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Summary

This on-demand teaching session explores the neglected topic of Obstetric Fistula, aiming to raise awareness and action towards differing preventive strategies. This condition affects a significant number of women, particularly in sub-Saharan Africa, and is primarily caused by poor access to suitable healthcare. The session promises to explore the topic in various unique ways, starting with a PowerPoint presentation and followed by the launch of a novel and a film related to Obstetric Fistula. A panel conversation and Q&A will follow where attendees can ask their questions. An ideal session for anyone involved with or interested in women's health or obstetrics.

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Description

We are excited to bring the Global Women’s Research Society Conference to Scotland for the first time, to be hosted in beautiful Edinburgh on 23rd and 24th September 2024.

Established over 10 years ago, the Global Women’s Health Research Society (GLOW) was initially established to facilitate education and networking among researchers based in the UK who were conducting work on reproductive, maternal and newborn health and stillbirths in low-resource settings. Over the years, this community has expanded to include those based outside the UK and to include both topics related to women’s broader health and of relevance to high-income settings.

The 2024 GLOW conference, supported by the Medical Research Council, will focus on the effects of the ongoing global crises of climate change, infectious diseases, mental health, and conflict and migration on women’s and newborn health. We will particularly highlight successful innovation and partnerships that are ‘rising to the challenge’ and meeting these crises head-on.

We recognise that not all pregnancies are planned or welcome, not all people needing obstetric or gynaecological care identify as women and that reproductive health encompasses the full life course. Researchers and clinicians in clinical, epidemiological and social science spheres all have relevant and important insights to share and all are welcome to come together at GLOW.

Conference Venue: McEwan Hall, The University of Edinburgh, Bristo Square, Edinburgh, EH8 9AG

http://www.glowconference.org/directions.html

Learning objectives

  1. Understand the causes, burden, and implications of obstetric fistula for affected women both medically and socially.
  2. Recognize the three areas of delay that contribute to the development of obstetric fistula: decision-making delay, transportation delay, and hospital-specific delay.
  3. Become familiar with the different types and levels of severity of obstetric fistula and develop skills necessary for their management, including surgical techniques like the marsh flap, Singapore flap and others.
  4. Identify the associated obstetric complications such as ureteric injuries and fourth-degree tears and their management.
  5. Recognize the importance of collaborative multispecialty approach towards understanding and managing obstetric fistula, involving gynecology, urology, colorectal specialties and more.
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Computer generated transcript

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

Welcome everybody. I think we're going to make a start. This is the last but not least formal session of the day. You know, there some other activities happening afterwards which we'll come back to. So this session is focused on a topic. I think a lot of us would agree is one that does need to have much more attention and for which there needs to be much more rising as it were to give more, more action. And that is the subject of obstetric fistula. And there's lots of reasons why this subject has been neglected. I'm sure some of this will crop up today in the conversation in the panel conversation. And also there are some worrying trends with obstetric fistula today with increasing proportion that are iatrogenic in origin. So this is a subject that many of us who work in obstetrics know about. Some will have worked on and some will have been involved in various rehabilitation and prevention programs. So it is most definitely a subject that we would like to obstetric fistula. There's opportunity for primary prevention and opportunity for secondary prevention through treatment. And the fundamental issue is one of poor access and a lot of it goes back to issues of poor access, whether it's geographical or financial or issues to do with timing or other issues that explain poor access. So, in the next hour and we're starting a little bit late, but we'll try and catch up. We have a veritable feast and I think I've said that correctly. A veritable feast of modalities. We're going to talk about this subject. Not in the usual way. We're going to start perhaps with the usual way, which is a powerpoint presentation, but we're then going to move on and we're then going to talk about the launch of a book, a novel about the topic of obstetric fist. And then we're going to see a film, then we're going to have a wonderful panel conversation and then hopefully there'll be time for questions from the floor. So we're using, we're being consistent with a theme of this conference which is to try and approach some of these sensitive subjects in a variety of different ways, not just in our usual, our usual, let's publish a paper. So I think on that note, I'm going to introduce all the panel members when we start the panel conversation, but there's a few bits that we're going to cover before that. And at that point, I'll invite, invite the panel up, but to start with, I want to introduce what I suppose is it become a new friend and colleague we met about a year ago under unusual circumstances which I'm not going to go into. But I'd like to introduce Dr very colleague who will give her, who has devoted a lot of her work and her life to issues around obstetric fistula. So very is a colorectal surgeon. I probably believe in this room. The only colorectal surgeon we have amongst welcome, welcome who works here in NHS Lothian in Edinburgh and she has been doing teaching and assisting and undertaking childbirth injury repair, particularly in Uganda since 2001. So, a long history of work in this topic, not recent at all. And she's worked for MSF and she's worked for set and freedom from fistula and has actually set up a charity herself called the Uganda Childbirth Injury Fund. And the book proceeds from the book all go towards that fund. So a great thing. So I think varies unusual for a number of reasons, not the least of which she's just published this novel. And I think I heard it described as a romantic novel on Friday, which is called The Bright Fabric Of Life. And this will be available for anyone who would like to purchase a copy afterwards and signed by very as well. So that will be available at the end of the room and not to be enough for a book to be enough, has also gone on to work with colleagues to produce a film about the book and the film is a dance. It's involved choreographers and fantastic creative artists will portray in what's called a screen dance, an aspect of the book and very will say a little bit more about this. So I'd like to start off by inviting to give us an introduction to the burden or an overview of obstetric fistula that we familiar to some of you and not others. We are a conference that let's not call it medical is about women's health. So of course, some slides will not familiar to some of you. So I'm not going to say it's a health warning. This is the reality of the subject in which we work and I know very well run through those slides very sensitively. So we'll have the powerpoint presentation and then we'll talk a little bit about the novel and then show the film. So I hope that's OK. So very over to you. Thank you very much and thank you for letting me come and talk to you as a colorectal surgeon. I know I'm a bit out of place, but hopefully you can forgive that and move on. I'm just going to talk a bit about fistula, the vesicovaginal fistula in particular, which is probably familiar to most people, but I know there's quite a few pediatricians around. So that might be kind of long distant past memory. So we'll just talk about a bit given overview, huge problem obviously in mostly in Sub Saharan Africa. Um Currently and the main cause being ischemic necrosis of maternal tissues being caught between the baby's head and the mother's pelvis. Um The, the way out of that, um if there's no medical care is either the mother dies or the baby dies. And when the baby has uh unfortunately died, the skull bones collapse and the mother is able to deliver. But by then, and by then means a good 24 48 hours, probably in excruciating pain. The woman will have a hole between her vagina and bladder or, and or bowel. Um This is a disaster for her and we'll talk about that in two secs. There are probably three areas of delay. I think that this has often been repeated delay in deciding that there's a problem delay in getting somewhere because you live miles away and there's no transport and then delay in the hospital. And sometimes there's an implication that that's a decision making problem, but often it's to do with supplies, fuel generators, not working. There's no doctor available. Lots of issues. Um, under underlying all these issues obviously is poverty and poverty is the main problem that's driving all this. It's not cultural, it is poverty and this is the result. So this is us sorry about the pictures. Hope you don't mind. This is as looking up the vagina and that black hole is straight into the bladder. So you can imagine that there's just an unrelenting flow of urine coming from that, which would be very difficult to manage in this society. But in a place where there's a little in the way of sanitation facilities in your home and there's no disposable pads or anything like that. It's just impossible. And these women are in all sorts of bother. So they've lost their baby, terribly bereaved and they've lost more than that though. They've lost their role because most of them, their main role in life has been to be a wife and a mother. And that's a huge thing of standing in many of these many cultures that have this problem. So it's a very big loss. Um And they're really left with nothing. Often, their husband or partner will take another wife because they need to have Children to keep the social structure going. And this girl has been unable to produce one is now surrounded by this fug of ammonia and is wet all the time. Can't be taken anywhere. So these poor girls are just left and often they are uh young, is their first baby, their teenagers, it's a lifetime of loneliness. So can we fix it? Yes. And not always, obviously, there always a caveat isn't there, but many of these cases can be fixed and it's not high tech. You don't need very many instruments. Um But you do need to know how to do it fo have produced an excellent kind of training journey to show how that can be done. And one of the reasons that that's necessary is that there's all sorts of different types of fistula. It's not 111 type that you can just learn how to do one operation and you're, you're sorted. Um, some of them are quite easy. So this one, you can perhaps imagine that the tissues are quite pliable. There's not much scarring, it's not a huge hole. You can, uh, probably reoppose the bladder and the vagina. And the principles are very much that exposure, no tension reoppose. However, sometimes there is massive tissue loss, lots of scarring and it's much more difficult to affect a repair that works. So you can imagine this sort of thing where you've got just a huge hole, tons of scarring. It's involving the ureters. It's not a very much normal bladder left. So to try and get a working bladder out of that is much more challenging. There are other operations involved. So, if you are a person who wants to do childbirth injury, this is when I make the excuse for being a colorectal surgeon, just the, the warning, there's all these other operations that will come through the door at a camp or at a fistula unit. Um Here's some of them. So this is a little marsh flap, pedicle of fat, which is very usefully present in the labia and can be tucked under into the vagina to shore up a repair or a Singapore flap. This is a really good one if you can do it well, you can get vascularized skin fat and fascia, which makes a massive difference to a difficult repair and can also give you some vaginal skin when there's a lot of loss there. Grais we're using more and more. It's not quite as chunky as it looks on that uh picture. So it is actually a very useful muscle to get into the vagina for difficult uh repairs where you think they're probably going to fail without some sort of graft. Then there are the obstetric ureteric injuries. Um There's a lot of talk about the incidence of that and I'm not going to steal the thunder of my colleague, Kate who's done a poster on that, which I think she's presenting tomorrow. Um But you probably need to know how to reimplant a ureter. If you want to be doing this type of surgery for a fistula, then of course, there's loads of fourth degree tears. It. Every time we run a camp of about 30 to 40 cases, we'll have more than 10 people with long term four degree tears. They're not so sorrowful as the fistula in that they've still got a live child usually and they've not lost their place in society, but it's still very difficult to, to manage life and with that degree of incontinence and, and that can be nicely repaired with an overlapping repair of the sphincter and building up all the tissues to have a a nice peroneal body again. So I hope that demonstrates that II do think that there's room for collaboration interspecialty between gyne urology, colorectal. We're very lucky to have all of those people those specialties represented in our team. And, and that works very well clearly in Africa. You don't have quite so much specialization in in every area and some doctors have to take on all of those roles in in one person. So again, I think that's useful to be able to offer support from all these specialties. From here in the summary, treating obstetric fistula is tricky but just incredibly worthwhile. And you'll never see a happier patient than an ex fistula patient who's now dry. Uh It's also wonderful to work with lots of different surgeons from lots of different countries. I think here we've got Sudan, Somalia, Congo and Uganda all represented and we're all working together, which is really a treat. Uh There's not to forget the nurses, there's a good, very good nurse training program run by my colleague Isabel Campbell. And her book is available on Glome for free. As is this book for anyone that's interested first steps in fistula surgery. There's a new edition by Andrew Browning that's just come out as well in terms of looking at what's happening globally. Um We've talked already today, I think about the Sustainable Development Goals by wh O and that does include maternal morbidity, which I presume it means fistula. I think most of us believe that the incidence of fistula pretty much mirrors the incidence of maternal mortality, same sort of numbers, which does mean that there are a lot of fistula happening. Still. If we still believe there's 300,000 maternal deaths happening a year, there will not be very much fewer than that women who are surviving, but without their baby and with lifelong incontinence, um, in terms of the campaign to end fistula, they've done a lot of work since 2003 and they're back up and running at the moment with funding from UN FP. But that funding did dry up in the Trump years and we don't know what's going to happen in November, big changes in the world. But, um anyway, that's 100 and 26,000 operations that they've done since 2003. Fistula Foundation is probably the biggest NGO out there. And they say that they've funded 90,000, I think operations in the last 15 years. Although they're escalating. Thanks to Amazon, you can feel a little bit less guilty about Amazon now because Mackenzie Bezos has given so much money to the foundation. Um So in conclusion, there are a lot of women probably still living with fish in the world, probably between one and 2 million. And we have not dealt with all the backlog. Many of them will have died, I suppose over the 2030 years. But there's still a lot of women out there, there's still a high incidence every year of more cases and the number of cases being done are not enough. We're not covering the incidence and we're not getting through the prevalence of the old cases. There's a big mixture of funding from NGO S and government and there's always the worry that if it seem to be an NGO thing, it's not a government thing. There has to be some negotiation so that the governments realize it is their responsibility. But clearly they've got a small pot and there's lots of claims on that pot. I think in terms of looking at the overall situation, there are three areas that are requiring input infrastructure. In other words, actual buildings, but also people and trained people, mentoring and training and then obviously supplies fuel cost money to run, to do an operation. And I think the who probably is the player that is working mostly on infrastructure. But I think there's a role for Ngos and for other countries to get involved in partnership and mentoring in sponsoring training in just working alongside our colleagues in other countries and in bringing some of that needed cash for the operations. Our estimate for our charity, it's about 250 lbs to um pay for all the capital expenses and make sure the local surgeons and, and nurses and midwives are paid. It's not that much, but it's too much for the budget of the country. So that's where we're at just now. I do hope we'll have a chance to talk a bit further about how we move forward because sometimes it feels as if things have stopped a bit for fistula and we do want to sort of invigorate our efforts a little bit. Hence, my last project around advocacy. Thank you very much. Very, a very good sort of scene setting for what's now going to happen. And this is definitely a challenge to be risen to so very consistent with what we're doing this conference. So just before we show the film, I just like, would you like to say a little bit about not a spoiler, spoiler because we want people to read this, but just tell us a little bit about the story within this book. Yes. So it's a bit of a mad idea to tell the story of obstetric fistula through a ROM com. But why not? Really? It's the story of an obstetric fistula patient and a surgeon, Scottish surgeon and kind of how they meet and sort of help each other. They're both, they both got challenges in their life. And I wanted it to reflect a little bit the two way traffic that happens between patients and us speaking as a surgeon and how patients affect us usually in a very good way, sometimes in an upsetting way. Um as well as actually telling the story of obstetric fistula and hoping to reach the massive audience that's out there that reads rom coms. Um, none of which ever talk about this. Sorry, this is not a subject that I've seen in a book ever. So, that's, that's the reason behind it. So it's a, it's not a misery one though. Ok. There's some laughs. It has a optimism to it if you can, if you can imagine. But we encourage you to have a read and will be available at the end there, be some book signing over there. But now we want to move on to, as I said, not happy to just have a novel. Then went on to think about another way to raise awareness and that is in terms of the dance. And I just like to thank the four sponsors who are the back of the room. So Medicare Medtronic, well, and who help to support the screen that you're now going to see. So again, how would you like to introduce the screen dance? Yes. So I didn't really know what screen dance was. And Wendy, Doctor Wendy Timmons is a doctor of dance will maybe tell us a bit more about that in the panel. But what we were looking to do for Glow was to try and tell the story to try and individualize some of the data that we're all seeing all the time and humanize it a bit. And we can't, it's quite difficult to talk about incontinence. It's a bit taboo people don't like you talking about it. So we're trying to really tell the emotional story um about the, the hopes and dreams and then a bit of the loss and disappointment of a girl very similar to anyone here um wanting to have her family. And so we're, we're hoping that that's what the film will communicate. Um And that it will reach people that in a way that perhaps a book can't. And it had its premiere on Friday here in Edinburgh. And so this is only the second showing. So it's, we're extremely privileged to see it for the second time. So on that note, we'll, I think I'm looking at the gentleman over there who was going to put up the, the dance and then after that, we'll have the panel discussion. So, thanks very. Yeah. OK. Yeah. Thank you very much for bringing us this film to glow and giving us this opportunity to merge science and art. We wanted this conference to be consistent with themes of this city, being very much a city of art and culture. So it's fantastic to see that film. So we're now going to move on to the panel conversation next, if I could invite up the panelists who are sitting here in the front row. Very lucky to have four members joining. Very, we have, we have enough seats there. So Professor Bo Alabi, we've already met a fantastic presentation this morning on Partnership TI is from university of Lagos. So, thank you. We also have Christine Woods who's a senior midwife from midwife from Simpsons Hospital, Simpsons Paternity Hospital here in Edinburgh and been heavily involved in working with very, particularly in Uganda with the Uganda and childbirth injury trust. We have Wendy Timmons. You've come on the state in a different order. So it's challenging me to in a slightly different order. So Wendy Timmins, who is a senior lecturer at the University of Edinburgh in Dance Science and Education here and has many years of working in personal arts practice and experience of teaching and training. And last but not least, we have of course, Professor Hassan Jha, who this morning was chair of the sessions that we heard and who is the vice president for the for Global Health. The RG also a practicing obstetrician based down in London. And we're very lucky to have such a distinguished panel. But actually, I've just been reminded of some very recent news that I didn't know about someone who is very modest on this panel, who really doesn't like to talk very much about accolades and various recognitions. And so I'm going to let Hassan have the floor and say a few words, thank you very much. So you may know that the Royal College of Obstetricians and gynecologists, we normally put out calls for honorary fellowships and distinguished service medals and our colleague who's here has actually nominated very for a distinguished service medal and So actually, the way we kind of look at it is um let me just read it. So it makes sure. So actually, so we confer a distinguished service medal to individuals who have made an outstanding contribution in a specific area of women's health on the 13 of September. So only Friday last week very was awarded in recognition for her dedication as a fistula surgeon for her work in Uganda to share her skills and train doctors, midwives, and nurses to contribute to the prevention of fistula. And this is awarded normally two distinguished service medals maybe once every five years. So I think she definitely deserved a round of applause. Thank you very much, Hassan and I would expect this from Barry. You are such a modest person and have had that award but not to have mentioned. So I'm really pleased that we could also join in congratulating bar on that. So now on to the panel and as well as the panel, we hope there'll be a little bit of time at the end for questions from the floor. So those of you got used to using metal, please start thinking about putting in your questions and by some wizardry and Harry Potter type magic, it will appear on my phone and we'll also, I will select some of those questions. But for now, let's start off with the panel. And so there are two rounds of questions. First, we're going to take a little bit on the film and then we'll move on to the substantive topic of cistula. So to start with, I'm going to ask divide the Panelist into two groups. So for Basad Hassan and Christine, I'd like to ask you separately to individually to say in looking at that film, what struck you about, which resonated when you have clinical experience of working with fistula patients in looking at that film, what would you say was the thing that sort of really struck you? Um And you think relates or portrays that scenario of fistula patients. So I'm going to start off with Christine's nodding, very enthusiastically. Let's start with you, Christine. What really struck you in the film that relates to your experience with working with obstetric patient official patients. I suppose the first thing that strikes me is the absolute privilege we have to be involved with these women to go out the hospital that was in the film is a hospital that I've been to for many, many times and just, just the privilege we have to meet these women. I think one of the things I was writing a few notes during the conference today and it's about building relationships and the relationships we build with the staff and with the women is just beyond precious. So to see these women coming in with such such lack of joy in their hearts and then to see them go home and potentially home to, to families just with that, with that hope again. And that's, that's what I see in the film. Ok. So going from a situation of despair, absolutely to recovery, which not obviously, sadly doesn't happen for everybody, but there can be joy, there can be recovery. And you thought that captain was captured well in the film? Thank you, Christine. Thank you. Um So the film, the film, um it was very tastefully done, I felt um because it's usually very difficult to um be relatable. Um when you come from the global North and you come to do work um in global South. And it's of something that comes from poverty from um you know, a lot of uh educational issues and cultural issues and the fact that you were able to do it in a tasteful manner. You had the young women there, that youth is also important because they, they seem to be the, they are the ones that have most um that are affected the most because of their undeveloped Pelvis. Pelvis. And the fact that you, you, it was, it was tasteful. I was going to ask why you dance and not um a, a um short story. But I think I understand it because it, it, it's more tasteful. Um It's more, it's, it's less um condescending and, you know, patronizing as it can be when, when you do that. Um And it, it struck me that um this, this was um put across in a sensitive manner. Um but still depicting, to an extent, to a large extent, the horrors that, that, you know, do occur because of a lack of understanding of some of these issues. So that, that's what struck me from the film. Thank you for when I say D is a universal language and you're right, storytelling would have the issue of how to, how to convey it in the local language and dances potentially could translate into lots of different showings has what what struck you. So I grew up in Sudan as you know, and obviously, it's one of the countries that has a lot of problems with obstetric fistula. And I worked in my early years um with professor a who was a leader in that field. And but what I've learned from him as a junior doctor is to learn empathy because the women there, they were actually marginalized, they were rejected by their families, by their societies. So the film actually brought negative and positive memories negatively, kind of reminded me of the marginalization of women. And that actually we're still having problems with obstetric fistula. So looking at the figures, um there are women are dying every two minutes. There's a woman dying every two minutes, 800 women dying every day. But what we tend to forget that about um 15 to 20 million women end up with disabilities and that is completely forgotten. And as we now learned, there's about at least 1 to 2 million with fistula. So I really welcome kind of the use of art in the form of film. As I was mentioning to you earlier, I've run at the college twice now, film and women's health. And in our Congress meeting in October, we have a full stream of small films to address some of the issues. But I noted that when I was growing up as a junior doctor of fistula was kind of had a high profile. But I think with the over the years, it's kind of people don't think about it anymore, it's not sexy anymore. It doesn't attract funding, it doesn't attract research. And I think for people like very and others who work very hard in this field, I think we're grateful that they bring that again to the forefront. So I just organized a congress in Muscat and I don't think I've put a lecture on obstetric fistula and I feel ashamed. So I promise for the one in June in London, I would definitely do that because people want to talk about maternal medicine, they want to talk about robotic surgery, but it's not fashionable. And thank you for bringing it back to fashion. So thank you very much. Thank you. Thank to her son. That's yes. So we will hold you to that, this, this age of accountability. Um So very and Wendy, I mean, you were obviously both involved in the film in different ways and to start with that with Wendy, I mean, coming from Department of Dance and all your experiences, all the sort of challenges of taking a subject like this and conversing into that performance. It was a huge challenge, but I want to raise the challenges as has found out. So when she came with the idea, I just loved it and embraced the challenge and speaking, not just for myself, but the whole creative team now be here with me. And for me, dance is often created to touch our emotions. That's why we dance. The, we talk about the joy of dance, but we can also put sadness and music is the same. So for me, when the two came together, that's how I knew that we couldn't tell the whole story and we couldn't tell the horrific things that we've seen in your lecture. But we could take some of that to touch the, the emotions of the people that were watching it. And that's actually quite a powerful thing because you don't need a language. This film can go anywhere and it tells a story without a language. And the music and the dance were created specifically to tell that story. And I think that's why it's so powerful. Thank you very much. And it was dances from your department. Was it the traditional forum of Scotland? The dancers, the dancers were a range of dancers, some of them were my students. They were on a master's in dance science. And education. Others came through the traditional dance Forum of Scotland, which is an organization that is wanting to advance traditional dance in Scotland, but not necessarily only Scottish dance. So we work with lots of dancers who are living and staying in Scotland. So Mary, just before we move on to the topic of the fister itself as a priority subject. As a colorectal surgeon, you must be also unusual in producing AFA dance, a screen dance as well as a book. So as you approach this idea of doing a dance, what were the sort of things that you thought were gonna be most challenging? And did they turn out to be the challenge? Um No, I think II didn't really do it, you know, Wendy and her team did it. Um So my, my part was pretty easy, but I think um it is a real challenge always to tell the story of obstetric fistula to try and mention it to fundraise. And I really was very keen that this was not an angry film, that it was a beautiful film and that it would show um people, a girl, just a lovely girl, like our own daughters, you know, just having a horrible time and, and obviously hope at the end for her, but I really hoped it would be emotive and I II find that dance very and music, very emotive and II hope that that would be the case. I also have great hopes for it, not just as advocacy for money and attention to fistula, but I'm really hoping that we might be able to use it within Africa when we go to engage communities to explain to them what we're about and to try and, uh, I don't know, just start a conversation which would be finished with dancing from uh from the communities we go to, I think dance is so important in many of those places that um perhaps if we say our pa they can say their pa you never know that might happen. I hope so. So one final round and I want to try and make sure there's no questions popping in through Harry Potter system here yet. But I'd like to have one more round of questions. And that's moving to this issue of the topic of citric fistula and from what you've presented and whatever, as I said, it's clearly an area of neglect need for much more attention, but of course action. So I'm going to ask a slightly different question to Wendy because I wouldn't ask you to speak to what to be done clinically for obstetric fistula. But for Christine and Hassan, if there was one thing, if you had a Harry Potter magic wand, what is the one change you would like to see that you think would make a difference and it can be programmatic, it can be training, it can be money. What is the one change you would like to see f for me, I think that um advocacy to the, all the appropriate um stakeholders, governments of a lot of the countries where it's most prevalent in, in the most respectful manner possible. And I have to emphasize that because a lot of people don't do these things or put the people in positions like this because they feel that it is the right thing to do. I mean, because they know that it's wrong and we have to, you know, um uh we would just want to make these women, you know, have this problem a lot of the time. It's out of um ignorance to a large extent and, you know, cultural values that haven't been challenged. So I think that if we could advocate to prevent um young women being married, you know, as respectfully as possible. That is the one of the mo most important things for me. Thank you very much. Bid Christine trainer, someone who's gone to these places. What is the one thing you would do with your magic wand? I think, I think mentorship and training is, is key for prevention of fistula. So as a midwife, if I had a magic wand, I would get amongst women and traditional birth attendants, which I get a chance to do and I would get among students and I would just, just work with them and just for the women, I want to just let them know that it's, it's not their fault. And I think for me, the women and how their lives have been affected and how they're treated is just beyond, beyond anything that I can imagine. So, if I could take, if I could teach him no embry greed, choosing two magic wands. But if I could teach recognition of obstructed labor and, and prevention of that, and if I could take those women and just hold them and show them the value that they are, that this hasn't been their fault. It's, it's, it's something out with their control. Thank you very much Christine. So I'm going to pass the magic wand now to her son. I'm actually going to use a quote from my fellow countryman, Professor Mahmoud Fatal, who was the Figo president one day and worked in a great advocator for women's rights. And he said women are not dying or suffering of diseases. We cannot treat, they are dying or suffering because societies have yet to decide that their lives are worth saving. And I think that's what we need to do. We need to recognize women and girls and not treat them like they nor there. And I think that's the problem with a lot of societies so recognition and advocacy for women's rights. That what I would do. Thank you very much and thank you for reminding us of that great leader Mahmoud Fatal who did so much in those very early days of what was called the Safe Motherhood. Initiative and it really sadly missed but left a huge legacy. So before I'm going to, I'm going to give very the last magic wand, but I'd just like to. But before that, I just want to bring in Wendy just to say, I mean, this has been an unusual experience for you, I think, can you see this dance being used not just in this clinical area but in, in teaching dance as well? I mean, does it have it, does it have a learning capacity or potential within the field of dance? Dance is used in lots of ways you can learn through dance. And in fact, our dancers in the film learnt a lot about fistula, had no idea. So we've already learned through this through this film. But most definitely, I can see how this film can open up this subject where it's probably never been spoken about before, just through a piece of piece of dance, a piece of choreography in its own, right? But it has a meaning and it's very touching and therefore it can open up that subject. So most definitely, I can see it being used in lots of ways for a from a dance perspective but also education through dance. Thank you very much. And there's an interesting comment from a colleague about Magic Wands. When I'm using magic Wand. I don't want it to sound like it's fictional or fairytale. The reality is that things can change and they should change. So this is not wishful thinking in the land of nothing can ever happen. I think we've had too much of that sort of sense of nothing will ever progress. So very, I don't know whether we want to call it a magic wand or not. But what is the one thing you would like to see changed? I would like to see government priorities being reordered globally. I don't know why we have to have so much money spent on so many weapons that cause so much awfulness and so little money spent on the women who are um to, to use my title who are literally making our human race, making the fabric of it. And they should be prioritized and um developing more and more expensive ways of destroying humanity should not be, that's I know that's a kind of miss world, I'll change the world desire, but that's my great desire. Thank you very much for being an incredibly compliant panel by keeping very much to, to I didn't even have to use my bell to keep you all the time. You do it naturally. So thank you very much. Indeed. I'm looking at the magic box I have in front of me, but I don't see anything except Andrew. Andrew weeks has said that following on from what Hassan's comment and mentioning if I had a magic wand, I would pass a law that means that all politicians had to give birth in their country's government health centers. This would focus attention. Thank you very much, Andrew. And I think, yes, I think a lot of us have had a similar sense that change can come about by those really realizing, what is it like to go into a place where with my work on infection control, to get on a blood stained table, to have no water to wash your hands or the provider not wash their hands. Some of these real hard realities, people don't realize until they actually go into the setting. But on that note, I think I will close it because it's good practice if you can to keep absolutely time. There's a few housekeeping. So a final round of round of applause for our panel, but in particular, I understand the book sales are actually going to happen downstairs because the publisher arrived late. So if anyone would like to see the book, it's downstairs, like to thank again the sponsors of the film. So those at the back, all four sponsors of the film and yes, a final round of applause to our panel and just a final note that very reminds me is that there's a suggestion, anyone who would like to continue the conversation about what next for fistula tomorrow? I mean, tomorrow at lunch time, there's an idea of getting together, anybody who would like to continue that conversation, we're not quite sure where, where we will hold it, but tomorrow at lunch time there will be a continuation of the conversation. I'm sure there'll be all sorts of other continuing conversations. So that's, that's tomorrow at lunch time. But thank you very much to the panel, just a few things to end on. So firstly, the conference dinner, which is going to happen at South Hall estate in the Leigh as it were of Arthur's seat. If you've not seen this huge mountain that exists in the middle of Edinburgh, you'll be quite as you go there, you'll see it in the distance. So arrival at night at seven o'clock. So for dinner starting at seven followed by a and I hope you've all got your dancing shoes. So we will be dancing in a very traditional Scottish social evening. Sorry, I'm just making sure someone's not anyone brought another thing up. Um Tomorrow morning, there's going to be those who are up for an early start tomorrow morning at 730. There's going to be, it's magically advanced itself. Thank you very much. So, the book signing downstairs and also a little bit tomorrow at lunch time, possibly with the book signing. But the guided walk tomorrow, I think the plan is to start at 730 in the morning in middle, middle me walk. That's a very hard thing to say. That's just behind this building. So very close to here. So you get yourself here and then go behind the building as it were to me walk and that's for this amazing walk that's been produced by fellow artists that have been joining us for the Glow conference. So everyone sort of convene at 730 in the morning for that. And I think, and I'm just looking to make sure I've not forgotten anything else. I think on that note that concludes a very exciting first day. Thank you very much for everything, for your energy. And I look forward to seeing more of that energy on the dance floor this evening.