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Good morning, everybody both in person. Uh despite the challenges of the tube strike, rail strike, getting here, well done those that have driven long distances and uh got here. Uh This is the first world offbeat concerned annual conference that we're doing as a hybrid version. So I would like to welcome the attendees from all over the world who have actually come to join us for what I think is going to be quite an exciting and interesting uh collection of things that we have brought together of interest to those of us working in orthopedics in low and middle income countries and bridging the gap, so to speak from uh first world orthopedics here and their responsibilities to global health. So really without further, I do, I'd like to just say thank you very much to Medal and to the V team and the college who have supported us and the B O A more from them later. And I'm just going to go straight into our prerecorded uh confidence talks. The first one is from John Jealous who have known for nearly 30 years and who really epitomizes the best of what we as orthopedic surgeons can do in developing global orthopedics. And with that, I'd like to welcome John Jealous is professor of orthopedics, Founder of Flyspeck and Lorette at the university teaching Hospital in Zambia and is now happily retired farmer but still keeps his finger on the pulse. John over to you, the chairman, colleagues and friends. Good morning and greetings from Zambia. My brief today is to describe the Flyspeck project, how it evolved, how it has survived to the past 40 years and why it is still needed for the foreseeable future Flyspeck was born in 1982 as an orthopedic outreach program for my unit at the university teaching Hospital in Lusaka, responding to requests from several up country doctors. I started to fly out to there hospitals with our junior doctors and medical students. I had already worked in Zambia for 14 years. The first two of which were at ST Francis Hospital, Keitt, a district hospital 300 miles east of Lusaka. The staff are not paraded for us. This was for a visit by the late doctor Kenneth Kaunda, the first presidente of Zambia in 1967. As one of only two doctors, I knew the isolations of working inr oral areas. Zambia is a big country, roughly 2.5 times the size of the British Isles 1000 miles across from southwest to northeast. In 1982 I was in Lusaka and a second orthopedic surgeon worked for the mines on the Copperbelt 200 miles to the north. This slide shows the many routes flown by flyspeck over the years. These have changed as the hospitals have changed and enthusiastic doctors have left 60% of Zambia's population live inr oral areas. Many are subsistence farmers living on less than 2 lbs a day. Zambia is fairly well provided with airstrips. This one at um Peka dates from being a staging post for hurricanes and Spitfires being Ferried to Rhodesia and South Africa. During the second World War, some remote mission hospitals have their own airstrips. This one at these one is able to taxi right into the hospital grounds. There are several reasons for the failure of the referral system. Many patient's dislike moving out of their home area, especially when they are sick. They may have never been on a bus and there may be a language barrier when they reach Lusaka, distances are great. And until the advent of mobile phones, communications were very poor. The cost of travel and accommodation is prohibitive. Even when they reached the overcrowded central hospitals, waiting lists along they will probably be sent home, asked to return at a later date, having exhausted all their funds. Successive governments have tried to overcome these difficulties with mobile clinics and other outreach programs funded by donors. But when the funding stopped, the project collapsed, this mobile dental clinic ran for a year perhaps before the truck broke down and there were no spare parts, aircraft though expensive to run have the economic advantage of being able to travel direct. Whereas roads often deviate for long distances to skirt swamps, rivers and mountains. We can fly to a hospital in four hours which would take two days to reach by road, traveling by air. The doctors are still fit to work on arrival at the hospital. The flyspeck project gradually expanded and as funding increased as we were able to publish the results of our work. Our orthopedic unit became a record, became recognized as a training center for British trainees and staffing increased with visiting teachers from world orthopedic concern. Between 2002 and 2007, we received a large grant from the Dutch government which allowed us to purchase more suitable aircraft, build a hanger to house them in and again expand the project. In 1994 we started our own M Meddoff training program. Flyspeck is an integral part of that training, the postgraduates gain invaluable one on one teaching experience during Flyspeck visits. They are involved in much more surgery than at the university teaching hospital. The visits also provide opportunities for teaching the local doctors, physiotherapists and nurses, burns management, non operative fracture management and emergency resuscitation are popular subjects. The success of a visit depends on efficient preparation at the hospital. They must collect the team from the nearest airfield and set a guard over the aircraft. Patient's must be assembled and those for surgery, admitted, theater and clinic staff must be allocated with sufficient supplies for long operating lists. And lastly, the Flyspeck team has to be fed and accommodated. High spec provides an experienced surgeon and assistant and all the special equipment and implants that may be needed if notified of local shortages, we try to bring. Those two visits are usually for three days. Even with an early start. Most of Thursday morning is spent reaching the hospital flights very from 2 to 4 hours by road. It would take from 6 to 14 hours. First, we examine all the assembled patient's. This varies from around 100 patient's at hospitals without a surgeon to 50 or so where there is a general surgeon and we only need to see those with whom he needs help naturally more major surgery as possible at those hospitals. We do ward rounds and make up the operating list for the next day. The whole of Friday is spent operating often late into the evening on Saturday. Any further urgent surgery is done, POSTOP rounds are made and the after care of the patient's discussed, then we fly home. 60% of the patient seen our Children. Zambia has a very young, rapidly growing population. Half of the population are under 18 years of age. Femoral neck fractures are relatively uncommon congenital deformities, bone and joint infections and neglected trauma are all too common. There is a high incidence of cerebral palsy resulting from teenage pregnancies, severe club foot deformities often untreated for a long time are still a major problem. These often need major surgery and skilled postoperative sprinting. This is the end of surgery position after the foot has been positioned with the medial release and tendon transfers. The medial wound is closed with a 4 ft rotation flap. Blount's disease is common even in Children that are not overweight, lacking effective early treatment. Hemet. Oh, Jenness osteomyelitis presents many problems. Doctor Gornje Vich joined us in 1994. He is Zambia's only plastic surgeon. He quickly became a keen member of the flyspeck project and is now an experienced pilot. He is the coordinator of the project. Currently, Goran has gained world world renown for his management of hair lip and cleft palate. This is the same patient after surgery. This is another patient with a severe cleft and this photograph was taken at the end of the operation. Severe bones are a common occurrence in this society that lives in thatched huts and cooks over open fires. The cold winter months come in the middle of a seven month long dry season. Teaching burns management is an important is as important as correcting the horrible contractures revolt resulting from delayed treatment. Another patient with a severe neck contracture and the view from the side, this is her appearance towards the end of treatment. Doctor Goran is still the only plastic surgeon in Zambia, but six orthopedic surgeons regularly fly out with Flyspeck whenever possible, they visit the same hospitals to improve continuity and communications. 10 post graduate trainees are currently on the M med program and take turns to travel as assistance, Alberto Gregory and Trish o'connor, who both spent six months with me at the university teaching Hospital in 1992 visits, Zambia for up to six months each year. They also run the UK office for Flyspeck organized fundraising and publish our reports and newsletters. Last year, Flyspeck made 64 visits to 15 hospitals. Nearly 4000 patient's were seen and over 1000 operations were performed. About two thirds of those were major surgical procedures. The total expenditure was 79,000 lbs. All patient's are treated free of charge in all the surgeons traveled over 14,000 miles by air and nearly 7000 miles by road. One of our surgeons alot Moyo does not like flying. He makes monthly visits to ST Francis Hospital got 80 by road, a round trip of 600 miles, seven hours of driving each way depending on the state of the road. How he remains so cheerful. I do not know. In 1988 our house burnt down and the Flyspeck records were lost since then. Though we have made over 2600 trips seen nearly 90,000 patient's and performed nearly 27,000 operations at remote hospitals. Why has Flyspeck lasted for 40 years? Whereas other projects have often failed first flyspeck needs, meets easily recognized unmet needs. It reduces the isolations of upcountry doctors and helps them in the management of the physically disabled. Secondly, it is run by enthusiastic volunteer pilots and surgeons to help equally enthusiastic medical professionals up country. Thirdly control, we have a memorandum of understanding with the Ministry of Health but received no government funding. The ministry does not exercise control nor dictate which hospitals we visit. We never go where we are not invited. Fourthly reliability, we agreed to a program booked six months in advance. Everyone knows when we are coming. This is extremely important. Patient's may still have to travel for days to reach the local hospital. The hospitals must be well prepared to receive them. If the flyspeck team does not arrive, it is a disaster. Occasionally the weather maybe unf liable or mechanical problems may arise with the aircraft. Then departure may be delayed or long journeys made by road but visits are very rarely canceled. What of the future? Much has changed over the last 40 years as a result of the M med orthopedics program, Zambia now has 60 orthopedic surgeons but most still work at the central hospitals. Some were posted to the provinces immediately after they passed their m med examinations and they struggled to work in ill equipped departments. Flyspeck can give them a lot of material support. The road network has improved but transport over long distances is too expensive for the rel poor communications are vastly better. Since the advent of the mobile phone, we can stay in touch with the hospitals we visit, monitoring postoperative problems and preparing for future visits. Meanwhile, however, the population have Zam as Alb Zambia has grown from six million in 1982 to 20 million. Now, the number of patient's needing help from flyspeck continually increases. The central hospitals are still not able to cope with their workload. The Ruhr A population is still impoverished and specialist surfaces are still out of reach. We have avoided any suggestion of becoming part of government services because of the rate of population growth. Ministries of health are always chronically underfunded. Their priorities are primary healthcare and the provision of basic surgical services in these fields. They are continually expanding. No resources would consistently be available for the local treatment of chronic physical disability. The work of the Flyspeck project is only limited by the availability of funding pilots and surgeons if these can be met, Flyspeck will continue in the foreseeable future. Flyspeck will still be needed as an economic answer to physical disability in the rle areas of Zambia. Thank you for your attention. Thank you very much for that, John. I think John is hoping to be online. Do we have him online? Yes. Are any questions for John from the floor and for the young youngsters amongst you? It's a great place to go and spend an elective or six months of out of program experience and hopefully people will allow us to do that in the future with the support of the S A C. Do you have any questions in the chat room? Okay. Okay. Yes. What would you change it? You know, are there less? It's the pathology that you see changing in any way or is it still the same old, same old problems that you saw when you first started? Good morning? I hope you can hear me. We can good. Um Yes, the pathology is changing. Uh better robes mean bigger and better road accidents. So the trauma in some of the neural health hospitals now mimics the trauma that you've seen in and around the city's. Uh it used to be more animal injuries and that sort of thing. But otherwise I think, you know, there's really little change. The conditions in the remote areas are still much the same as they were 40 years ago. You've got another question there. Hi. Uh No excellent talk and really inspiring. So again, on the lines of the same question, which is the first question, the pathology changing. Uh What is the role of you think those 60 orthopedic surgeons who are already in place? Do you think you're seeing less of neglected trauma or delayed presentations? And is there any sort of thought of integrating and we were having a chat with Alberta this morning uh integrating the traditional bone setters, which are quite so if you know, the first go to in these countries normally for people from the Ruhr, a population especially. Uh so has that been brought into the picture? Maybe so if you know, worth training them uh to apply better plasters uh or early ruffle. Um So just your thoughts on that. Yes. Um Zambia has never really had a great tradition of uh bone settings. Uh I remember uh seeing um uh examples of their work of several of our Association of Surgeons of East Africa conferences uh from, from Uganda and East Africa. But there really hasn't been much of a traditional home setting um picture in, in, in Zambia. So uh there really is no integration. The bigger thing is that Zambia has a relatively good physiotherapy service and there are physiotherapists in many of these royal hospitals and clinics and it's them, I think who will take over the, the the primary care of things like Club Foot. And you know, there's a great deal of effort to, to train them in, in the methods of treatment of uh deformities and and primary care. But uh there's the village doctors have not to my knowledge really ever been very interested or treating fractures. They seem to recognize that this is something for the hospital. And after giving a supportive potions will send the patient on to the hospital for further treatment bill. Uh We have a question from the online audience um from Sioux full of love in Southwest England. How does Flyspeck raise so much money each year? Well, really, you should ask Alberta the question over to the chairman. Um, uh, most of our money does come from, from Britain. And America Goran raises a great deal. He puts his funding from Smile Train and Research International. Uh, they support his work that is done through Flyspeck. So, a good deal of money comes through that. There's another organization in America Wings of hope. They have supported us very well in uh sourcing the aircraft and spare parts for us and also fundraising for us in the States. But I think still the major surgery comes from Britain and it comes from a multiple of organizations. The, the, the bite trust is one or often helps us with material things like a new engine for an airplane or something of that. And uh as I say, Alberto and Trish will tell you more where they raise all the other funds which keep us going. We have another question from the online audience from Zealot went and they're asking what stage of training do you need to be at to join the project as a surgeon? That's a uh quite a difficult question because it really relates to what ones experience has been of the sorts of pathology that one's going to see in Africa. Um I think a preliminary visit is always necessary to see the setup where it, where it goes. We used to have regular visits from the older orthopedic surgeons of walk some 20 years ago and they were familiar with a wide range of general orthopedic surgery. I've not practiced in Britain or Europe in the last 50 years. But my impression is now that, um, surgeons are becoming rather super specialized and they would be very welcome to come and teach aspects of their experience at the, at the teaching hospital. But when it comes down to actual work in the remoter hospitals, um it's a whole new ballgame to be learned and some awful mistakes can be made if you don't understand the pathology, the the lack of uh laboratory support, the comparative lack of follow up and this sort of thing. So I think it's best to get in at an early stage and get experience of this type of orthopedics and gradually uh see by visit um how things are developing and learn new skills because I think a lot of uh teaching hospital uh orthopedics from, from Britain America and such are a little bit irrelevant in detail. Whereas obviously the basic principles still exist, John, thank you very very much for joining us. We really appreciate this insight into what has been an amazing journey. As uh one of my colleagues in Zambia said the father of orthopedics in Zambia, but possibly one of the uncles of orthopedics in East Africa. Thank you very much John. It's been a pleasure and a whole new technology for me. Thanks very much.