Dr. Monica Langer - Global Pediatric Surgery: Landscape and Journey

All right. Good morning, everyone. Today, I have the great honor to welcome Dr. Monica Langer to speak to us today, Grand Rounds. Dr. Langer came to us by way of growing up in Canada. She got her undergraduate degree from University of Calgary, moved a little bit east to the University of Saskatchewan for medical school, where she graduated with great distinction. She did residency at the University of British Columbia, and they liked her so much there that she stayed there for her pediatric surgery fellowship. She did research fellowship with Dr. Jackson, which is where we got to know her. And after her pediatric surgical fellowship, she went to main medical center where she began her clinical practice. During that time, she got her public health degree and master's of public health and developing countries of the London School of hygiene and tropical medicine. And after her first five years in Maine, she then moved to the Northwestern in Chicago, where she spent roughly the next decade before coming to us. And just this past year. The most sort of her great passion, as best I can tell from reading about her and talking to her, is her global health work that she does. She commits about half of her time in Tanzania, where she has been working diligently developing a clinical and education infrastructure for pediatric surgery there. And that's what we look forward to hearing about today. She's really made some awesome progress every time I hear what she does there. She mentions it and just casually and passing. And it's really amazing work that she does. She undersells it on a regular basis. And for my personal perspective, as a fellow, it's awesome having her across the hall. We bug her all the time as she makes the mistake of leaving her door open. And she always brings really a fresh perspective to us where we get so used to the way that we do things here in a research rich resource rich environment. And she'll stop you and say, why are you doing that? Well, that's how I do it. She goes, well, why you don't need eight pro wings. You can just use one micro for all of that. And I think that's it's really great. She sort of makes you question everything you're doing and making sure you're really thinking through it appropriately. So I look forward to her talk as I'm sure I can speak on behalf of our house and say that we are excited to hear about your talk today. Thanks, Dr. Lair. Thank you so much for inviting me to present grad rounds today. And I can't really see you guys, but to the fellows and everybody who's come. My only disclosure, I don't know about this closure slide, but my only disclosure is that most of my work has been focused in Africa. So you're going to see a definite bias towards Africa here, but it doesn't. It shouldn't infer that that means that global surgery isn't very global and encompassing the whole world. It's just that that's where my experience lies. It's also an area of particular need. So briefly today's talk is going to cover a few things. And I spoke with quite a few of you about how much I should introduce global surgery is something everybody already knows about or should I just start with fairly basic understanding and the consensus was definitely start basic. So we'll just talk about what the definition is and sort of how it's evolved a little bit. Why I care about it and why I think others should care about it or what's the value of global surgery and some of the facets of global surgery and specifically looking at some examples of work that's been done from here from Harvard Medical School, some examples from my work and then future directions. And then what often people want to know is how do they get involved or how did I do this and how could they have a experience in global in global health. And so there'll be a few slides at the end for that. I would welcome any questions. So please interrupt anytime. So this is what many people and what I used to think of global surgery doctors flying around Africa doing it in a certain surgery in places that didn't have anyone there and in locations of need and some people I would say the majority of people when I talk about it now ask me if I'm going on mission trips. And that is definitely one way of doing global surgery is still probably the most common way that surgeons are involved. Also very common way for students to get involved and it has definitely tangible value and some deficits or some things they can trip you up, but it's not exactly the focus of today's talk. I'm going to be speaking more about the academic side of it. The second picture is a doctor looking after a child in Somalia. I think is from the 1992 famine, which is the first time I woke up to the idea of global health and I saw a program on CBC, which is the Canadian Broadcasting Corporation and my mom tells me I don't actually remember this conversation, but I walked away from that and came and told my mom mom someday when I grow up. I'm going to be a doctor who looks after children in Africa and unlike my dreams of being an Olympic figure skater or foreign diplomat. This one I never really lost that drive. So I just wanted to highlight before I show the definition that this paper is from the Lancet from 2014 so 10 years ago and global surgery defining an emerging global health field. So this is a relatively new field. If you don't know the definition, that's great. Nobody did 10 years ago and you kind of have to search for it. So this was really in preparation for a publication the next year, the Lancet Commission on Global Surgery. I'll talk about in a minute, but it specifically says that global surgery is an area of study, research, practice and advocacy that improves health outcomes, achieving health equity for all people who require surgical care. Specifically focusing on underserved populations and populations in crisis. It's a synthesis of population based strategies with individual surgical care. So importantly, this is sometimes not a good marriage, but it's a marriage between public health and surgery, which are a bit competing. So we often think of looking after individual patients and focusing on one person at a time and when you think public health, you really think population based and global surgery brings these together. So it's hopefully benefiting or using the strengths of both of these. So then we can talk about what is academic surgery and this isn't specific to global surgery, but I like to include this because actually for me, it's a reminder of what the focus of academic surgery is for no matter what your particular area of interest. And some people just think academic surgeon is somebody who works at a medical school or is part of a faculty at the Department of Surgery. And a more precise definition might be anyone who contributes to the intellectual life of a department or discipline of surgery in a serious systematic way. And in this paper, they talk about seven different ways where you might contribute to the intellectual life, identifying complex problems, becoming an expert in the field, innovating, observing new treatment outcomes for your innovations, spreading knowledge and expertise, asking important questions and training the next generation of surgeons and scientists. And certainly this is amenable to any of the particular areas of interest in surgery, but definitely also in global surgery. And I think some of the problems that we have in global surgery are complex on a scale that we don't really think about all the time. And the opportunities for innovation are really also enormous. So when I think about it in the, this was my Venn diagram, what is global surgery is really the overlap between public health or population health and surgery and academic global surgery is just incorporating that into an academic career. So the facets that I'm going to speak about today is really these five areas, which is epidemiology, you're looking at the burden of disease from surgical problems advocacy and policy change clinical work training and research. And so I think as I said before, if you just think of mission trips or things that's more on the clinical work side of things, but I'm going to look at all of these areas. First of all, epidemiology or as I'm considering it in this talk, the landscape of global surgery. So what is the landscape? What's the question that's only really been asked recently and until 2015 we would have basically been in the dark. There's not much that we had to go on. There was no sort of large systematic overview of it. And it hadn't been well described. And I have, I had a picture of the blind leading the blind. And I think there was leaders. I'm not sure they had followers. So they're the first time that people really coalesced to work together in this field was the Lancet Commission for Global Surgery. And John Mira, who many of you will know, was the first author on this paper. And there's many people who contributed from Harvard Medical School because it was particularly a big focus of the FGSSC, which is a program for global surgery and social change. And it's our landmark study. So I think if there if anyone is interested in global surgery, if you want to get a flavor of like all things were in 2015 and it's not that much different now. This is really the paper to look at. It's the paper that everyone references. And it's what started sort of an academic rigorous pursuit on a bigger scale because we then had the problem sort of outlined our epidemiology of what was going on defined and could move forward. The website here is basically a way of going through that paper in a sort of very digestible format because it's about 50 pages, but it's great. I would highly recommend it. So what what is the landscape? 5 billion people lack access to safe and affordable surgery. So unless you know that the world's population is around 8 billion that doesn't sound that impressive, but 2 thirds of the world does not have access to safe and affordable surgery. Now in a high income setting such as ours less than 5% of people lack access, but in low and middle income countries and LMIC is a abbreviation you'll see throughout the stock low and middle income countries. Almost 95% of people lack access or in 2015 lacks access to safe and affordable surgery. And from this heat map, you can see I hope it's showing up well, but the darkest areas are the ones with the least access. And so that's Southeast Asia and the majority of sub to sub to her in Africa. This the need is can be a little bit staggering. We need yearly 143 million more surgeries to meet the needs just just basic needs. And when we say safe and affordable 25% of people who access surgical care around the world will be impoverished because of it. So this also has to be addressed because if accessing surgery puts your family into poverty, it's a real barrier. So why do why why is it such a big discrepancy through the world? Why why does 2 thirds of the world lack access to surgery? Well, the workforce is a big problem. So this is a study that was done. Only ever published in abstract form, but it forms a huge backbone of some of the recommendations of the Lanark Commission. And what they did was they use population metrics, so they use maternal survival. And this is importantly something that every country records. So they everybody records what their maternal mortality rate is. And then they graph that against the surgical workforce density. So the number of surgeons, anesthesiologists and obstetricians for 100,000 people. And what you can see here is that there's an inflection point on this graph around 20. So your maternal mortality increases significantly with a workforce for us below 20. There's plenty of things that affect maternal mortality. It's not only access to surgeons and anesthesiologists, but there is definitely a direct correlation. And that's for cesarean sections postpartum hemorrhage, other things like that that need surgical care. But it's also likely a marker of other things that are required for surgery that are going to be affecting the care of patients. So an adequate blood bank that has blood available. If you have surgery, that becomes a priority in your hospital. And if you don't have surgical care in your hospital, you may not have the same access to blood. Laboratory services. The ability to resuscitate patients, maybe an ICU, all of those things are not necessarily associated with surgery, but are more likely to be there when you have surgeons, anesthesiologists and obstetricians looking after patients. So it may be a marker, but it's also true that the workforce density is important. So that became a goal. And now for low and middle income countries, the goal is at least 20 surgeons, anesthetists and obstetricians for 100,000 people. In many countries around the world, it's less than five. And as you can imagine, the efforts needed to scale up to be able to have that kind of a workforce is enormous. The Lancet Commission's goal was that by 2030, 80% of the world would have access to safe and affordable surgery. We really aren't on track to meet those metrics, but we need to keep that in mind. So distance to a hospital with surgical capabilities. If you live more than two hours from a hospital, they considered that poor access. So two hours, they measured it in different ways, but within two hours of somewhere that has surgical capabilities and actually does surgery. So you may be near a hospital that has an operating theater, but they have done three cases in the last year. And shockingly, this is not that uncommon. And then protection from impoverishing catastrophic costs, because even if you live down the road from the hospital that has a functional operating theater and actually does cases, if you can't afford the surgical care, you may not access it. And I see this a lot that people wait because pushing their family into poverty isn't something that people are going to make that choice voluntarily. And then poor quality. And I've put that specifically last. It's often a focus of interventions because, you know, it's something you can say, like, OK, well, we can do quality improvement projects for your department of surgery. And I think that's great. I mean, that is needed. Certainly, because there are poor outcomes in much of the world. But a couple of my colleagues in Tanzania were talking in the hallway. So a couple of the surgeons, they were saying, uh, that's quality stuff. They're trying to push on us. They're totally disparaging, but they said, you know, you can't really talk about water quality until you have some water. And it was really like enlightening to me. Like we have to have some water before we start measuring the quality of what we're drinking. So now I'm going to zoom in a little bit. So that's sort of some of the landscape. And now we'll focus a little bit more on Uganda where I worked for around 10, 12 years. And it is the Pearl of Africa. And many people don't know about, don't know exactly where it is. So hopefully now you understand it's sort of a landlock East African country. And it's a beautiful country is actually like so green and lush, which isn't how I imagine things. Many people, they're only thought about Uganda is from the movie, The Last King of Scotland. And certainly the effects of Edie Amine and his rule and then the subsequent rule of the leader who's currently in power have a massive impact on the people and. And how people function there. And then I think when we think population pyramids, this is something you would have seen from like the 1920s in North America or maybe the 1800s, but it's actually a pyramid. And you can see that more than half of the people living in Uganda are under the age of 18. And that is very typical of many sub-Saharan African places, which is why pediatric surgery is so important as a, you know, let's looking after half the population. So currently there's 47 million people there, 27 million of which are 0 to 18. And in 2011, so when I started working there, there was one pediatric surgeon. John Cicabira, he was looking after 20 million children and he himself had only gotten training in pediatric surgery because there was a visiting surgeon from England who came and saw that he was volunteering. So he was a general surgeon volunteering on the pediatric surgery ward and had been for seven years not paid. He did some general surgery on the side to like keep himself going keep his family fed. He's got four children. But he was so passionate about pediatric surgery that he was there volunteering looking after these children. And without this surgeon from England's intervention, I don't know if he would have ever gotten formal training, but he arranged for him to go get training in South Africa. And I think that is one thing that there was no opportunity to train in Uganda. There was no possibility to do a fellowship there. And so he went for two years, worked in South Africa, did his fellowship in South Africa and came back and was really providing pediatric surgery. But he's only one man. He got two OR days per week. There was no pediatric anesthesia. So he tells me that often he would integrate the patient and then do the operation because he couldn't trust anyone else to really integrate very small children. He's amazing. And now I'm going to focus on one patient that was one of the patients that I met the first time I went in 2011. And I think that it's a really good thing for an annual reximal affirmation and we should be giving definitive surgery to these children, particularly because in Africa, they don't have stoma bags. So they just wrap a rag around them. And then it's particularly difficult in their society. Children can't go to school with an ostomy. So if you have a stoma, you don't get an education. It's also hard for them to just function in regular day to day life. Like their families don't really feel comfortable bringing them to church. We're going to the market with them and things like that. So they're really sort of hidden away. But with one pediatric surgeon in the entire country, she wasn't able to get to Campala. It took her and her mother and their younger sister over a day to walk to Isshako where we were doing a surgery camp with the local team. To access care to get a piece of art at the age of doing a half or almost three. And her mother thought that that was great because she didn't have to go to Campala, which would be multiple days trip and then she'd be stuck there because as you can imagine, there's quite a backlog of cases. So if you come with something that's elective, you get added on to their weight list, which when I last looked at it in 2021 was over a thousand cases. People just don't come off the weight list. In this particular hospital in Isshako, it was a newly built hospital in the last 10 years. And they had some beautiful operating theaters and they had never been used because they didn't have people there to use them. So there was three or four lovely operating theaters and good anesthetic machines. And we were the first team to really like come and use them. I think that they've been subsequently doing more cases, but it was shocking to me. We were able to provide the surgery for free, but for most people. 70 to 80% of their healthcare expenditure is out of pocket in Uganda and much of sub to her in Africa. So I'm using Uganda as an example, but this is a this a normal thing. And when we asked I had a medical student do a project with me. Actually, it was her idea and I thought, who seems kind of odd. I sure I'll help you with it, but she went to a hospital and simply asked the families of children who had surgery. How did you pay for it? And they did exactly what we would do here. You ask friends and family. So we don't have go fund me there, but they have lots of friends and families. So they ask their friends and family. They sold things that they had so they would sell their livestock. And 60% of them used the only savings they had, which was the school fees for their other children or for that child. But that's such a tragedy to me because that means that education, which is the best ticket out of poverty is them being taken away from that family. And that's like the that's the impact of impoverishing costs. It's not it's not that they don't eat because they have their subsistence farmers. They actually are going to eat. So they'll survive, but they might not get an education and that's going to have a massive impact on the next generations. And then I do know of some adult surgeons who are doing peace harps. Obviously, there's a whole backlog of cases and parents are desperate to get their children looked after. And there was some real tragic cases that had been operated on by adult surgeons and just had terrible outcomes. And as you can imagine, that's worse than a colostomy. So she's the example for me of like these are sort of the tangible things of the impact or the reasons for the lack of access. Collins isn't an anomaly. I just want to like put this in perspective that 94% of children with a congenital anomaly are born in low and middle income countries. We're only seeing a very small percentage of these children 85% of children with cancer live in low and middle income countries. And of the children who die of trauma 95% of those are in low and middle income countries. So the scope of the problem is actually humongous, which means there's so much potential for impact. Like the problem is enormous, but interventions that can improve access to safe and affordable surgery can make such a massive difference because there's so much potential people who can benefit. So access affordable high quality. And so research that is driven by local problems with solutions that will work locally is so important because our solutions are not always you can't just, you know, import our solutions, which are often very resource intensive often involve a lot of workforce. And often aren't really like culturally how they do things. So it's a very foreign way of doing things as well. So that brings us to surgical workforce density and I showed you the graph before of this correlation between maternal mortality or survival and surgical workforce. And so one question that I had was, can we look at infant survival or childhood survival or neonatal survival and see if there's a correlation with the pediatric surgical workforce density. And so we did a study looking at this we graph the pediatric surgical workforce density in a number of countries that we actually had like robust data. So we needed to have very accurate data to do this. And this is our graph looks quite similar to the graph on maternal mortality and looking at the gosh, the experiment correlation coefficient. Basically the cut point was we need at least 0.37 or almost 0.4 pediatric surgeons. And we didn't include anesthesia on this pediatric surgeons per 100,000 children to change to for the inflection point of survival. And it was the same for neonatal infant and child survival. And we might say like, okay, you have a correlation, but like does it really mean something for actual surgical problems. And this was in the setting of a study that I've been done one year earlier looking specifically at survival from surgical problems gastroskeases, a soft, a deal and a test and a tree and tie fight perforation. So we found really things that need a pediatric surgical care. And they found that the pediatric surgical workforce density of 0.4 for 100,000 children was what was needed to improve the survival to have an adequate the inflection point for the survival. So we found exactly the same thing with our population metrics as they did looking at specific survival from these particular diseases around the world. I think it's so fascinating because obviously neonatal mortality is a lot more than surgical problems. In fact, most of it isn't surgical. Again, though, a lot of the important things that come with having a pediatric surgeon are going to be brought to a hospital in terms of resources, expertise. So how many more pediatric surgeons does Africa need then if we say that we need 0.37 for 100,000 children. The pediatric population in sub-Saharan Africa is 650 million. This was a couple years ago, but around there's two years ago or three years ago, there was 110 pediatric surgeons. So one for every six million children approximately. And so they need around 2,295 more surgeons at that time. That's a staggering number. I mean, we train a lot of people in North America, but 2,295 is just a humongous number. And so this is sort of this was my part of the contributing to this. So when I started working in Uganda, I went there in 2011 as a fellow and I spent two weeks with the team there. And John Sykabira, as I mentioned, was the only pediatric surgeon working there. And afterwards I was working and I wanted to do some global health. So, you know, I called John up and I said, can I come help? And basically he's like, sure, great. Love to have you. So I went and did some clinical work. I would cover him so he could go to a conference. Otherwise, there was really no one covering the service. And in 2014, he decided to start a fellowship program. And it was accredited by Kosteksa with a stipulation that they had some external faculty so that they aren't trained by only one person. And our first fellow was NASA here and then Philis, Arlene, and innocent sister, Missenga, Stella, who was here. This is not the most flattering picture of Roving, who was supposed to come, Felix and Charles. These are the graduates of the program and there's six more in fellowship training right now. And it means that they no longer need external faculty for their program. Now, is this, it's like a drop in the bucket for compared to needing 2,295. But this has allowed them to have pediatric surgeries at three centers in Uganda. That has improved the access to care for those children dramatically. And everyone you add is like a huge improvement. So while it's like a slow start, they really, it really has made a massive difference. So this is kind of talking about my path and then I've become redundant. So I'm no longer really needed in Uganda in the same way. And I think that success, that's great when they can take over. Now do they still need international collaborators? Absolutely, there's many things. And I've done some research with them. I continue to be involved in helping with their training programs. So I do some like zoom lectures and help them prepare for their exams. But one of the pediatric surgeons who was trained there was from Tanzania sister, Missenga, and she started pediatric surgery in one of us. So just across the lake, which is a massive lake. And ask me if I would comment help her with a clinical program and hopefully getting a fellowship started. And just this last week, we heard that we've gotten a accreditation from Josexa to start our fellowship in January. So it's very exciting. And we'll be starting with a couple fellows in January. There's there's sort of 10 million children with this hospital and currently there are two pediatric surgeons sister, Missenga, who's started it and is also the chief of surgery and refile, who's one year into practice. So you can imagine they were hoping to have a little bit more senior help. And so that's why I've been having a higher commitment there. And I'm excited to see how it's going to change as we have fellows there. And I expect that many of those fellows will like stay on or else go to other communities that don't have pediatric surgeons at the moment. I just want to highlight something else from Uganda because I don't know if people know how amazing some of the people are and Ben Warf is a pediatric neurosurgeon here. And he spent I think 10 years living and working in Uganda and he actually had a clinical focus of neuro oncology before he went. But he felt called to go to Uganda. He took his whole family. They worked at this chair hospital, which is funded by I think American charity. But specifically looking at neurologic problems and what he found was neuro oncology is a problem. But what they really had a lot of problems. This was hydrocephalus. They have congenital hydrocephalus, which I have just been educating myself on in the last week. It's relatively high. It's almost four per thousand live first. And then they have a lot of acquired hydrocephalus, which we don't see here, which is a post-infectious problem. And our solution is VPCIns, which are very good at treating hydrocephalus. However, anyone who has been in the operating room will know that there's lots of re operations for VPCIns. And if you have very poor access to surgery and very limited resources choosing a surgery where you need very good immediate access to re operations with high quality care is a very difficult choice. So he developed this endoscopic treatment. And this is one of the coolest things because it's one of the very few south to north in innovations in surgery that I know of. I'm sure that there are others, but it was specifically addressing the problem that they had with the way that things were being treated surgically. And it came up with such an innovative solution that is now used around the world. And in fact, he's a charity that trains neurosurgeons around the world in this technique helps it like gives them mentorship and provides them the resources that they need in terms of infrastructure to actually be able to do it. And it's really amazing. I just think it's so amazing. And he's actually gotten the MacArthur, Jr. Award because of it, which is totally appropriate. So some of the things that people wonder about is isn't surgery very expensive and isn't sort of a luxury item, maybe along the lines of a Louis Vuitton bag compared to vaccinations, let's say, which obviously are cheap, kind of like these plastic grocery bags. And I just want to compare the costs, specifically using the example of tetanus compared to inguilernia. So what are we treating or preventing we're treating neonatal tetanus or preventing it with immunizations and causes deaths, but we're doing great actually around the world. The number of tetanus deaths is very, very low now compared to what it was because it's getting at least two doses of DPT. So what are we treating with inguilernia? This is kind of a graphic picture, sorry, but hernias in Africa are sometimes lanced because they're thought to be abscesses. So this is a lanced hernia. And the cumulative incidence is actually fairly high in young children and it's an instance of around 7%. In voice, around 0.7% in girls. So relatively common problem. If we look at the cost of DPT, let's say in Africa, 21 cents for 10 doses. So it's very, very cheap. You've got some syringe costs, the health care workers costs, travel costs, but it only costs around $12 for disability adjusted life, you're saved. And I'll go into what that is in a second. So how expensive is surgery? So the only way to compare them is to find a common denominator in terms of how you can look at the outcomes. So disability adjusted life years are the metric that we use to compare surgery to vaccinations. And one of my friends, Gareth, who was a resident in University of British Columbia, did a small study looking at pediatric inguilernia repairs done. At the same time as I was looking, we were looking after Collins. He was collecting data on all the hernia patients looked at 65 patients who had 69 repairs and he measured the cost, cost and did a mark off model. So this is just an example of some of the research that can be done. So the system was $87 and then he also included the cost of the family. And if we looked at the estimates of years of life lost due to death or disability, then you can calculate how many disability adjusted life years were saved. So this is a disability adjusted life here. We should be living from birth to our optimal limit of life, but death, early death or illness can shorten the number of healthy years that we have. And it allows comparison of different diseases, problems and treatments. So it's like a really useful metric for comparing things that are very different. You know, vaccines to vaccines is one thing, but comparing clean water to vaccines or clean water to surgery, you really need a different metric. So how expensive a surgery when we look at tetanus, inglo and hernia repairs are the same for disability adjusted life years saved. It's $12. Anything below $35 is considered extremely cost effective and should be funded by all governments, basically, is like sort of the public health. So Logan for disability adjusted life years and the cost of care, it's not at all a luxury item. And when we look at comparing cost effectiveness for all sorts of surgery, this is from the Lancet Commission. So sure, there's definitely some expensive surgeries like we've got orthopedics comes out here to around 500 ophthalmic surgery, you can go apparently into infinity. But if you look at hydrocephalus surgery, general surgery, adult male circumcision, that is not for your logic problems, that's to prevent HIV transmission. And then we compare them to some medical interventions. I just want to show you that I think everybody thinks that people with HIV should get antiretrovirals. And in fact, there's been huge strides made throughout Africa, so that most people who are HIV positive have access to antiretrovirals. And that's at a cost of, you know, around $5 to $600 per disability adjusted life years saved. We're, we're well below that with general surgery. And you look at vaccinations, they're, they're down here, but bed nets from malaria are the same as some of our general surgery interventions. So because we have so many people who need surgery, I told you we need 143 million more operations every year. It's still costly to scale this up, no matter how cheap the surgery is, it's going to cost a lot. So it's the Lancet Commission estimated that it will cost around $420 billion to scale up so that 80% of the world has access to safe and affordable surgery. The cost of not doing anything is actually much, much greater. It's not as tangible because they're not, it's not an actual output, but it's the loss of productivity because it's often people who need surgery often the ones who are earning money or it affects their ability to earn money. So if we do nothing and I have to say the trajectory is more for the latter, the cost to the, to the world is 12.3 trillion. The three key steps that they talk about is including surgical care within publicly financed health coverage policies. Getting everybody universal health coverage is a real focus of the world health organization. And surgery has almost never been included in that. So just including surgery in that is one of the steps that they're recommending they take. Scale up in surgical services within national health services and monitor financial flows to ensure that there's accountability and transparency. That's some of the, I hope that gives sort of some of the landscape and some of the areas where people are working. And now I'm going to sort of focus on what people might be interested in as should I get involved is there's a way for me to participate. And I think of it as sort of like an analogy to being a surgeon scientist, not everyone is going to have a PhD and run a lab. But people still want to be involved in science and it might be that you're contributing a case, you know, some cases to a case reporter case series. It may be that people collaborate with researchers or scientists to provide the patients or to test out the new surgical innovation. It may be developing academic expertise or innovations or it might be that people are getting a PhD and running a lab and doing amazing things to address a particular disease and problem and dedicating their life's work to that. I get the impression that people tell me because I work half time in Africa right now. They're like, oh, but you're doing it the right way. Well, actually, that's not true. There's lots of ways to do global health. And there's no right way just like you wouldn't say that science in surgery should only be done by surgeon scientists who dedicate their entire lives to doing page to doing sort of high level work. That's great. And we need to collaborate with them. And obviously they should be leaders in the field. But there's lots of ways to be involved. So supporting trainees or surgeons in low and middle income countries through remote options is maybe like a very easy way to get involved working with people from low and middle income countries either here or there. There's a lot of observers who want to come here and work and just showing them what we're doing and giving them the opportunity to see things. That's helpful. They don't get the experience of looking after patients the same way we do. And maybe they will never have ECMO, but it doesn't mean that they can't learn from that. Some people are going to develop academic expertise, innovate and develop programs and some may live and work in low reserve settings. And I think often people think about Paul farmer as an example of like that's what global surgery is. And that's one amazing way of doing it. He's had a massive impact on the field. But it's not the only way. So if you're interested, there's all of these facets of global surgery. And there's all sorts of different ways that people can get involved students and trainees can work with students and trainees in low and middle income countries and incision is an international student network that has students all over the world who are interested in surgery and you could participate in that and get involved in the things that they're doing. Research projects this. Gareth is now a surgical oncologist in central BC who doesn't really do pediatric surgery, but he did this as a small project during his research year. And it's actually cited by a number of people because it was the first time people actually measured the cost of doing an ingloherner of parent children in Africa. People could do a research fellowship in global health. And there's ways of doing that here. The program for surgery and global change global surgery and social change. I'm hoping to have research fellows join me. There's also clinical experiences and I first did an elective as a medical student in South Africa. And that was really amazing. I got to see so many things and have experiences that I wouldn't have had otherwise. And I think it's like often the way people get interested. You don't know if you want to spend time working in Africa or working in Southeast Asia or in some resource limited environment. It's not for everyone. I'm not saying everyone should go do this, but if you don't have any experience of it, it's hard to know. And then there's advocacy work. So G4 Alliance is the advocacy organization. That's sort of the prominent one. And I was involved in some of the work that they were doing when I was in Chicago. And some of the work that they were doing was just putting it on the agenda of USAID. So there's essentially zero funding for research basis or for clinical interventions or other things for global surgery. And what they were asking for was $50 million from USAID, which is really actually in their budget, not actually a lot of money. But they almost got it. And then there was some, I can't remember. There was some crisis that distracted, distracted them from that. But I think it's actually not that hard to sell. And you can sell it a number of ways. I'm sure that there's the whole political spectrum can get behind needing to improve access to safe and affordable surgery around the world. And one of the talking points that they were mentioning was, you know, if you want to limit the number of people who are illegal migrants, one of the ways of doing it is making them be able to access healthcare in their home country. If you can't access surgical care and you have a family member who needs it, it's a really strong impetus to go somewhere where you can get it. And if you're a faculty, I think clinical work is best done within a long term collaboration with a local team. So it doesn't, there's lots of different ways of doing that. It doesn't have to be one particular way. And long term collaborations have to start somewhere. So maybe it isn't long term to begin with. But the goal should be to collaborate within a long term collaboration. But you have to be the one going there for the next 10 years, but it should be something that is set up so that it is. People are collaborating in a is sort of a not a one time event that is really very, very common and very off putting for the people that I've worked with. So the question is that is a really easy way. And of course, I'm going to be recruiting people to help with the fellowship training in Tanzania. So two people want to actually go there. That's amazing. And there'll be so much people can offer here because they don't have any experts in any particular type of surgery. So the really limited training in anything that's beyond sort of general, the scope of basic general surgery. But also giving a lecture online. I have so many times that people ask me to talk about things that I know very little about. Like I have to give a lecture on animal bites and like venom. Because it's a big part of their trauma care. I know almost nothing about that. But there'll be people here who do. And local adult surgeons to do specific pediatric cases. So this is one opportunity for the future that we're looking at in Liberia and for all sorts of different surgical specialties because we're not going to have. 2000 pediatric surgeons in the next little while, but they already have some general surgeons who do a lot of pediatric cases. And maybe don't have a lot of expertise. So we're hoping to develop some training so that in specific elective surgeries or emergencies, I suppose, that would be very limited. The local general surgeons are able to provide high quality care. And I think the idea is to start in Liberia. Training medical students and residents, either people here who are going to low a million countries. I have a lot of students that are interested in joining me. And that's great because that's how they get interested. But especially students there, you can see this is Jeff Blair. So this is the first time I went. This is one of my bosses and luckily he's tall. But we would regularly have 20 medical students watching an operation because they didn't have an opportunity to see surgery otherwise. And they also don't have an opportunity to learn from surgeons. And we had things to offer that nobody else can really tell them. And then collaborating with surgeons or trainees on research is so valuable. They don't have the sort of heritage of mentorship. These are a couple of nurses that I've worked with have come from British Columbia to Uganda. And they were the favorites. I have to admit, the nursing staff was so excited that a nurse would come and teach them. They don't have scrub text. And so they don't even like know how to be a tech for a case. So cat was like they were watching how she did. She scrubbed for our surgeries and we're just amazed and learned so much about sterile technique, which was really lacking. And Cheryl was the recovery room nurse. And again, they don't have recovery room nurses. So the amount that she was able to train them and run a palace course for them was actually amazing. Mentorship is also lacking in nursing. They don't have specialized nurse training. So all of that education that we kind of take for granted is so valuable. And then collaborating on clinical projects or research. I just want to thank the people who have allowed me to participate in their in their countries and in their work. I want to work with me and in research and especially for all the people, all of my partners here, all of you guys that are allowing me to go and do this work and hopefully get involved with it as well. These are some of the, this is the Ugandan team. I'm always easily spotted. And this is John Cacabira. This is NASA our first fellow. Drew Osgit is who was, has been a mentor of mine and Jeff Blair, who was the one who took me to Uganda in the first place. He was my, he was our chief of surgery in Vancouver. And this is some of my team in Tanzania now. I would be happy to take any questions. Well, Monica, that was the spectacular overview of something that is out of the wheelhouse for most of us. And you have made this your passion and your commitment. And I'm a half of our team quite proud of the fact that they chose you to join us. As we sought to spend a faculty, we sought to see the right person to be a member of our family. And somebody who could add a dimension that we didn't have in our usual way of doing things. And we have quite a number of people who have done mission work or have some long term partial commitments to places around the world. But none of us have done anything to the extent that you have in terms of commitment to particularly the education to allow the local population to sustain themselves. What you have achieved and Uganda going from one pediatric surgeon to a self-sustaining training program to the point where you consider yourself a necessary is indeed success. We so much look forward to learning from you as we just did and participating in any way. What many people probably don't know is that Dr. Langer did all this in the last decade, decade and a half on her own. It was minimally supported. She gets a little siphon which from over there which doesn't cover her flights to get there, which were out of her pocket all these years. And she went back and forth every month because she had a cover call. And we said, well, we can do something a little more flexible than that and we will support you. So we are incredibly resource rich here. And it should be our part of our mission to contribute to that. And I can't think of a better person to lead us in doing so. Thank you for joining us. We wanted to give you a few months to get acclimated to us before you gave感an rounds. And we know we'll hear lots more from you over the years and hopefully have people who you mentor up on this podium to follow you on what they've learned. I can tell you that. As Monica said, some of her colleagues, trainees from Uganda were here in the spring and I get to spend some time with them several other stead. And when all of us go and we're visiting professors on the police and get really special and they take care of the dinner and they roll through the carpet and you feel kind of kind of special and you come back here and. And you're just one of the people of Boston Children's and you can't really lift your elbows because you're going to bounce on somebody else's shoulders. I think it feels special for me. I can tell you that people who were trained by Monica, it's not just like she's just going to she's revered. I do that for what she contributed and so we're so pleased to have you join us. I'm sure there's people who have questions about your experiences and opportunities. It's such a pleasure to be here and I'm so glad to be able to join you. Well, I have the distinct advantage of being mom and because office mates, I've learned a little bit just from being in close proximity. But my question is about the general surgical workforce in the low middle income countries. Are there plenty of general surgeons and people are just not choosing to go into pediatric surgeons surgery? What is kind of the background that's leading now to the ability to have the influx into a needed specialty? No, there's barely any general surgeons as well. I would say there is, let's say Uganda, for an example, they have less than two surgeons of any kind. Surgeons, obstetricians or anesthesiologists for 100,000 people. So that's like a tenfold less than they need just to get their maternal mortality up to acceptable. And all of the specialties, all of the types of surgery are missing people. And they would have to scale up their training programs and everything really. There's certainly more general surgeons than there are pediatric surgeons appropriately. And the general surgeons there do a lot of pediatric surgery already. Like I have never taken out of an appendix in Africa, having worked there for 13 years. You know, obviously not full time, but that's the most common emergency surgery I do here. So the general surgeons are looking after a lot of things. I don't really look after children over the age of 12 because those are considered appropriate for adults. Other than maybe some rare congenital anomalies that haven't been looked after or cancer patients. But there's a lack of workforce in Liberia, for example, where we were thinking of going and training the general surgeons to do some pediatric surgery. There's less than 20 general surgeons for the whole population, which I don't know how many millions of people, but it's a lot. So they're missing for everything. I think some of the solutions are going to include task shifting. So Sierra Leone is a great example where they have a shorter training program. So two to three year training program for surgical technicians as a way of task shifting. So it's a great show that they have similar outcomes for surgery and that they increase the volume of surgery. So certainly some of that is going to have to happen. So it's a great talk Monica. I have a follow-up question that's similar to Terry's and has to do with pediatric anesthesia. You know, it seems like that would be kind of an important bottleneck or a considerable bottleneck. So we could deal with a lack of pediatric anesthesia, particularly for younger ages, are there adults that do kind of at cross coverage or are there other kind of similar pediatric anesthesia societies who have similar efforts and then how do you collaborate with them to deal with that part of the care pathway and needs. Yeah, that's a great point. That is one of the most stressful things I would say working there is not having pediatric anesthesia. And pay Evans is one of our anesthesiologists here who was working with Pada, which is a pan-African training for anesthesia, like pediatric anesthesia training in Africa or something like that. And they are developing a fellowship program for anesthesia. All of these things, I mean, Mary, Navikenia, who was here along with Stella, did training at UBC. So she did an extra year of fellowship training in Vancouver, because in Canada, you don't have to do USMLE's and it's a little easier to get to get a paid fellowship there. They supported her and some of the others have gone to South Africa. But I think it's really something that like is a great opportunity for training is to provide some anesthesia training. Currently, what we have at the hospital, I work at in Tanzania is technicians and anesthesia techs, which are kind of like CRNAs. And of course, I have my favorites. And so if I have Jovian and Ivan, I'm like relatively happy and they do anesthesia for a soft gila treature repairs. I mean, they are the only ones there providing the whole anesthesia and amazingly these babies don't do saturate. And they do have adult anesthesiologists who are providing some of the anesthesia care. So if there's a kid with PINGEN, heart disease or something like that, they'll help with that. It's definitely a deficit because the technician doesn't have the same understanding of physiology doesn't even is enabled to anticipate problems or respond to them in the same way. Luckily, the PATA training program is training one anesthesiologist from our institution. So she's going to be joining us soon with pediatric anesthesia training, but it's something that all over the place is like a real lack of it's a real deficit. Let me try for one more. Hi, good morning. My name is Debbie. I'm a visiting pediatric surgery fellow from Mexico City. I'm here for a one month observing everything. I guess my question to you would be we always talk about resources and level different levels of availability. So two quick questions. One is what was your biggest concern regarding availability of materials because sometimes we operate based on what we have in Mexico City at a public hospitals. And my second question to you was, is it was swahili a problem or is it is the teaching done mostly in English or their regional languages? Is that a barrier when you're trying to train other surgeons? Thank you. Well, the swahili I'll answer for some terrible as swahili. I am supposedly learning. But luckily the language of education for higher education is in English. So they have a hard time with my accent. So usually what happens is I'll say something and then someone will retranslate it into English with a swahili accent and then they understand. So in terms of materials, that's definitely a problem. And I have for years taken boxes of not always expired things but discarded things from operating theaters and brought them. And I have brought duffle bags of sutures that actually kept the pediatric surgery program going because they have no nothing smaller than a two oh can you imagine doing a cussi with a two oh? And so and they would barter. So I didn't always get the all the sutures I wanted. But sometimes they would have like an oh something or a number one something that the trauma team really wanted. And they would take their two ohs for the for their for their own silver or whatever it was. But it's infrastructure in many ways, including the supplies is a problem that I'll just use this opportunity to say that there's an. There's a new opportunity here partners for global health, I think is what it's called is a out of Maine and I used to work with them when I was there. And they basically collect discarded items from all hospitals in Maine and now they're collecting starting last week, I think they signed the agreement to do it here as well. And so we're going to be donating our unused supplies or the extra supplies that we have. And they particularly need pediatric supplies because that's in short that's something that's very needed. So I think that there's lots of innovations like that, but really developing a good supply chain is what actually needs to happen in the countries. And these bandage solutions are so are better than nothing, but they are just sort of band is I think developing a robust supply chain and sort of funding for that is just critical as you know more than the rest of us. Thank you for that question and thank you where we're obviously well past the hour. We all so much look forward to learning how we can help and as Brian said we're learning from you. When you ask us the questions, why do we do that and we're all looking forward to doing a KSI with two O's. But the resource you have is which which you need to work with and so thank you so much for this lecture and particularly for joining our team or truly honored. Thank you so much.