Computer generated transcript

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

right. Hi, everybody. Um, it is my absolute pleasure to get the third session of the day going. Um, we have two fantastic speakers. Next, Um, the first of which is Mr Mark Schulman Covic, who is a consultant, colorectal and general surgeon, based at Salisbury NHS Foundation Trust and a visiting lecturer at the University of Winchester, the Center for Global Health. He is the founder and trustee of the charity Swifts, which stands for the surgical teams working in Africa together for, say, for surgery. He is passionate about global health, and together with his family, he lived in Morihisa, Tanzania, for several months, working at Saint Augustine, designated District hospital, developing surgical services and assessing up a sustainable mesh hernia service using mosquito nets. This led onto a fantastic partnership with the Tanzanian Surgical Association, of which the flagship flagship project is the Tanzanian National Mesh Hernia project, which aims to develop similar services throughout Tanzania and beyond. And I can tell that he is a sustainable, a global surgery sustainable champion. As I noticed his keep cup over by his laptop just now, it's very impressive. The second speaker of the session will be magnesia Norinco who is a general surgeon from Tanzania, based at Kilimanjaro Christian Medical Center, KCMC in northern Tanzania. He obtained his fellowship of General surgery from the Celexa, the College of Surgeons of East, Central and Southern Africa, and is the founding chairman and director for the Neck Artery Foundation and Initiative, aiming to improve quality and safety of surgery in African training and research. He's passionate about providing quality surgical care, mentoring his juniors and surgical research. And I personally had the pleasure of working with him on a project at the moment with sex A gas stock. And they are CSI, um, and he's a wonderful person to work with. So without further ado, if you could take your seats, I would like to welcome Mark our first speaker. Uh huh. Right. So thank you very much. Many Thanks for this opportunity. Um, as you've heard, I'm sharing the stage with magnesia. Who I understand can hear us, but you can't see him at the moment. Just one thing to say about magnesia. He's an rather incredible individual and in fact, just recently has been elected to the post of president elect of the Tanzanian Medical Association. So, uh, you know, there's a lot of congratulations to be said there, too. So something a little bit different. I'd like to tell you a story, and this story doesn't start at the beginning. We'll come to that in a moment. It starts on a bus on a bus on the 18th of January 2019 3.5 years ago. It was an early start, having got up at 4 30 to catch it. There you go. But a little while later, the sun was rising over the incredibly beautiful African savanna. Two months into a five month adventure, living and working in Tanzania, there was much to think about on this eight hour journey. Chewing through all that. Perhaps it's not surprising that Dream began to emerge hazy at first with lots of escape for evolution, but powerful and inspiring. So hold that thought. Nope, we can't really continue the story without a bit of context. So some big picture stuff. First of all, uh, hopefully as people who are in a global surgical conference, you'll be aware that 95% of the world's population consumes just 5% or has access to 5% of those resources. Whereas 5% of the world's population that's us in the UK consumes 95% of those resources. Sorry, I'll try and keep the microphone a bit closer to provide some context. In contrast, the UK or Tanzania is four times the size of the UK. It has a population that 85% that of the UK. It has a life expectancy. Is that 17 years less than that of the UK? Its GDP is just 2.2% that of the UK's. In terms of an average salary, it's about 14%. Although a point of clarification here, these are people who declare a salary and in fact, there's an awful lot of people who don't declare a salary and live on a lot less than that. So some Healthcare Metrix, uh, the, uh, maternal death rate is about 44 times that of the UK, And if we look at surgeon's well in Tanzania, they have about 400 specialists, surgeons across all specialties, compared to the 8000 we have in the UK. Uh, and that is, uh, not including any of our trainees or training grades. Now this dream is about hernia repairs, and we need a little bit of background of that to give some further context. So hernias are the most common surgical problem worldwide, and hernia repairs are the most common general surgical procedure performed worldwide, with the exception of Cesarean Section. If if you include that as a general surgical procedure. But it's a particular problem in countries like Tanzania, where in Tanzania there's 800,000 outstanding hernias, so it's a bit difficult sort of talking and looking at the sides at the same time. In Tanzania, the common approach to repairing hernias is with suture technique, and that is by contrast to that in the UK And the important thing here is that the gold standard in the UK and in many Western countries for over 30 years is by using a prosthetic mesh. And that reduces the recurrence rate by a considerable margin 300.5% as opposed to 20 to 40% and even the best hands now. But that another way, if every hernia was repaired in Tanzania today using a mesh, you would expect about 4000 recurrences over the next five years. Whereas not using a mesh, you would expect there to be 100 and 60 to 320,000 recurrences. So quite a stark difference. Most journeys start up on the work of others, and it's important to acknowledge these two giants in the field. Ravi, an Indian surgeon, dedicated his life to selfless service and innovative service, and he pioneered the use of, uh, manufacturing a mesh created like a mosquito net but made out of the same materials PTFE that commercial measures, and Andrew Kings North, who came across Ravi and they work closely together. And Andrew brought that concept back to the UK, subjected it to really quite rigorous scientific analysis, including electron, microscopic and various other things, ultimately deciding that it was a good way to repair hernias and used that in his charity, Hernia International and their model, where missions are sent out to places, they take the mesh out with them and they Since 2005, they repaired over 10,000 hernias using this worldwide. Now, back to the beginning of this story in 2018, a family moved to my head's A in Tanzania, and clearly there's a lot more that could be said about that. But for Now we'll concentrate on other things. I would work within the surgical department. My wife, who's a GP, would work in the pioneering hospice there and my Children as well They would go to African school with various success and have quite an incredible experience to give you a flavor of what working there was like, um, this is the main hospital corridor. Now that would be pretty familiar to anyone who works in those sorts of hot climates Very open. This is a typical ward, um, and we'll pause here and talk about the intensive care unit. This is the intensive care unit, and it's intensive because it has just four beds to the one nurse who is there most of the time. Uh, it has access to an oxygen concentrator that works some of the time. Uh, they have a pulse oximeter, one of the two in the hospital. Uh, and they have the EKG machine, which works again most of the time, quite significantly different to the intensive care units that were familiar with in in the West. There was an X ray machine while I was there for five months, it worked about 80 about 20% of the time, So the vast majority of time we didn't have it. And the blood fridge is a fridge with blood in it. And the expectation is that if a patient needs blood, there is a A relative is expected to donate to replace that, and anyone that's worked in a resource poor environment will identify with multiple issues. For example, power cuts. Um, here, the national grid was off. The hospitals generator had run out of fuel. So we're working with a head torch and, uh, in the background there, you can see a monitor that we've taken out. But, uh, it was all about training and working with the individuals. And these are the 2 a.m. o surgeons. So not medical, not technically medically qualified. They have their healthcare workers in a different pathway. Uh, and that's training them to do, um, the mesh hernia surgery. Now any sort of medical conference quite like some clinical pictures. So that's what I'm going to put in here and to give a bit of context when you're working in these sort of environments. It's not about one service. And it wasn't about setting up a mesh hernia service. It was about the whole package and there's a lot of pediatrics. Uh, there's a lot of issues with wounds in these sorts of environments, and one of the things we had was we took a mechanical mesh skin, skin graft measure out with us. And that meant that limbs that might have been unsalvageable became salvageable. Uh, also, there are many issues with healthcare, and and the child who had this foot tumor wouldn't go anywhere else for treatment. So as a general surgeon, here I am taking out a tumor on the foot. And this is another interesting sort of case. Uh, this was a 14 year old boy who was being treated for malaria, but his abdomen was particularly tender. Ultimately, we didn't have a CT. We didn't even have an X ray. And it was a clinical decision to take him to theater and do a laparotomy. Not a small decision, but ultimately he had a small bowel intussusception that had infarcted, and he did very well with the small bowel resection. But these are just to give a little bit of color to the difference in the environment in which, uh, our compatriots who are providing to 95% of the world's population are working and everyone likes a good story. And this fortunate or unfortunate young girl was attacked by a crocodile. It was fortunate because it was a juvenile crocodile and actually again, she did very well. So this story is about hernias, and this is an example of one of them that we repaired when we were out there. This is a, you know, reasonably sized one and again just to give some color to the picture. Those eagle I give you will see that I've just dabbling in some anesthetics out of necessity again as a general surgeon. So it's a much broader scope of working. So in my head, uh, we took this concept of using the mosquito net mesh, but rather than bringing it over, ready, sterilized in from the UK, we would prepare it on site and then use it, and again, I could talk a lot more about this. But needless to say, there were lots of hurdles and challenge is to overcome lots of learning, not least how to sterilize the mesh properly. And, uh, this is, uh if I can get that to work. This is a a steam autoclave, and the interesting thing about this particular mesh is that if you look here in the top hand corner, it has to be sterilized at a certain temperature a few degrees below that. And it's not sterile. A few degrees above that, which is the temperature that is normally use 135 degrees it melts. And for any of you that have been involved in Blue Peter endeavors, if you imagine that crisp packet that you put in the oven to create a badge, that's what happens to the mesh. So very temperature sensitive. But ultimately we did put together a local service that was hugely successful. We prepared 50 hernias when I was there. The last five were done by the 2 a.m. o surgeons independently, two of those when I wasn't there. Uh, and since leaving, they have now, uh, undertaken 230 hernia repairs without major issue. So that's a bit of background, and this story is about a dream on that bus. I've been visiting other health care facilities throughout Tanzania to understand the wider healthcare system within which I was working and What was becoming clear to me then was that what was being done in March is a could be absolutely, in many ways very easily transferred throughout the country. And I just want to pause for a point of clarification. This dream is not just about a project repairing hernias with Mosquito net in Tanzania, it's about much more than that. Medically speaking, it's about working at the coalface and the process of improving surgical services and in doing so, improving surgical care more generically. So it's not just about one operation. It's about improving basic theater pathways, raising basic surgical skills and ensuring that basic surgical equipment is available, for example, a diathermy machine. But it's also about process, governments and aspirations, and it's about networking, collaboration and friendships. And ultimately, it's about narrowing that gap in healthcare inequality, even if it is in just some small way. But to do this in a tangible and sustainable way through training and education, it's a bottom up approach we've heard a lot about top down approach is, and so the dream was shared, and the story now becomes one of ideas and collaborations and a lot of hard work from a lot of people both in the UK and Tanzania and also further a field so swift were set up as a charity to enable this word. But having heard Lee Parks talk, perhaps it should be called a solidarity rather than a charity. And the concept of the Tanzanian national Ms Hernia project was born and then a whole host of other things took place to make it a reality. We managed to set up some phase one sites and then our friend coronavirus hit, causing chaos and not just medically speaking, but also in many other ways. For example, we were part of the way through several major grant applications. But the U K government back in May 2021 cut the amount of GDP from 0.72 point 5% in to the UK A budget, and that pulled out a whole load of grants. Uh, and actually, I've also just realized that they have now put on hold what they call any non essential overseas aid use. So again, lots of things going on. But other fund holders were also diverting their attention to Cove ID and the monetary landscape. Currently for global surgery is pretty barren. But despite that chaos, the work has continued and the sites that have been set up continue to cement their services. Furthermore, we were creative and worked with magnesia and collaboration with the University of Winchester on a completely separate project to look at the development of some qualitative research methodology. We've been developing some simulation models and even worked with health education England on a Google glass project to use augmented reality from the UK to Tanzania. And the sad thing about that is that although the hardware seems to work very well, the software currently is just not up to it. But perhaps most significantly, we were working with a Greek company to create a, uh, an electronic hernia, uh, registry, which is the first of its kind to our knowledge. And I would just reflect back on one of the things that, uh, Parker talked about in terms of data from from healthcare, uh, process is being able to inform the policy that gets taken forwards. And so the story continues and the dream grows. Uh, and these are just a number of the things that we are currently working off, so we will get magnesia to the UK He was going to be coming over for this conference. But again, Visa application seems to be exorbitantly long winded. Uh, we're actually going back out to Tanzania in a couple of weeks, which is very exciting. We are still looking for that Major Grant. Uh, we are nearing completion of the University of Winchester project. The registry will go live. We're always looking for new faculty and also development both in the UK and in Tanzania. Uh, and overseas were very interested in the idea of technology enhanced learning and augmented reality. Again, with our simulation, we've got a number of simulation tools that we're putting together. And what's quite interesting is that as a if you like, as a dream, you know, if if this model was to really take off and to spread widely throughout Tanzania, it's then a potentially a model for any other country as well. And we've already had interest from, uh, some people in Malawi. But there's always more work to be done, and, uh, swift certainly is always looking at other possible projects and then, as anyone who works in sort of global health and global surgery will identify with as soon as you sort of start making those steps forward. These collaborations start building loads of other things crop up. And so, for example, in my head, uh, they didn't have a pediatric intensive care unit. So we then worked with Hereford Hospital and Salisbury Hospital to create some funding to try and get some form of kit together to provide that environment. So hopefully magnesia is now going to be seamlessly brought through. And you're now going to hear from magnesia for sort. So I think the plan is I'm going to move magnesia slides forward. You're on magnesia. All right? I think you can put my first slide and thank you very much. Yeah. Yeah. Should I go feel been contacted several times, uh, to be ready to make this particular presentation. Thank you, Doctor. Mark, for alluding what we have been doing together. And I will take a little bit in 10 minutes. Uh, a few things that I think that is very important. As I've been introduced. I work at a sec and I'm with a fellow, the college at the college of, uh, next slide, please. Uh, yes, that's my family. and I I work at Kilimanjaro Christian Medical Center. Next slide, Uh, a couple of slides that we need to move them on, uh, at the hospital where I wake up. And I am also the the founder of Netcare Foundation, an NGO that is envisioned to improve improve livelihood here in Africa, in Tanzania particular also work with the mission of training skills for development. And that's why we are with Mark to improve the quality of Henry A surgeries. Here in Tanzania, we have a couple of programs that probably your audience might be also interested, including the Surgical Thursday program. This is the weekly learning platform for residents registrars as part of continuously surgical, uh, education within a couple of, uh, non technical skills for sergeants. And we're entering a group of 30 doctors, young ones to be surgical researchers. Next slide, please. Sorry I'm rushing, but this is part of the things that we've been doing. And we are really happy to engage with the community all over the country, from the northern to the central to the southern to the eastern part, uh, moving here and they're teaching skills and improving. This picture shows that we were training nonoperative treatment for traumas. Uh, by applying the past, we also have the hands on basic surgical. Still calls in Arusha, which is the northern Tanzania, and a few days to go less than five days ago will be hosting a surgical conference here in motion Tanzania. Next slide, please. Yeah, the next slide. Yeah. So this is one of my work that I was doing teaching doctors using the locally available materials like the canvas skin, uh, the canvas to act as a skin when we are performing lateral laparotomies and, uh, raising the colostomy. These are a group of young doctors. Registrars just finished the internship. Next. I'm very happy. This is our country, and Mark has spoken some of the things we are in the eastern part of the, uh of the South Africa, and we have a couple of good shows, and, uh, I'm speaking to you now. We I am just right at the foot of Mountain Climb on Jaro. This country has got a lot of history that we share together. We in the UK and also we have a couple problems, and I think next slide will be telling us a lot of the problems that we're having and the opportunity that we're having next slide, please. Yeah, the healthcare in Tanzania has really gone from the pre colonial times. And I went through the colonial times during the time when we were part of the Dutch East Africa and let's around the British appropriate under the U. N. Governance, Uh, that particular time when German lost to the Cold War and again, uh, we had the nationalization of health care systems and then, uh, after 1919 1995 we started the construction tearing program. Currently, we, uh, a part of the universal health coverage program, and we are revamping our laws and regulations to incorporate all people in Tanzania to be, uh, on the on the on the insurance scheme Next slides? Uh, yes, our healthcare system is hierarchical, whereby we have patients coming from the dispensary level, healthcare level, district, hospital level, regional and consent. That iron mark, Uh, we are really making sure that we include all district levels, uh, hospitals that included in the program and at least at the conservative level to, uh, the government attended to facilitate all the 60% of the of the health care facilities here, and, uh, a couple of public private partnership, including the faith based organization NGO and full Private. The top 10 list, uh, diseases in, uh, our healthcare system is the seventh in the list of the top 10, uh, countries in Africa with the healthcare system. Next. Uh, well, the workforce, we have 12 medical schools, five year long training of undergraduate. Then we have one year of internship, and the, uh, specialty training takes a minimum of three years through the university program degrees. This is masters medicine. Or if you go to the College of Sergeant east central South Africa, you can go to five years training five years long, training our doctors to, uh, population ratio is one doctor to 100,000. And sometimes in villages or several district hospitals can go beyond next to patient ratio is a little bit of background. And I thought that I should have put them in this particular talk. RSS ratio is 1 to 20 and the Allied also stuff are also present. And, uh, according to the National Surgical anesthetic and, uh, anesthesia plan that we're implementing, we have currently 0.3, uh, surgical providers 100,000 population, which is lagging behind to the standard of at least, uh, five, uh, at least above 10. That is committed by the global global surgery. Uh, initiatives next slide. Uh, well, the healthcare financing many people here in Tanzania not insured. Although we are now, uh, deliberating at the parliament on how to include, uh, everyone in the insurance scheme. Currently, the only 16% of Tanzania's assured and, uh, the budget financing is, uh, around 60% financing by the government. And also, we have some donations from complimentary, uh, development partners that supports us up up to 40% next slide. Well, now they're not, um, itself for us to collaborate. At least you must have, uh, this particular, uh, data at hand. And, uh, you need to know the idea. You need to have the problem. You need to know the research, the gap, and then how you can justify you need to make the stroke. You need to make the documentation you need to make some adversity, and you need to make some ethical clearance and licensing of the particular project that you want to engage and you have to take note of the couple of things that may if they are not taken care well, they may lead to, uh, several, um, problems Next slide. Yeah, As we are speaking, you need to know the physiology. After you have finished the you have finished the draft document you need to test. You need to see how best it fits in the cultural aspect. You need to see how many resources you need to be required. You need to have the right ideas. You need to have strategies on how to execute the program, and in the end, you need to review and get feedback. This can be organized in different contests, whether it's, uh, on site or offsite, depending on how you you think around otherwise, after the end of the physiology, you need at least to start talking like the way it has been said in the opening session, Uh, that you can write on Twitter so that you can walk the talk and then you can come again to the ground so that you can talk the work next slide. Well, um, I understand that, uh, as we are discussing at this particular moment, we're trying to look for opportunities on how best we can engage between high income countries and low income countries like Tanzania in the UK, And, uh, we need to focus into four things as we come to the end of this particular presentation, we need to know the bowl. Uh, this is the These are the context. What's the problem? Was an issue that we have. We need to have a roll. These are the instruments required, and then we need to have a target. This is the goal that need to be achieved. And now we need also to have the right posture so that we hit at the right target. And I think this particular meeting is is particularly one of the points to really learn how to position ourselves as we want to reach the target next slide. Yes, Uh, although those are the basics. But we need to find you in our skills so that we can, at least in the same target with other techniques and they're for innovation. And creativity is key, uh, towards making this particular project going on. As you may recall, as markers said, uh, during the pandemic, we have to switch skills that we have to switch techniques so that at least we can get the progress of the project get going. And we had to learn the the, uh, qualitative research method in line with the same things. Next line as I'm finishing, I want to, uh, really, uh, say that we have opportunity to collaborate as individuals, as countries. There's gas stock, uh, stakeholders who are sitting in this particular whole listening to us that we have a collaboration platform full of opportunities. We have elected and exercise programs. You can come and do some site visit so that you can develop context. We can still work on on site and also offsite using the technology around. And therefore, if you have investment, you need to invest in the healthcare system. We still have an opportunity in our hands. Like, uh, many other things have been said. Also, we need to continue training, find out new ways of doing things in this particular, uh, world, uh, last slide. And I think this is my proposition that we should be part of the changes that we wish to see in the society. And the, uh, tomorrow belongs to those who prepares for it today with all those few words I want to say. Welcome to Tanzania. We can formalize some collaborations program between We need care Foundation I as an individual. I as many other things in, uh, the UK also the opportunity from the gas out to everyone, thank you very much. And I will show the successful conference for the next days.