit of a mouthful. So Gill's is the shortening there. And basically, uh Gilles is a technique that's used to allow the use of laproscopic surgery. So, again, this idea of using keyhole surgery techniques in the abdominal cavity. So where you lift the abdominal abdominal wall up to expose the underlying organs. Um And this kind of surgery has a lot of benefits or brings a lot of benefits. Um, in general, for patient's, uh, in contrast to open surgery, which is the alternative, you remove the need for this large incision that would go all the way across the abdominal war. A large incision like that means that you're kind of, your recovery time is quite long because you've got to wait for this large incision to heal. Uh you risk hernia, you risk infections as well. So using a laparoscopic technique with just small incisions, means that the patient can recover much more quickly. You reduce the risk of them having an infection and you enable them to get back out of the hospital uh and into their kind of daily life much more quickly. So that's very relevant for low resource settings, particularly when people need to get home, maybe they have caring responsibilities for their family, maybe they're, you know, earning money and they need to support their family. So they don't want to be laid up in a hospital for a long time. Uh It can also reduce the expense associated with having to stay in hospital for a long time. So there's a number of advantages to the laparoscopic technique in general. Unfortunately, it's quite difficult in terms of the level of resources, it requires to deliver in low resource settings. So one of the things it uses is carbon dioxide gas to lift the abdominal cavity. Now, that can be difficult to uh to either obtain or to ensure that you have a regular supply of that in these low resource settings. It also demands the need for general anesthesia and anaesthetist team to administer that. Again, these are difficult to obtain in some low resource settings or neural areas which are remote from say big hospital centers. So the gas lis approach innovates by um changing a couple of those scenarios. Instead of using gas to lift the abdominal wall, we use a small um I suppose it's like a ring that's inserted through the umbilicus and that mechanically lifts the abdominal wall. So you can imagine it's sort of a ring that's inserted through, it's like a spiral through a small incision in the umbilicus. And then it mechanically lifts the abdominal wall. Uh So because it mechanically lifts it, we don't need the gas. So there's no resource requirement for gas because of this, it also enables you to use a spinal block rather than general anesthesia. So you don't need that. You don't have the cost and the complexity of the general anesthesia. You have the relatively far more simple spinal block, which can be administered by a lead surgeon. So as a whole is a technique which lends itself to low resource or neural environments very very well. So our involvement came next slide please. In that the equipment used to perform this surgery, we need a lift device. So essentially a bit like a retractor. So it can hold this, um, this disk, this coil that's inserted through the umbilicus, uh, and then it can be anchored onto the surgical bed and then used to physically lift the abdominal wall. The challenge was that, um, the existing equipment used to deliver that had a number of limitations. It evolved over time so it could do its job, but it was very heavy, it was difficult to clean and sterilize to modern standards. Um And it's quite complex to keep it, it was very vulnerable. Um in case of any damage it was difficult to maintain. So we stepped in here working with a team um of product designers, engineers, surgeons from the UK and from Northeast India, uh identifying the need for a kind of a modern fit for purpose piece of equipment um that met modern standards. Um And we went, we went away and we went to engineer a new device for Augusta surgery. Uh And so the first part you can see here is that we took a long time, given the lessons I've explained before, to really get a deep understanding of the need and the context. Um So really understanding the process of gas this surgery, the context in which it's used. So what kind of hospital environments would this be deployed in and what were the needs of the surgeons and the patient's in these type of scenarios next slide, please. So that took quite a long time, but it was really, really valuable. And what we gained from that was a close group of uh surgeons and not just one surgeon as I've explained before. Actually, a team of surgeons who we work with and we went through this innovation process, we often sort of say it's quite an iterative process. So formally, we might call this participatory design, But basically, we worked closely together with those experts surgeons, uh not just at the start, but actually all the way through that process. So we produced a series of prototypes which got increasingly more complex, increasingly more realistic until we got to the point where as you can see in the top right, we produced a system that could be used in cat of Eric studies and we did that in India. So we rapidly went through this process. We used a process called frugal innovation. So we tried to keep the system as simple as possible. Uh removing this sort of complexity that might kind of make it more complex, uh more expensive or more challenging to design or to commercialize. We kept things simple as they could be once we had that understanding. But the participatory design aspect meant that those surgeons kept us on track when we tried to make things too simple or missed this sort of the right functionality. They brought us back on track and that was a really important part of the process. Uh Next slide, please, you can see there that we went through a series of iterations, five main kind of loops, five main iterations until we got to the point where we had a really nice candidate system. Uh And at that point, we had to work with another set of partners. So we've had uh sort of designers and engineers, we've had clinicians and surgeons and healthcare practitioners. And now it's really important to work with industry experts because we felt we had a system that could be commercialized. So we worked with a manufacturing partner called Excel. Oh, based in India, they make orthopedics orthopedic equipment and they have lots of expertise in this sort of domain in terms of commercializing equipment. Um So we worked really closely with them to get from the prototype that we had to a commercial version, which had regulatory support. Next slide please. And that enabled us to produce a system in a commercial way which could be used by surgeons. So we could only produce a single prototype somewhere like the University of Leeds. And we couldn't produce that in a way that would be possible for surgeons to use. Uh We wouldn't be able to get the regulatory approval. A commercial company has all the right standards and can go through the regulatory process uh and is able to do that. So it's that bridge that's really important in making our work more accessible uh and lots of expertise fed into that process. So there was clinical and surgical know how as well as the engineering kind of testing that goes into that. So all of those aspects kind of combined. Uh and we tested this uh and then the surgeons went uh and you can see a number of snapshots here of them using it inr oral uh parts of India in the northeast of India. And from that point, I'm just conscious of time. Next slide, please, we've been working with that same team to translate the work and translate the use of the system from parts of India to Sub Saharan Africa and through some of our network through our contacts, uh we've heard increasingly that Sub Saharan Africa, uh in particular Uganda and Kenya, there was real opportunity for this kind of a surgical approach and the need for this kind of technology to support advances in the provision of surgery. In actual fact, the map that you can see there is color coded is shaded according to um the provision of surgery around the world. So lighter pink is higher levels of provision, darker areas, sort of darker reds are where there is less provision or less access to surgery. So you can see it's really kind of fundamental important to work in these areas. Uh Next slide, please. So the nice message here is that we then have been working with those same uh surgeons uh kind of clinical champions if you like. Um And they've run workshops in different parts of the world in Kenya. And you can see shops here from Uganda in Kabbalah. So it's in the south west of Uganda. Uh They've been running workshops to showcase the technology and the approach of gas list surgery. Um two people from different hospitals uh and to, to kind of highlight how innovation can then be translated to these different regions. Next slide, please. So I think the important message here is that it's really important to work together. Uh and the virtues of doing that are that your, you build a team which enables you to kind of go through this long journey. Uh And there's lots of kind of challenges along the way, but you need these different skill sets and those same people that have helped us understand the problem. Initially, you can see in the top left, there's uh Doctor Bijou who practices in Northeast India. Um He has now gone on to be an advocate for training in gas list surgery and help people from different parts of the world to gain those skills and to gain the benefits of that innovation. So working with those communities, you actually build skills and expertise that translate as well as the actual technical operators itself. So uh I can't underest, I can't emphasize enough the importance of that kind of collegiate collaborative working together. Um And I think that's probably just brings me to the last slide, a series of kind of thoughts there just in conclusion. But those three lessons to kind of underline um that we need to work together that initiatives like this, actually, the fact that you're still here listening to this is fantastic because we need to work across disciplines uh as teams and we need to work internationally as well. So not just within one country, but we want to see innovation across different international borders because that's the only way we can kind of really fully understand the challenges of the healthcare challenges and address them in ways which are appropriate to the local context. Um I think it also empowers people as you've seen their people working in healthcare um can and should get involved in innovation because their knowledge is absolutely fundamental to doing so. Uh So I won't go on too long. Um Just to say many, many thanks and I look forward to your questions. Thank you so much, Pete. And that was really, really inspiring talk and thank you so much also for share ing with so much honesty about the learning points that you've gained from really all all the many projects that we've taken on and we'll have questions for you uh later. But uh straighten to introducing June now, so we have June May data with us. June is an enthusi fantastic and dynamic engineer researcher and senior lecturer with over 16 years of experience in biomedical engineering training and research doctor, moderate's specialty is in biomechanics and she's the current coordinator of biomedical engineering at the School of Engineering and Technology in Kenya to university. So over to you uh June on gambling your slides up in two tickets. Thank you so much in um are they on? So as you've introduced, I'm June Maudette. I am uh biomedical engineering uh engineer who's very enthusiastic. I'm trying to see my slides. I think I'm still on a different view. Perfect. Um And I'm very passionate about combining engineering and health sense is just as Peter's just said because that's a gap we noticed. And yes, I started with biomechanics and biomechanics. It's looking at the body as a machine and you can't do that without involving the people who treat the body and the people who can fix the body. So it's very key. So uh we have several case studies that I wanted to look at, but I thought a new people come with all his innovations. So I thought I'd do context based in Kenya. I'll highlight some innovations next light. So biomedical engineering, it's very new in the Kenyan context. We started it as a as a degree course in 2013. Uh So far, we, there are 23 universities in the whole of Kenya who offer it. And we are as we go on, we're learning. And I would like to just give you a path we took, we developed a ventilator during the COVID 19 period. Instead of me talking about the ventilator, I want to tell you about the lessons we learned because we reiterated so many times because we do not understand our own context when it comes to medical devices. So I'm going to give you a snippet of the lessons we learned. And some of the examples from the lessons in London says how to overcome some of the challenges. Next slide, please. So we cannot talk about designing those states starting on the regulations and standards. If you want to describe that context, if you don't understand how to develop sustainable technologies, we have to understand how it is. So in the beginning of 2020 most of the systems in the area sub Saharan Africa were using the AU process because it was already established, did not require any specification for ventilators, we did not have any. So we had to develop them for our context. We had to understand what the the device was to do. For example, for the ventilator, we we drew upon the medical device directive which is in the eu but there are things that they had specifically, for example, they were not specific about power and some of our ventilators sometimes can't work with the with our power fluctuations. So Kenya developed specifications for our contexts, how it can be classified, how it can be applied so that it can understand withstand the dust in the power uh fluctuations and for the market and different manufacturers in the area. Do we have manufacturers in the region? At that time we were not importing. So how are we going to regulate how a manufacturing center for medical device looks like? Uh next slide, please. Sorry, I'm looking at two slaves. Um The aspect it must demonstrate to operate effectively and safely. It has a checklist that has to be fulfilled with all medical devices, but our checklists could not be the same as other contexts. The responsibility must be determined. Is it the manufacturer or is it the user or is it the designer? We have to think about how this device is going to be reviewed. And remember, we've never actually had a medical device that has gone to market in the country, designed, made, manufactured in country. So we're learning these compliance had to be important from the time the product specification is done to the time it goes to market next slide. So yes, we did use standards. We, we're not going to reinvent the will. Of course, we had ice a standards that we looked at to think about the quality of the systems, risk management and other various guidelines for clinical investigations. We also thought about uh the electrical components, the sterility of the components. And of course, the it was a device that is going to be important in the body. So we were like, okay, it's not only one uh standard, we're not only going to look at what the Kenya context is. We're going to look at how safe it is for the body. So we were learning as engineers. As I said, we came, we made a ventilator in less than a week, but we do not look at standards. We didn't look at regulated Buddhists and we do not look at the user, which is very, very key. So we had to start the process again because we had uh Bureau of Standards next slide, please. Uh huh. Coming for certification. They started asking us the question that the ISIS standards want. So they were like, where are the boys, the conformity matrix? They're like, oh, we have to do that. We went back to the drain book, always the risk management plan. We're like, we didn't think of that. We had to go back to the drain both. So we had all these doses that we had not thought about and it was important for us to do it in the beginning. And this also informed the Bureau of Standards how they can address when a medical device goes to market. Next slide, please. So as I informed, we used the common international standard. I, so when it comes to medical devices and it was interesting to start and dig into that rather than just teach it, but actually use it on a device that we have designed. Next slide, please. We had specifications that as I said, the Kenya, our Kenya Bureau of Standards used all the information the land from our findings to come up with a critical care uh specification which we advised. And they also learned from us, which was actually quite brilliant because it brought about quality specialists. And what about standard and regulatory bodies? It put about all the engineers, all the users, the anesthesiologist come together in a room and actually start discussion of how we can get a medical device to market in our region. Next slide please, this is just showing that we have a another board which is called the pharmacy and poisons board. And it has guidelines on conducting critical clinical trials, but they have only conducted trials on drugs, never on devices. So this is also knew we we helped inform as academia, what are the steps that need to be taken? For example, for drugs, they have to have a placebo for a device, you cannot have a placebo over a ventilator. For example, how do you advise that? And how do you go ahead, how do you enter different phases because they have strict guidelines on different phases. So we helped inform that we are different visits. I want to go into details with this to the next slide and all the visits were informed by different aspects that they've seen in other devices but never from medical devices. So we're learning together, for example, as I said, we had to use uh standards for the sterilization, we had to have manuals in place, we had to have protocols in place. We had to have good manufacturing in place. Next slide, we have to look at the electrical safety and this was one of the toughest stages because as I said, we just invented and we thought we'd just go to market, but it had to pass certain safety guidelines and this was informed by the standards as well. Next slide please. And finally, this ventilator had to be operational. We have to look at calibration, we have to look at different confirmations that it had to go through. Not because we're thinking about the safety of this patient, have to think about labeling different interfaces that are going to be used. And this really informed us as academia as a nation, as a country and all the all the regulations and standards bodies on how we can approach the the learnings of a medical device development. Next slide. This is just reiterating the different uh device to see how we needed. We needed technical features like the drawing and the composition. We need the risk management, we needed bench testing, we needed to get clinical data. So it was not just about making uh something in the lab and taking it to market had to go through different processes. Next slide please. As I said, we have to look at clinical trial, this is going to be an invasive device, what is needed for this protocol to be discovered when you get to do the protocol and learn how a protocol for devices conducted. We need to submit this to an ethical review committee. We need to submit this to the poison pharmacy and poisons board in the country for a review. And we need to get clear clarification to that and to the hospital to approve. So we learned through this process and by the time we got to this process, we had so many reiterations, we wish we started this from the beginning. So this is the journey we took as Kenya to understand the medical device landscape. And we got to a point where we had um an idea of what steps you can take. And we developed different groups, different multidiscipline in groups. So we can we knew how to do the documentation from the beginning, we knew how to understand what standards to purchase or to access from the beginning. So from this information, when we started any device development, we knew what steps to follow. So I can give you an example of some of the devices that we've gone through next slide, please. So we have the uh and a need that was provided to us. We need an affordable alternative to the whole laparoscopy procedure. Pete has shown you how you can have gas lis procedure. So we were asked, okay, can we do we have to have the whole light system that is very expensive to be used. Can we simplify it, use the Gas Tlhis kit and also use the a simple one. So we had this discussion with the users from the beginning, we put a team together from the beginning, what is needed. We started documentation from the beginning even when we still had the drawings. So the components that were chosen were specific for medical devices. The imaging that was received was what we needed. So it did not take as long for us to actually go to the point of having a prototype that is working next slide, please. So I want, I want to go through all this, but we developed a device that can actually be showcased and um you know, given to the users not exactly used on the patient, but we have a device that can actually presented and demonstrated and we get reiterations from them. So that process people saying where you're okay, they'll tell you to address, remove this, you change the iteration to fit what the user needs next slide, please. So that's just my team working in the lab. It's not a medical device, certified lab, but it's a start. Next leg, please. You can go to the next innovation and it's nothing time. Um Next. Yes. So we have another device that I can. I'm very proud of. It's a phototherapy box. It's not surgical but it's used in the newborn unit next lead. So we had a team from the uh from the lab, put together a design that okay. The problem we're solving is we have very big phototherapy units that are made abroad. And when they come here, we have very many babies that need to use. And most of the hospitals can only afford one or two and maybe you have 60 babies. So he came up with a design where you have the same, the um phototherapy lysed occupies the same space but can take up to three babies without passing infection across each other. So this is a problem that was found by the user. The user said we have this problem. I don't want all my babies to be in one unit, but I have to, should I ignore one baby and put the other one? How do I choose? So this was a design that actually came from the user next slide. So we managed to prototype it and we, we took it to the user and the way they said it's something that can work because actually the light was not coming from above, it was from, from the side. So each component, each uh each of the three was getting the enough flights that are needed. So our next step is to see how we can get this done. And all the out out outputs that we use the properties of the material, all the frequency that we needed. The wavelength of the lives that is needed was was able to be achieved. Next slide, please. So another one is a suction machine. Next slide. So one of the students went to the hospital as well and they discovered that most suction machines in the lab are not uh have a backlog backlash. So when the suction happens that the liquid goes back and spoils the mechanics within the machine and there was not affordable unit that was in the market. So they developed a device, it's still in early stages. So this is just showing one that has been put together in the lab. So the the simulations it done, this was put in the lab and it was able to stop the process. If there's fluid passing through a a certain place, then it stops the process and the fluid does not go back to the uh secretary and damage the machine. So this is another thing that the user came to us and said we have this issue. How can we mend it next slide, almost done. Another one is the medical gases monitor with the remote alerts. Again, the student went to the hospital and found that some of these, the gas is finished before uh the the information reaches what whatever it is, the gases are normally placed outside sometimes a distance from where they're being used and these manifolds that go through the whole hospital. So how can we know that the cylinder is almost halfway or almost done or damaged? So he came up with an I O T based um up and device that is attached to the manifold that can be able to real time monitor how much gas is in the cylinders when it's time to change. And if there's any fluctuation in pressure, which is a problem that was discovered again, we we got this problem from the users and return it to the user and we're trying to retreat it to fit what they suggested. So next slide, we can skip this one. Um The same time, I want to emphasize on the challenges and limitations. So next slide, this thank you. Uh for us, we found that calibration equipment was very hard to get and sometimes very expensive. And that is something that would be nice if it was easier to get because we are doing the testing before it goes to the market. Um sometimes getting parts in country to complete. A prototype was quite difficult and sometimes the manufacturers are, you know, if you, they don't want, you can't buy one piece, they want you to buy 30 pieces and sometimes for a medical device prototyping, that's not possible. Approvals for regulatory bodies sometimes are in silos and they take too long because there's a learning process, especially when it comes to devices. It was important to have a dedicated team to test and go through the process. And sometimes you either get the team starting the beginning and they drop out because the process takes too long or sometimes that you get a new team member coming in and changes the whole process. So it takes you back. It's very important to have that from the beginning. It's good to have space and capacity to prototype. And of course, this means funding next slide you can go to next uh next idea again, reiterating what it says. Multidisciplinary team is very key, um document documentation from the beginning is very key. Sometimes it may take you back and approvals, take a long time to be patient and not quick to go to market. Also uh saying what you said, you don't think you're going to go on the whole thing and that enabling space is very important. Uh Sorry, it was the end. I've gone fast. But I think my most important key message is the context, the challenges we have and how we've come to overcome them and learn some of the lessons. And I would love to collaborate with anyone to get insights from the uh from uh everyone out there and to understand how we can improve or even how we can add to what we have. Thank you so much. Then go to the final slide. It has made contact details. Thank you. Thank you so much. Thank you. Thank you June and thank you people for really inspiring uh talks on tech technology in biomedical engineering and how it really affects our clinical work. So to our audience, keep the questions coming, I'm just gonna start off our kill. Any, I have a question uh really to peace and do uh you talked a lot about on uh collaborations working across a multidisciplinary team and really for peace, you have even highlighted so multinational team's working together. I just wondered if you had any challenges or any uh insight that you, you uh any problems that you experience with, with sort sustaining these relationships because oftentimes, you know, clinical demands can get in the way of things and you know, affect these partnerships. What, what's your experience with that? Um I can go quickly June and then passed to you if you. Um So maybe um so one interesting point here is, is the, the last project I mentioned um with the gas less surgery, we were fortunate to be able to, to travel in person to India uh and to meet a group of surgeons. Um There was some funding that enabled us to do that. And so we all got together and met face to face and I think where possible, there is nothing better because you, you just, you start to understand people on a, you know, you make those kind of personal connections. And that meant that subsequently, when we had to do things remotely, actually, the pandemic meant that we did a lot of the development work during some of the lockdown periods. But because we established that good rapport, that good working relationship previously that really helped. So we kind of had that good working relationship to build on and to, uh and to use, I guess that's not always the, you know, that's not always possible. And actually the, the project we did in Mango, uh with, in Uganda, in, with Mango Hospital, I've never been and we as a team couldn't travel because of COVID and that just relied on being flexible. And I think there is perhaps one of the things that I've taken from this that as an academic, I'm often set up my computer, typing away marking reports or whatever. And that's not the reality for a lot of people, particularly working in healthcare where they might be very busy day today. So email might not be the best communication or setting up multiple teams meetings might not be best. And actually some of the the most useful communication we've had there is via say whatsapp or sort of much more agile communication platform. So I think it, it's kind of responding to the needs of the overall team and being reactive to that. So you can't impose, this is the way we do it. You have to sort of work as a team to find methods that work for you. So that that would be some of my kind of um yeah, where possible meet in person but otherwise be flexible and be reactive. Uh Thank you Jean for me. I think Peter's mentioned most things. Um And for me, I think one thing that I found is you need champions, champions that are actually passionate about what you're doing. And sometimes the champions come from uh in person meetings or even just responding to an email or inviting them to a seminar, they feel like they're part of the journey, part of the process. And yeah, communication is also very key. Um I think if 11 person communicate on the other one doesn't and vice versa. So you have to find a way that you can both communicate. Um not only uh stick in your lane, but try and find out how best to communicate with them and that move things along. And also just to bring people up that uh you know, our students or the interested in research and are interested in innovation and, you know, just trying to get them to um uh stay in your dream or focus on your dream and then they'll bring more people on and they also have friends in other different discipline, they're different countries and that also helps some of us are stuck in our ways, but they come with a, with a nice picture. Thank you. Um That's a great talk for both of you. Thank you so much. Um I was just monitoring the chat box um around very good feedback. Um Actually Anele me and jean were both were all actually in Kabbalah. So next door to us, when we were seeing what was happening in the Gills workshop and we had some joint playing and hearing from prop Nana Raj. So it's, it's really hum to see how things are going. So, thank you so much, uh Emmanuel um, made a comment and I think that was directed June and all round compliments again is that, uh saying the first steps are always the hardest. Thank you for breaking the ground and setting the pace in Sub Saharan Africa. We seldom think about our uh innovation of our own technologies but happy, overly dependent on developed countries so well done for setting the pace and setting the ground. Um That's wonderful. And I must say, um I haven't seen what you guys have been doing. I don't know where you find your tenacity and your pash in for your job. I was just like all hats off to you all in uh pursuing and pushing and keep sending those envelopes out and that's, that's all around humbling experience. Um Any other questions on the audience one minute left? Um And we really take it. Sorry, go on there. Oh, I was about to be cheeky as well because um any steep peaks about what your current projects are and how we can help is basically um my, my question um as we have got quite an international multi disciplinary audience and that was the strength of gas on. So anything, any, anything you're working on it, you need someone at once a term again, participatory engagement. Uh We're more than happy to give you uh whatever we think about things. So, yeah, any peaks of what's happening? Uh Interestingly. So we, I met June recently, we went to the uh Isaac's conference in Kenya. Uh um And that was really fantastic to get some good discussion's going. Um um One of the areas that I think a few people have been working on is around the area of surgery, um visualization, light sources. Um So camera systems for laproscopy, uh I guess not limited to laproscopy, but typically they're kind of expensive and um difficult to maintain. Um So I know June um some of her students presented some fantastic work at the conference and a group from Delph that we've worked with are also interested in this area and we have also had interest in this area because it kind of goes is quite complimentary to the lift device. Um So we had some, I think broad discussion between us all that it would be nice to collaborate. So hopefully looking ahead, we can all kind of get together. Um I guess the space is kind of there for us to hopefully work together and see what we can do in this area. Mhm Yes. Um The laparoscopy one is something that's key for me. And because the thing is we've got students who are interested, mixed with stuff mixed with like it wasn't all a project that the student will abandon. So it's something that will go on. They met with Pete, they met with the team from Delft and they met a team from India whose also trying to do the same thing. So this whole surgical area, I think it's something that we can definitely collaborate. Um as, as I surely we have different student projects where we can definitely collaborate. Um We have two dental just do projects, abandon them because they've graduated. So they don't need to make money or anything. So that collaboration would, would be very key. Like I try and get them to present their work, try to see if we can get some funds. Okay. Let's go for conference. So they feel like they're, they're someone is listening to their work and um something like that, a collaboration even just, you know, publishing or even a shelter from feet. Uh It always works. Um And yes, so just ideas on getting our students motivated because they are very smart, but they, they're all silent. I don't know why uh the move that along would be amazing. Amazing. You're giving them the less. So hopefully we'll see more and more of them. Um That's wonderful. Gene, your tricky question. Uh I'm just raising one more question, have given the opportunity to the audience. I'm gonna get my question and it's a question uh two piece really about the guest list, laproscopy. Um I think we have a lot to learn, you know, in terms of building uh low costs, uh equipment and, and, and uh sort of in the context of conservation. I just wonder, you know, um in, in, in the UK context, what, what is the take up of guess less laproscopy as? Uh it's a really interesting point and I think, um here often it's seen as maybe a bridge. So I think if, if full gas laproscopy could be offered, um people probably wouldn't adopt gas lists because although it can produce kind of comparable surgical views in a single quadrant, um if you want to do sort of more complex procedures, um then I think there are some challenges. So it's, it's particularly suited to, I suppose more routine procedures like removing the gallbladder. So luck Kohli's and things like diagnostic laproscopy as well. So it's very good for those kind of core um procedures. Um I think there is sort of more broadly something to learn though about that kind of, it shows that you can kind of take something which is a, a routine procedure. And so the UK Agus laproscopy, uh laproscopic operation and the resource uses huge. Um We did a green surgery challenge and looked at all of the the resources that are used and often now we use single use instruments in the UK and it's incredibly wasteful. So from an environmental uh and a cost perspective, moving away from that and looking critically at the kind of the equipment that we use, I think is really important. So there's lots of initiatives, I think there's lots of overlap here to think about global health or better provision of surgical instrumentation worldwide and also environmental sustainability. Because the to kind of go hand in hand if you're designing responsible reusable equipment, uh it should also be inherently uh you know, environmentally sustainable as well. So I think there is some good lessons and ways that we can maybe harness some of the, obviously the trend certainly in the UK is to fund lots of areas of sustainability. Um So if we can kind of piggyback off that hopefully we might be able to benefit um for the global community. So I, I don't know if I really answered your question. Actually, I think I went off on a tangent but really answered it. I, I think there's so much bidirectional learning really and things that we can pick up in terms of reducing weight stage, you know, keeping an eye out on environmental sustainability because when we're not, we're not just looking after the patient's in front of us. We are looking after the patient's in the future as well. Yes, absolutely. Thank you so much. Is there anything else you would like to add Julian Pete? I'm just thankful that I've come, I've got to meet you. I feel like I know you, but I'm happy that uh this has happened and I'm waiting for more collaborations and uh contacts from anyone that is interested? I'm available. Thank you. Yeah, just to echo that. So I think it's a great message that as a um it's a really good uh gas stock is great and just that's the place where ideas and new innovations come from. So um engineers gonna do things if we understand new challenges. So, yeah, keep the ideas and communication open. Thank you so much to June and we thank you so much for your precious time giving us uh very great talk. Um So to close this session, I just like to thank everyone again and thank you, put that on speakers, Lember E G. Uh And hopefully you'll see Maria in a catch up content. Uh We'll recall later on, just have to remind all our audience that could be a certificate of attendance. You can fill out our feedback and you'd be able to get certificate attendance and all of this talk that we've done today will be recorded and again, uploaded as catch up content. Hope you've all enjoyed very inspiring two hours. Hopefully, lots of new ideas to come in the upcoming through your innovations schools, of course. And if you have any questions, people in touch uh guess off and we can put you in touch with us because so thank you, everyone again. Let's say goodbye now. We'll see you at our next event. Thank you. All right.