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So our next session is on trauma and we've got two speakers. Um So I'll introduce them as they come up to the stage. And Tim Law is the David Knot Foundation's Chief operating Officer, which was set up in 2015 by Mister David Knott and his wife. He David KN is an NHS consultant surgeon based in London where he specializes in vascular trauma and cancer surgery. F Law has a wealth of experience in senior leadership, strategic and operational positions most recently at Shelter Box, a humanitarian and international disaster relief for MG O. Prior to entering the humanitarian sector, he had a distinguished career as a diplomat and soldier completing his service leading the British Defense team in Beijing through the recent pandemic, Miss Elizabeth Ti is an NHS trauma and orthopedic consultant surgeon and leads King's local health partnerships work in the Democratic Republic of the Congo King's alumnus. She also has a master's in tropical medicine and International Health from the London School of Hygiene and topical medicine. Her research focuses on trauma system development aimed at improving leadership and institutional management in the main trauma hospitals in Congo Central. This interview come up Ok. Um, far away. Can you hear me at the back? That's good. Ok, I've got terrible tinnitus and I could barely hear that last time. I'm so sorry. Um, so I'm hoping that you're better off than I am. Um, so, um, I think it's evident, um, from, it's like what I am, but II think it's also evident from what the introduction you just had is what I'm not and I'm not a medical professional at all. You know, I am a charity professional. I currently run a charity um that is currently actually absent a CEO and um they're doing some um interviews this week, I think. But, you know, I run the charity um that delivers um or a liver safe, skilled surgical care for all in conflict zones in particular. Although we do work in uh other low and middle income settings, uh The foundation as you've heard has been um set up for about nine years now um in its 10th year and has delivered about 67 courses, I think now to um 1914 medical professionals worldwide. Uh our most recent courses and the ones that we um put more sort of strategically in our programming um framework are in Ukraine, in Syria, in Palestine, and in Libya. Um but we do um teach elsewhere including Somali land where we'll be returning um later on this year. So that in itself obviously a low income setting rather than something that is specifically affected by conflict at the moment. But of course, things can always change. Do I move the slides or do you? Hello? Oh, there we go. Um One of the benefits of working for um an NGO and understanding, understanding the NGO environment is um that you learn where to get free resources online. And this um resource um was accessed about a week ago uh from something called ACC and I can't remember exactly what it stands for, but armed conflict, um sort of information and what that map shows actually is explosive events, um often related to conflict, but obviously in the United States of America, more often related to events, um crime um ridden and all the rest of it. But what you can see there is the distribution of those events over a particular period of time, which is not a very long period of time. Now, if I went out onto the streets of London and asked 100 random people to name the three or four or 10 most um you know, violent places on earth where, you know, the skills of the N knot, foundation surgeons, anesthetists, obstetricians and nurses would be required. Um I imagine that most people would be able to name them too. Certainly, Ukraine and Gaza, um obviously heavily in the news. But what this shows is that like we've heard probably over the last couple of days. Um elsewhere, there is an awful lot of under reported and under um underresourced um places where there is a lot of violence happening and where there is a humanitarian need that is greater than the supply. Um One thing I think that's really important though is that whilst it's very important, I guess to aspire to do humanitarian good in the world, it's also important to think about the humanitarian principles in doing so, so remaining neutral, independent and all those things, but equally making sure that we do no harm. The key thing here, I think from a medical perspective is that you, you need to learn lessons from um previous experience where people who are well meaning and have flooded into potential places where um humanitarian assistance was obviously required and they didn't necessarily leave that place in a better place than they should have done. And that is why it's really important to link into the system that I'm gonna show on this slide, which is basically the UN cluster system. Now, I don't know whether as medics, you've really heard much about how the UN cluster system works. But in essence, there is an organization within the UN called OA the organization for the coordination of humanitarian activities. OA basically establishes a global cluster system that each of the agencies that you can see there are around the blue parts of the sector get to lead. Um Obviously, within the health sector, there is a global health cluster led by wh O operates out of Geneva as you'd imagine. Um David Knock Foundation and other charities like MSF um Medical Aid, Palestinians, all those other um great charities will dial into those. But that's really at the policy level at the country level when there is a crisis, let's say one starts tomorrow in Madagascar. Um The Madagascar Office of the World Health Organization will establish a cluster if it doesn't have one already. But within that cluster will be all of the NGO S that are present in the country, delivering humanitarian assistance to the various programs and projects that you know, form the basis of the healthcare system. Um That is in essence of by um the third sector. Um most of those third sector organizations will be local, which is great because that's what we're all trying to achieve. Um But some will of course be international. We might have the country office of MSF represented. Uh We might be represented on the trauma working group. And in that way, we can all best coordinate where we put our resources so that we don't end up with one hospital in a particular part of the country that's very easily accessible and safe for people to visit really well resourced and then places that are less safe or further away from the main population centers totally unsourced. And it's that which we seek to try to do within our programs to understand whether need is greatest and then to try to deliver um services to service that need. Um of, no, I suppose. Um in the last few days, we've been in contact with the Eastern Mediterranean Regional Office of the World Health Organization, which is based in Cairo, discussing what can be done post ceasefire in Gaza. Obviously, that's an aspirational um situation that we're not yet at, although they seem more confident than the World Press um seems to be at the moment. But um we're in conversation with them about what realistically we can do in terms of capacity building and the totally more about the healthcare system that currently exists um in the country. Um So that's in essence where we are. So I keep on pressing the wrong button for this. Um So what is the David Knott Foundations sort of raise on detra? I think we generally have these three sort of pillars of activity or objectives, building capacity, building, community awareness. And so we, we try to raise awareness of global surgery and global surgical standards in war zones um in general. And we do that partly through the condition zone programs that we run. Um As I said, we have established programs in several countries um in Ukraine, for instance, we'll be going there again next month. Um It was gonna be khaki, whether or not that lasts the test of time and passes our insurance company's test and to where that should be. Um you know, we'll see. But um yeah, that would be the 14th mission to Ukraine. And we're now in discussion again with the World Health Organisation's office in Kiev to um fund um a remaining series of programs that will lead to complete localization of delivery of the courses that we've run in Ukraine. And those courses are surgical as these, the logical. Sorry, I get that wrong and um in future, um nursing, and I'll come onto that in a little bit more in a second. So um the David Knott Foundation's Genesis, as you probably are all aware is in um the individual after whom the foundation was named and who's still a practicing surgeon at three London hospitals, including uh Principal Saint Barry's. Um It started really with a course that was designed um with the benefit of 30 years of surgical experience working for other NGO S and an understanding that when um international aid workers leave a country or serve there one month or two weeks or whatever they can get out of there program, you know, sometimes what's left behind is not necessarily what is needed for that country in the longer term. Um In, in the start at the start of all of this. Um we funded people to come to the UK and attend the Royal College of Surgeon of England. They course the um for that surgical training their environments, right. Yeah. Um And um we ended up finding it very difficult to get visas particularly for people from Northwest Syria, for instance, who really in many ways of statements, because obviously the actual state for which they hold a passport is not necessarily contingent with their own particular place in, in um with that is now um Northwest Syria. So, um that became quite a challenging objective to achieve. And in fact, it's also quite an expensive way of doing business because in reality, what you want to do is to massively localize the impact of what you're doing by going to the places where you need to teach. The people aren't required to leave their places of work for very long periods of time. Um Working out what the requirement is because it's not always easy to produce that um from afar and um you know, through, through online techniques and then actually trying to meet that requirement and embed that um out outcome in, in local um facts. And, you know, just to give an example, our last mission in um I was finished about a week ago, we trained 33 surgeons there. But if the faculty that was all of the faculty members were Syrian by origin, including two faculty members who had traveled from the UK. So they are Syrian doctors who have come to work in the NHS. Um Both of them work in the northwest of England and they were there obviously training um training people who they had previously met. And the other 13 members of the faculty and I know, it seems a lot of people that have to train, um, only 33 people but that's partly because of specialisms and all the rest of it. Um, those were all people that we had previously trained and are now considered by us to be local faculty in Syria. Yeah. Um, I just wanted to touch a little bit before we move on to the next speaker on what the duty of care is to people who want to do humanitarian missions. Because I sense um given the audience that many of you will want to give your time in future to um NGO S to go and do good in other parts of the world where people have less agency to help themselves. And there is quite a big gulf of difference between um NGO S and charities that will look after you um when you're deployed and agencies that won't. And I think it's important for you to know what you should expect because then you can demand those things when you actually um have discussions with places that um want to send you. So um there isn't really an international law that governs this, but there is an international standard. And if an aid agency like David, not foundation signs up to the Global Interagency Security Forum, then it's sort of responsible as part of that membership to deliver against that international standard. There are really three elements for that and you can see them on the slide. But in essence, what they are is a requirement to provide you with a safer working environment as can reasonably be expected. But obviously in somewhere like Gaza, that's not very safe. But, you know, having said that, you know, there is still, there are still things that you can do to improve people's safety life, for instance, negotiating with local authorities to make sure that the UN is aware of your presence and to demark the places that you're in as safe zones and free of um potential attack by any of the um, opposing factions. I'll come onto that again in a second. The second thing is to provide people with warnings so we can't realistically expect surgeons, anesthetists, obstetricians, nurses in the NHS, um to really sort of fend for themselves in terms of their own safety and security. It's not really their expectation that they would do so because actually the job that we require of our people is to go out and actually teach the knowledge that they have in their head to people. Um And, and, um, you know, that doesn't necessarily involve them, you know, constantly worrying about whether or not the next um, missile attack is gonna be coming their way or whether that thing that they can hear outside is a Iranian drone or someone mowing the knot. You know, because, um, they both sound pen. So the idea is that um, NGO S and people like me and other people like Kirsten, who's in the audience here, one of our program managers um will be linked to all the various entities like the United Nations Department of um Safety and Security, like the International NGO Safety Organization, but also commercial entities that provide warnings of things um that might go wrong and that we then react to those things. And finally, in terms of reaction is having a crisis response mechanism, you'd be surprised how many NGO S don't really have a proper crisis response mechanism in being um interestingly from our perspective. And it's not because I'm giving this lecture today, we've got a table top exercise, not foundation tomorrow to go through our processes and in the event of things going wrong on an operation, what that means from our, from our perspective and in particular, the sort of things you might want to have in place like family, liaison officers or people trained in family liaison and people trained in trauma incident management. Such that counseling can be um uh guide guided, we can be guided towards counseling. So these are the things that you really want to look out for, but we do expect things from you as well. And I know that um surgeons, anesthetists and um other people, particularly at the consultant level are very busy. Um But we do ask you to read these security reports that we send you, we ask them to sign up to the contract and the rest of it and understand what it is that we're trying to achieve so that you can set your activity within the context of the wider program and understanding of where the charity or what the charity is trying to achieve in terms of impact. The reason it's important actually shown on this slide. I don't know if anyone's ever heard of um Steve Dennis, who's the chap top left in this picture or indeed the Norwegian Refugee Council, which is the um NGO for which he worked. But in um 2016, he was uh with a team of four, the other three there at the front of the screen um working in a Dadaab two refugee camp in Northern Kenya. Um There was a VIP visit there and that VIP visit had been sort of publicized quite widely and therefore, you know, became a bit of a target for insurgent groups. And in fact, uh he and his three colleagues were captured by ABA militants and um held captive for four days. Now, you know, of course, when you're capture, you don't know the length of your detention and sometimes you don't know that you're capture. At first, you might be sort of held somewhere, you know, pending safe, you know, passage, going somewhere else. And then after a while you realize that you're a captive. And of course, if you're in somewhere like that, you might, you know, he said that the worst um might well happen of Steve, he really didn't consider that and actually was unable to work for three or four years after um the event because of serious trauma that um came about as a result of what he ultimately perceived to be the Norwegian Refugee Council's um negligence. Now, no one really wants to take a charity to court and claim money from it because, you know, in essence, it's owners are giving them money not to pay claims of negligence, but to get impact on the ground. Of course, you know, charities do take insurance out public and employer liability so often that will be covered by that insurance. But in the end, Steve Dennis, after a while, decided that he would take um his former employer to court and he uh won the case. The Norwegian Courts agreed that um the NRC had been, they should have foreseen that that risk was there and they should have um put things in place and they should have provided better preparation and training and what's more better price mechanism um when um that happened. So, you know, just um note that as being particularly important and you know, this brings it maybe closer to home because this patron was taken by a member of our teaching faculty in January. Um That's plaza um that is a um a house that was occupied solely by medical professionals working for medical aid, Palestinians. Um Two of those people working on that mission were not foundation um consultants. I mean, frankly, II can't claim what they were doing because obviously it wasn't out of charity work, but they were people that are also associated with our charity. And one of them took that photograph. Uh the other um probably only survived the impact of the blast and the blast, the blast that caused um the window to, to blow in because he was bending down to um plug mobile phone to charge. I don't know why he was doing that at six o'clock in the morning, he had done it overnight, but it's probably a good thing that he they did do that because that um crater there is a 1000 lb bond with a, with a, with a um precision targeting um device attached to it and that has been verified by UN DSS and the device was supplied by the Americans um to the Israeli Defense Force. So, you know, whilst, you know, I'm a humanitarian by nature and I don't ascribe, you know, II subscribe to the principles of neutrality. You know, that to me is either a deliberate targeting of medi medical professionals by one side party to a conflict or it's a very um grave error in targeting which you know, needs to be addressed by the international community. So, you know, these things are important and therefore, you know, do rely on things that um will um um I wouldn't say any more because I know that there's time for questions. And I also know that the next week is much more qualified than I am to speak about trauma in low resource settings. So I'll leave it for questions for now, but I'm delighted to be able to chat with you this morning and pass over to this it, that screen. Is there any way I can see what time is? Yes, here. And what time do I thank you for sharing. Bye bye. OK, cool. Um Hi, everyone. Uh Do I need to hold this up here? This this sort of level? Cool. Um Yes, my name is Liz and I'd like to talk to you today uh about the work that we're doing in the D RC. Uh And for a very long time, I was very reluctant to um give talks like this because I felt my Congolese colleagues should be giving this talk. Uh What, why do I have to stand before you today uh to talk about a country that is not my own. Um So I told my Congolese colleagues this and they uh they got really upset with me. Er and they said, what do you mean woman, you had an opportunity to speak about us and speak about our country and you didn't take it, what's wrong with you? Um So I now say yes to these sorts of talks. Um and not because I'm telling their story for them, but I hope that you can hear their voices, um, their voices, um, through what I say today. So, the Democratic Republic of Congo is a country in central Africa. You've heard? Uh, it's been on a map a few times today. It's a really massive country rights mapping of Africa. Um, it is a different country from the Republic of Congo which is a little bit smaller into the north, the part of the Democratic Republic of Congo, er, where I've been engaged and involved. Um historically, way back when was actually the Congo Kingdoms felt with a cave. Er And then it was a huge kingdom that covered most of Southwest current D RCA little bit to the north of it. Um And then also quite a big chunk of Angola. Um and it was a Congo kingdom that was really, really rich in gold, um had a very well structured society uh lived in harmony and in community and their wealth was based on gold. Uh as these stories often go, it didn't stay that way. Uh And the early kind of contact with the outside world was through the Portuguese. Um So cow sailed around Africa and found that there was fresh water in the Atlantic Ocean and thought what's going on here uh and made contact with the Congo Kingdom. Uh history kind of progressed and we've now got these artificial borders um that have divided up this kingdom. But the area where we are is also spelled with AK rather than the c of Congo time sequence of leaders, some phenomenal, the early um Congo kingdom, um early uh independence was Patrus Lumumba, who I think by all accounts would have been an excellent leader and was an excellent leader for the short period that he was in power um assassinated by the CIA uh a sequence of uh further problematic leaders. But the current president is um Felix Giske. Uh And as you've heard, it is a country that is uh at war. Um There are troops from uh Burundi, Rwanda, uh South Africa and Uganda all on Congolese territory. Um And probably don't hear very much about it. It's an enormous country population, 86 million size of Western Europe. Um but well structured and well divided into different health zones and the area where we are, which is a province is marked by the Congo River which connects which uh basically there's port towns of Boma Matadi, this is Matadi. Um and it brings in a huge amount of commerce and trade into the country. It's the main port route by which stuff gets in. Now, there are some rapids just beyond Matadi. Um And those rapids mean that ships come in and then can go no further and the rest of the journey has to happen by road. Uh and so big containers um get offloaded at the port in Matadi and then have to make the journey on this big truck. No, that didn't work. Um in this big truck and you probably can't see. But underneath that truck is a flattened vehicle, completely flat, like a pancake. Uh And so this is a picture of the big, that big road and it illustrates really the, the problems particular to this province. So motorbikes which are basically a factory for open tibia fractures, um a container container and a flattened car underneath which you can imagine is kind of a matched casualty event pretty much. Um, because that little vehicle wouldn't be just transporting one person in the way that it would in the UK, that little vehicles probably got at least 10 people in it. A container truck would have had people traveling between the main cabin of the vehicle and the container itself and there would have been people sat on top of the container. So that's another, I don't know, 20 or 30 people and then driving by at high speed is a government official over four by four, making no attempt to stop or do anything about the situation. It's difficult to know what to do. Talked about the open tibias. This is the daily reality. This is trauma in a low resource setting. Yes, there's active conflict but actually on a, on a regular day in day out basis, this is trauma. An open tibia fracture is a game changer for that patient even in the UK. That's two years of your life, you're never getting back and your leg is never gonna be the same in this sort of context. That leg is never gonna be the same if you keep it, your entire family is affected. So nine times out of 10, this happens to the breadwinner, their income stops, they have no money to pay for their treatment, their family, their entire village is in financial hardship and financial property. So thi this is a, this is a game changer for that person and for their entire community, this is the health system where we are. So there are 31 health zones. Um And I put this picture up because you're starting to get an idea of the complexity of managing this. And this is the level of organization that we're working with for that province. Um Six about 6 million people. Uh and just underneath you see a leader must dream of changing the world. Uh And this is the reality, right? This person sat down and said, I need a map of my province. I need to know what my province looks like and they took it upon themselves to draw it themselves um to tackle these enormous challenges. So as a surgeon, I've uh wrestled often with the care of the individual and the care of the population. Sure, there are many of you perhaps uh in other fields as well who feel that way? Should we just all be public health position? Should we just like sprout the day job? And just think about population health or do we think about the individual or do we do a bit of both? And how do you reconcile a health system that's functioning on, you know, this bit of paper with a really complex challenge of man managing an open tibia. One of the ways of doing that is working in partnership. And this is how I landed in this space of thinking about how do I care for the individual and how do I care about the population? How do I make it better for more than just one person? So King's mental health partnerships is an initiative based out of King's College London. So it's a university as well as the NHS Trust that are associated with it. Um And we really seek to partner together uh with people to change, change what we do and change and improve the quality of care. So there are currently five partnerships. Uh one in Somaliland, which is the very early one which is now in its 24th year. Uh There's a Zambia partnership. Um Sierra Leone, which really uh grew and got started and joined the Ebola outbreak, the D RC and we've been there for about 10 years. Um And the Gambia just joined uh last year, we're really all about long term relationships. We're about um connecting with people who are there and working together to tackle challenges. So it's all about the people. Uh And these are some of the people that I've had the pleasure of working with and I always put up this photo, the man in the red hat. Sell us down Maland. Um, he is a Congolese gentleman from the province where we are Congolese diaspora that came to London in the nineties when er, war was really bad and across the whole country, he said to Andy Leather who is a surgeon at King's, he said, see what you in Somali land come and do something in Congo. Uh And that's where that started. And then the other gentleman I wanna know as well is a ophthalmologist, Congolese ophthalmologist uh who came on that very first trip. Um and he sadly passed away from COVID, but I always mention them both by name. We also work with institutions and I'll say a little bit but more about this uh in a minute. Uh and this is a map just showing those port cities, the bone and theta that I spoke about. So the river only get you so far. And then unfortunately, you can't keep going on the river. You gotta go along that road and these are the um hospitals that we work with at in the province. But along that road, which is where the kind of main uh population kind of conglomerates are, wouldn't really Matadi is a city. Bma's a town, the rest are really villages. I just wanted to mention three kind of uh frameworks in which you could think about improving trauma uh from a kind of assistance point of view. The first is thinking about an individual patient and how they work through that system. And we often call that roadside to rehabilitation. So what do you do where they have their crash? How do you get them to a he healthcare facility? What happens in that healthcare facility? And then what do you do for them afterwards? So that's a kind of a nice way of structuring what you might be able to do at different points for an individual patient or how you might improve the system. The other way to think about it is through the wh O building blocks. Um So this is the health system framework that um is often quoted and I think it's actually still relevant, it's a bit dated, but it still works. Um uh And this is about access coverage, but also quality and safety. So you might think about the individual healthcare building blocks and how you might improve an individual block to make the overall uh better. The other thing that you want to think about is the quality of care. Um And this is from the Institute of Medicine and you're talking about patient centered care, timely care, safe, efficient, equitable and effective. So just three frameworks that you might use in pretty much any domain, I guess. But this is how we kind of have been conceptualizing what we might do specifically related to trauma care and all of that is to strengthen the health system. So the institutions that we work with in we work with the provincial Ministry of Health also a little bit now the National Ministry of Health, but it's quite devolved um the division of health which is a technical branch of uh kind of service delivery and str strategic thinking to the province. And then as I said, um healthcare institutions. So the main hospital, the referral hospital in uh and then also the university which is based in Burma. Uh and people are really important. So some of these people I've worked with for many years, uh Doctor Patricia, she's uh one of only two anesthetists for the entire province, 6 million people. Um I first met her in 2013. Um She's a friend and a colleague. Um And uh really just a lot of what I'm talking about today is because of her and the people you see on the slide, uh our partnership is governed by a General Assembly. Uh And this is our meeting in October of last year. Um So the people standing on the picture uh lead our strategic work and our good governance of what we do. Um They're all in and then on the little screen, you can see the team in London um during our general assembly meeting last year. So I just wanna give a few examples. 23 examples of what, what we're doing in this space in terms of health system strengthening just to give a few kind of concrete bits of what we do. So the first is primary trauma care. How many people have heard of primary trauma care? Not very many more of you should um how many people have heard of ATL S? Yes. OK. So think ATL S but for a low resource setting. So ABCD E yeah, you, you, you guys get this at medical school for a lot of the world. It's revolutionary to have a framework for how you approach a sick patient that lets you breathe and be calm is amazing. So ABCD E is revolutionary. Um And the primary trauma carer lets you do that is a framework, two days, doctors and nurses get trained together on ABCD E with the resources you have available to you. So it really emphasizes on kind of uh clearing an airway but not necessarily intubating the patient. Um We don't have any ventilators anywhere in. So there's no point teaching people to intubate if you then can't put them on a ventilator. So we've now trained about 400 people and this is a course that sustains and runs itself. Um And as part of that, it's now integrated in the into the program. So that's the National Congolese um Ministry of Health Framework for managing um emergency care and humanitarian disasters, that sort of thing. And primary trauma care is now integrated into that. Um And the other thing that we're currently running is a trauma registry. So the WH O has a clinical registry where you log cases that come in and follow their outcome. And we're piloting that at the moment in Matadi. And I just showed this because it's kind of an example of what I mean by partnership, working and working collaboratively. So, on this side, you have a UK based group of volunteers. Um There's a radiologist, there's an ed nurse, there's a Peds nurse. Uh There's a couple of master's students and they're involved in implementing the WH O registry in the D RC all in the distance, all remote. Uh And then on the other side, you have the project implementation team who are based in Matadi. Um So there's the hospital manager, uh there's the coordinator for the National program for emergency preparedness. Um And there's a couple of er doctors and clinicians who work at that hospital. So it's just two groups, different people working together some remote, some on site. The other program I wanna mention is safe surgery saves lives. I, about 10 years ago, had a notion I was gonna treat people how to fix tibias. Actually, what I realized was that people needed to know how to wash their hands and how to monitor oxygen saturation and BP. Um And so we've gone right back to basics. Uh and we introduced this program for it for the first time in 2018. Um and its current iteration, we've just finished another round of funding and about to start a new one. So it's based on the Wh 0 10 pillars uh which is about using the wh O checklist, washing your hands, patient monitoring and working with individuals, institutions and systems. And the idea is that you have a well equipped, well trained, confident, skilled person, nurse, anesthetist technician delivering good quality care in an environment that's well equipped and with a system that is well led and has adequate data. Part of that's a surgery program of work because it's been focused on the quality of care um then made its way into the national quality of care strategy. So this is in Kinshasa in February, uh where we met with um various members of the Ministry of Health at national level to talk about how you introduce surgical anesthetic obstetric care into quality of care conversations. Because today, most of our conversations worldwide in global health, when we talk about quality of care is about H I VTB, malaria material and child health. Uh and the rest of everything else doesn't really get a look in. So this for me is super exciting. Um I'm gonna, I'm probably gonna run out of time because I could talk about this for a long time. Uh But just to mention two of the other things we're doing at the moment, we're um just starting on a program of work with the AO Alliance specifically to talk about fixing tibias. After 10 years of investing in some of the basics, we feel like we're able to move on and start talking about limbs. Um And the other thing to say is that there has been research throughout, but really our focus on research has been around capacity building. So running lots of courses on like um research ethics, basic stats from medical students, um that kind of stuff. So I come back to the title of my talk, which is second crutches. Um And uh I wanna end with this story. So when II lived there for a year 2016, 2017, just worked in the main orthopedic department. Um and this was a patient I treated, he had an ankle fracture for anybody vaguely surgical in the room that was bimalleolar unstable ankle fracture. And I had no kit except for one screw. So I fashioned the best treatment I could uh with my Congolese doc er colleague, Doctor Manu. Um but he really needed to keep this cast on and he couldn't put weight on that ankle or the whole thing was gonna fall apart. So uh he was in bed for quite a long time because he didn't have crutches um because he has e everything is out of pocket, you have to pay for everything. So he had no money to buy crutches. Uh Somebody had gone back to the village to see what money could be gathered in the village. To get him some crutches so that he could then go home, basically leave hospital. So I'd see him day after day. Still in bed. Still not really mobilizing. I was like, what about your crutches? And he may let's see him one day, he's got one crutch and then he's walking with his friend here on the side. Like, no, I told him you can't put weight on that ankle. It's gonna go, it's gonna be a disaster. You know? What, what do you do? Why have you only got one crutch? Like even their right mind buys one crutch. Like, why didn't you buy two? I said doctor have it. I'm so sorry, but I've thought this through, like at the moment I've just got money for one crutch. So I bought the one crutch and my friend here is gonna be my second crutch until we've got enough money so that I can buy the other crutch. So whenever I need to go somewhere, my friend is gonna be with me. He's gonna be my second crutch and I promise you, it's all gonna be like, uh, I mean, there's a, you can, um, you can draw out a lot from that. Um, my first learning point was godless. You're dumb like you haven't got a clue. Uh You have so much to learn. Um, second learning point is your patient probably knows best and they're, they're not done. You might have done, but they're not done. They know what they're doing. Um And then also, I guess the bigger, bigger picture and the bigger story about we face enormous challenges. We were having a discussion this morning about the world is really beautiful. The world is amazing, but it is also incredibly sad and incredibly broken and just of it myself. Um And we face really complex challenges like this is not easy, right? How do you make, how do you make healthcare accessible of good quality for everyone who really needs it? It, it's an enormous task and we're never gonna get there. If we're go alone, we're never gonna get there if it's based on ego and we're never gonna get there if it's based on money or um some kind of other stuff, but we're gonna get there. If we can find a buddy who can be a second crutch, we're gonna get there if we can learn from each other, talk to each other, um make some mistakes along the way, but at least talk to each other and learn from each other. Um I'll just end here um, because I think we've got plenty of time for discussions and there's a whole lot more I could say and please do come and grab me and have a chat. Um This link will take you to a little video. Um We, it just finished a couple of months ago and it's about our safe surgery program of work. Uh And it's all my Congolese colleagues, uh speaking in French and telling you about our safe surgery program of work. Um Also, please do have a look at the website because King's Local Health Partnerships has a number of opportunities at the moment. And uh I've been asked by my Sierra Leone colleagues particularly flagged that they're looking for, sells for Sierra Leone at the moment. Um But there are always lots of opportunities. And also if you go to the website, um, sign up for the newsletter and find out what we do and what have you. Thank you both so much for your thoughts, Angela.