Bruce Biccard, PhD - Improving Outcomes in Africa

Good morning, everybody. Good morning, everybody, and thanks for attending the Grand Rounds this week. It is my distinct pleasure to introduce our speaker today. Dr. Bruce Becard is a professor and the second chair in the Department of Anesthesia and Parioperative Medicine at Gruechur Hospital in the University of Cape Town in South Africa. His research interests include Parioperative Medicine, Parioperative Outcomes and Global Surgery. He's a proponent of International Collaborative Research as I think he's going to talk a fair amount about today. He collaborates with the African Parioperative Research Group Network where he has led the African surgical outcome study and the ASOS-2 trial as well. He's also Co-led the African COVID-19 Critical Outcomes, Critical Care Outcomes Study. I've heard Dr. Becard talk about this stuff before and it is always fascinating and always unbelievably enlightening. I think for those of you who have been following the work of the COVID Surge Group and find that interesting, I think you're going to find this really very cool. Without further ado, I'm going to let Dr. Becard go ahead and take off in Dazzles. Thank you, Bruce. Thanks, Craig. It's very kind of you. Thanks to, well, your department's for allowing me this opportunity. So, can you see that? Yeah, happy. Yes, we can see. Okay, good. Okay, so I'm going to take you on a whirlwind trip about spheros of outcomes in Africa and the work that predominantly the African Parioperative Research Group has done. And sort of my thoughts on how we can improve their opt of outcomes. So, my criticism hospital, this is, I'm actually in the hospital at the moment. So the new building on that left. Our department is about four floors up there in the theaters and critical case there. And in the background, you see the old building. And basically, the center of the old building is where the trauma used to be in that way. It was where the first heart transplant was. And in the background, you see devil's beak. So the work today is going to touch on some of the work from us, African Stratical Arkham study, which was 11,000 patient observational study. And then a SOS 2 trial, which was a 29,000 customer animus trial. And then the critical care outcomes that he in COVID 19, which was just under 4000 critical care, COVID patients in Africa. Funding, we got a bit of funding from MRC for us. We got a sub grant from breakout from the building and the gates for SOS 2 and from a WFSA about a dollar per patient. We got support for our database from the critical case study of Southern Africa for Acres. And we've got some support from the evidence-based, we're of the medicine group to develop the member database for Apple. On a stothisory with Salomi Gawir, she was first a time person of the year in December 2014. She had been working on the front lines with a bowler as a nurse. She basically lost more or less her entire family. And at this time, I think she was about 24. And in 2017, 20th February, she had a caesarean section. She had a boy. She was discharged, returned to the hospital next to 21st February after having had a fit. So basically, she wasn't admitted to the hospital for three hours. There's quite a lot of anxiety. She has eventually admitted and she died. So, years of women, she survived the whole Ebola pandemic in Liberia and lost her whole family. And then she dies as an off-dissedry for the Zeran section. I think her story speaks a lot to the points I want to raise today. They're about a vegetable death. And that's what characterizes Africa. And you could see her death as you could explain it in a number of ways. The led access to care. It could have been because people were scared of Ebola that possibly didn't have the resources like adequate PPE. Maybe there is a educational component which is contributing to it. And then the very important issue of quality of care. So if you think of maternal mortality, it goes back to 1700s in the Swedish parishes where they started recording the mortality of the individuals in a parish. And from that, there was national mortality from about 1750 and maternal mortality from about that time. And so you can plot maternal mortality in Sweden beautifully from early 1800s at 900,000 to that today at about 400,000. I want to tell you two quick stories about maternal mortality and they important for if we want to improve care in Africa. So the first is Andrew Topping. So he was a medical officer in Lancashire and in the 1930s and Roschdel had the highest maternal mortality in the UK. It was running at 900,000, the UK was running at 160. He said about a quality improvement project with ensuring good memory of free and he dropped maternal mortality down to 300,000 over four year period. The next is here in Cape Town where we are in the 1950s maternal mortality was running at about 300,000. But really the problem was we weren't getting to the patients fast enough or the patients weren't getting care fast enough. And so they started applying sport, which was literally a midwife and another mid one for a doctor on a back of a land road and they drove to the patients. So they went to their houses, they dropped the maternal mortality from 300 to 100,000. Florence is not a girl that did some of the thing just through hygiene and she had a 95% relative introduction. Roschdel was about 67 and the flying squad about 78. It's a massive relative reductions but simple interventions. This is Africa today. Africa runs at 5.33,000, that's Sweden in 1880. So that's a challenge we've got. If you want to look at surgical outcomes in Africa and let's see in sort of a comparable way, we got that daughter from Isos, which is elective surgery in hospital mortality data. We got the apricot and we got nest web data. So if we look at adults, elective surgery, you see in Africa, we run at about 1.1% compared to about 0.46 internationally. You look at apricot and you compare that to sepsos, sepsos with a South African pediatric surgical outcome study in hospital mortality running at about 1.1% compared to 0.1%. If you look at the zero in sections, this zero in section from right from Esos was 0.5% compared to 0.01% in the states. So if you're surgery in Africa, you twice as likely to die at the end adults, you at least 10 times as likely to die if you're child and if you ever see their in section 50 times as likely to die. Just a bit about the pediatric outcomes in South Africa. So in hospital mortality, about 10 times greater than high income countries, we really don't have good data for the rest of the African. There are three fundamental differences when you look at pediatric outcomes with higher complication rate and it seems to be a gradient from a high to low income countries. Our predominant complication is different, it's really driven by infections and the risk factors associated with complications are different. These are related to urgency, severity and effective indications. So we are in a state of a critical incidence, about three times out of high income countries and you should see this very pursuing in the NA. So if that's what Africa looks like, the real challenge we have is how can we increase access and but ensure quality or as a surgical environment. And really that's what this talk is about. That's about strategies or solutions to this problem. So you could work on the disobedience principles of quality care and let's looking at the structure that you have to provide care, the processes and how these impact on outcome. And really I'm going to speak about it through instruction processes through advocacy, regulation, finance, quality, education, political leverage. Those are things ready we've got to do if we want to improve outcomes in Africa. So let's look at instruction. So I mean through the Lancet Commission we had these great indicators and as it bench box from which we should aspire to work from. So if you look at access to surgery, again, we'll describe the insularin sections. So what you see is you need to provide about 19 to their in sections 300 live births to be able to say that you're providing an adequate surgical volume below that point you see the inflection. Sorry above it inflection point you see how the mortality goes up. This is Africa. So the blue purple blue is all below 19. C's is 300,000. And if you look at the Lancet Commission, they reckon you need about 20 to 40 species, 300,000. So that's obstetrician surgeon and need to. And in Africa in us us from 250 hospitals are participated with average of less than one species per hundred thousand. How many physician and ethnoes do you need similar approach? So for this inflection point with maternal mortality, it seems to the point seems to be around about four physician and ethnoes. So again, this is Africa. So these are all and if these are providers, these are in positions. Red is less than one. So this is a challenge that one has in this environment. If we look at the surgical volumes, the Lancet Commission, Rickens, 5000 cases, 300,000. And using data from us, I saw the global search projects, we put all the data together and then did modeling for surgical volumes for different countries. And this is sort of what you get. If you in a low income country, you need to provide 25 times more surgery than you're providing now. So to give a bit more context to the surgical volume challenge that we have. So this is a colleague of mine, Dolly and Lambo, who is a need for us in Kinshasa. So he tells me the story about this woman in Bandung, who is collecting wood for fire. She's pregnant. She falls from a tree and she's got a thoracic injury. Google Maps, Rickens, it takes you nearly seven hours to make it to Kinshasa. She made it in five and a half in the back of the motorbike. Fortunately, she survived. But the really the thing about the story is about the issue. It's not just about volume, it's about the types of surgery. So let's assume the UK is what surgery should look like because they do run at about 5,000 procedures for a hundred thousand population. And this is a proportion for procedures that they provide. So if we look at Africa and this is from ASUS, we're providing about five. ASUS is for a hundred thousand population with a target of 19. So for Africa, we need about three times more seizures. In fact, there's what low income countries need as well. But when you look, you break it down into different type of procedures. You see two signals here. So the first is obviously as a GI falls, the amount of procedures that you need increase substantially. The second thing you need to see is this. So the procedures that are most frequently provided are our sezerin sections. So third of all surgeries in Africa, sezerin sections. And then you see cancers we probably need about ten times more. But nine, those are other non cancerous surgeries, surgeries and then other. Other are surgeries that constitute less than five percent of total volume of surgery surgeries. So there's all the specialties cardiac thoracic, ENT, plastics. Those are all totally unrepresented. So 60 times more in low income countries. What about beats? So we could really say all surgeries are neglected. And pediatrics. We really don't have a good handle on the number from, but from sepsis. We reckon that in South Africa, we meeting about a quarter to third of pediatric surgical need in South Africa. So imagine in the rest of Africa's way worse. So what we have to do is we could advocate for this. These benchmarks. And so defining point was the World Health Assembly. Resolution 68.15, which really made it. Part of the WHO. And then Richard Horton did amazing thing when he also global community. What are the five most important things to talk about? You know, when I go back to WHA. And out of the five number two was safe and affordable surgery. And so there's been tremendous advocacy at a very high level and a lot of work done from where you work. And you know from John Mirrors group. And the Lancet Commission is its phenomenal work. And so from an advocacy point of view, I think we're doing well. But really what we have to do now is we could embed this into our health care systems. And that you do through NSAPs. Countries have given us the mandate to demand that these benchmarks or these standards for surgery and anesthesia and obstetrics are embedded in every country's health policy. The sad thing is is when you look at Africa. Only eight countries have responded. Only four of developed the answer. And four started. I've been involved in South African NSAP. We had one start and it failed. We've had a second start and I continue to not moving very very fast. So this is a real issue. I think Tanzania provides a great example of the potential benefit of doing an answer. So you have the human resources is really limited less than point. 0.9 anesthesia providers for 100,000 less than 20 physician anesthesia providers when they started their answer. So remember I told you that inflection is running at four for physicians. So they set up in the end so that they're actually going to target what turns out to be 2.2 for 100,000 less physicians and non-positions. But it's a scale up in their country at 25 fold. It's massive increase in ability to provide safer anesthesia for surgery and working on the concept of task sharing. But I think the most starting thing is when when you cost up the answer for them to do this is going to cost them $2 per person per year to make this change. It's incredible. I must as a cost to provide safe surgery and universal healthcare. Globally we spend $8 trillion on health to provide universal health coverage costs $100 per person. We spend eight times what is necessary for universal health coverage. So this is what the expenditure looks like. These are what the government spend in low middle and upper middle income countries. And then when you put what the donors spend, this is what you get. So once you get to low middle income countries between the governments and donors, you're over that you HC limit. But then how's it possible that we have these bad outcomes and it's just two things either the allocation of the money is inappropriate and all the quality of care is inappropriate. So I think the first thing you need to do is look at where the deaths are happening. So over time what we see is that infectious diseases deaths are dropping the proportion of deaths and mother and child are dropping non communicable is escalating and injuries that more or less the same. But let's look at the finance 3000 fold increase in financing infectious diseases over that period nearly 1000 fold for maternal and child health. And 2 to 300 fold for the other two. So there are two messages here. And the first is maybe if you put money into something outcomes will improve. But the other is we're putting a vast proportion of money into the wrong places. The money is not tracking the diseases. Surgery contributes about a third of all diseases. So when you look at admissions to hospital. A third of the patients admitted to hospital are going to require some sort of surgical intervention. When you look at global burden of deaths. The most the third most common cause of association is or you know cause association with death is surgery patients dying in the period of the period. The deaths following surgery exceed HIV TV and malaria combined. And the donor at the funding like donor funding HIV, malaria and TV get $4 billion a year. Surgery gets very little. There is no fund for surgery. So what are the problems? I think one of the problems is funding is in silos. So surgery falls into things like health systems and that. And so it gets scraps of all time. And if you look at the essential or total health package about 10% of the health package you can pull the procedures off or surgical procedures. In the low income countries about $5 per person, a low middle about $7.50. And at the moment, what's the benefit is like 27 cents and 87 cents. So I mean how are we going to sort this out? We need a global health funding plan. Surgery needs a silo. Funding needs to be allocated according to disease projections. So from a third of all admissions hospital needing surgery and knowing that about 10% of universal health care is surgical, we need a budget for surgery, which is carved out at about 10 to 30%. So what about health care providers? So while we push governments to finance surgery more appropriately, what can we do as health care providers? And so this is talking about processes predominantly. And I want to talk about quality of education. So we got great documents. Yes, one. So these are standards for safe practice by the WHO for NSZ. So if you look at ACOS, for example, which is the African COVID-19 critical care outcome study, what we saw is that 11 to 23 exists this in Africa. So if you admitted to ICU with COVID. So in ACOS, we ran a mortality, COVID mortality of about 48% in ICU. The global average from a systematic review, which we conducted as part of the study's citizens in the supplementary material is 31%. So the massive exists this. How can we expand it? Well, the first thing is only one in two patients refer to critical care word method. So we only talking about the patients got into critical care. We got no idea about the patients who didn't. But the interesting thing is these are ICUs, not every patient had an oxygenator. And the resources are terrible. And then when you look at the interventions, interventions for the more better for the severity of disease, we're about 70 to 14, and then we're about to call less than worse should then the patient should have received. So and then you ask, we asked the app organization network. Do you see it research priorities? So what I wanted to do training standards, minimum provision of case standards, I just showed you a greater article about four slides back. We've got those articles, but it says something when the resources is so inefficient, that these greater articles actually did not provide the information that clinicians or health care providers on the ground need. So what they're asking for is they're asking for support. They are asking for education and training support to improve the quality of care. And so we need to provide support to these providers that they can give the best quality of care with what they have available until we can sort up the resources. So I would call this stepping stones. So we're still working in these low resource environments, the stepping stones to go from where they are to what we decree to be minimum standards or acceptable standards of practice. And we're not doing that. So if you look at quality of case, we go again, back to maternal health. Across the HDI, different HDI groups where the countries or centers have been rated them for resources, quality of care, varies 12 fold for maternal mortality. So there's a massive problem with quality of care as well. And we looked at as I saw a global surgery, but all the data together and we looked at the checklist. So this is a checklist. And what you see is basically use a checklist mortality drops, use a checklist, first of complications drop. But what this is standing thing is when you know low HDI countries and the surgery means from elective to urgent, the user checklist drops. So in the environment that you want it must drops. And this may reflect broader issues with quality of care or maybe the checkers is redundant, you know, like when you're asking questions about, you know, do we have blood or do we need blood? Well, there is no blood. So it's a bit irritating to ask those sort of questions. We have to address this problem of this excess mortality with low access to surgery, low volumes of surgery, limited resources and low quality. Because really the impact is just going to increase. If you look at the population projections to 2100, the world population will be 10 billion, 4 billion in Africa, 4 billion in Southeast Asia. The rest of the world will be 2 billion. This is a huge problem that needs to be addressed. So let's look at some other things we can do. So this is these are slides from Fay. But one of the things is obviously education. So we've talked about the need for education and in the Apple group education and training campup is number one. And Apple hasn't worked in this space very well, but Fay and some colleagues of mine and kept on Rebecca Gray are involved in this. But this is about improving period of care for children in Africa. And this is known as a part of project or pediatric anesthesia training and Africa project. And really, it's trying to address the fact that the science, most of population being in Africa and Southeast Asia was also going to happen as a demographic of the countries going to be totally different. And about 2050 billion children more than half the population in Africa will be children. And so you got this large population with limited skill providers and high mortality for these kids. So this project is really to develop pediatric anesthesia leaders and it's about trying to develop programs, fire fellowship programs to train pediatric anesthesis and non physician pediatric anesthesia providers. And the concept is they train fellows within each fellow trains five non physicians and ideas over five year period is five and then 10 non physician anesthesia providers massive impact, similar to the Tanzania project with the need for and the answer. So if we want to improve qualitative care, we can also look at processes. So we got two things here. We got environment where you got resources which are from optimal probably like your environment to holy and sufficient and you got processes from an adequate to optimal. So I'm going to tell you about the epoktrial. So the epoktrial, this is a UK trial. And so we're going to assume that the resources are optimal. And so this is about process. So this is for emergency laparotomy across whole energies. They put together this beautiful plan quality improvement project and really it was doing all the right things at the beginning before surgery during surgeon after surgery and ideas 90 day mortality will drop for emergency laparotomy. So they have this hand in a just project. And this is what happens. There's no difference in 90 day mortality. So doing the right thing does not necessarily result in improved outcomes. And so when they speak into the epok leaders afterwards, the nice thing then what would you do differently. They say they start to talk about I would work on leadership project management. How to get senior support for what we're trying to do, engaging people that are work with more infected effectively and communicating the data better. So here we have the epoktrial. Optimal resources, but the process is a still suboptimal. Really what we interested in in a low resource environment while we advocate for increasing resources is can if we optimize process, can we compensate for the lack of resources. So this is our jump. So he's another colleague of mine. So he's in Ghana. So I just when he was in turn, he has this patient with pneumonia and he looks after him through the night. And there's a problem with antibiotics, but the in those about a trial that's running and he manages to source of some antibiotics. Next morning, the rest of the team arrive, they've found it that the patient's alive. And so Ajiko is a home. He comes back the next night. Patients dead. And what you see in our story is this whole concept of failure to rescue. So you don't have people or you don't have adequate healthcare providers to look after the patients. And so they deteriorate and they die. The only reason that patient that's through the night was because Ajiko spent his time with the patient. And this is exactly what we saw in ASUS. So in ASUS, we saw that if you have surgery in Africa, you twice as likely to die. But more importantly, although the complications were the same, you were twice as likely to die following a complication. And that's fairly to rescue. Complication leading to death. You look at mothers. Complications were two and a half times high income countries in the SCASC US, but mortality 50 times. And really so what we see is if you have adult surgery in Africa, twice as likely to die of scissoran sections. Your failure to rescue is 50 is sorry, 20 times. I suspect we don't know what the numbers are for pediatric surgery, but I suspect the numbers are going to be very high for pediatric surgery. Is the things that really make a difference between scissoran sections and all adult surgery is this rapidity of the death. And it's hemorrhage and anaesthetic complications. And then the success data. We see about 40% of the patients who die that children that die are as they want to. And there's certainly a big component. I think of failure to rescue with rapidly progressing complications, especially anaesthetic, for example, and as these are related. So if you look at Africa, you have lower spations, lots of emergency surgery. We have limited resources. Patients develop complications as failure to rescue and as death. And so obviously if we could increase surveillance of these patients, maybe look at the patients, your high risk, we could decrease failure to risk and decrease mortality. So then we went on to see can we do a pragmatic job to try and do this. Now was as I do. So the whole thing was we know mortality is twice that of the global average. We know that almost all deaths happen after the operation on the ward. And we think there's unrecognized clinical deterioration and valetir rescue. And we also know that at these sites that the staff levels are 20 to 50 times less than the Blancet Commission's recommended minimum standard for safe practice. So we thought if we could re-advocate human resources to your high risk patients to increase surveillance for those patients, we would decrease mortality. This was a class of randomized trial. Oswald also class randomized into center of care or increased surveillance for higher risk patients and primary outcome was in hospital mortality. The plan was to randomize 600 hospitals and about 60,000 patients. And then what we would do to increase surveillance was. So there are many of these things as possible. So for patients in high care, was in planned, increased the frequency of nursing observations, put the patient in view of the nurse's station so that they can always be seen. Allow family members to say with the patient so they can give you the heads up if their family members cheer rating and put a high risk. That's a guide about the bed. It's this patient's high risk. These are complications that kill the start for patients. These are early interventions you can do. So these are results. So we ended up randomizing 332 hospitals and 60 and for increased post-opera surveillance, 172% of care. The risk stratification was good. About to any percent were high risk with a mortality of 5.6%. But no difference in the primary outcome. The intervention arm, there was no increase survival. And the conclusion is that you can't do generic fix to for excess surgical mortality in Africa. So why didn't it work? And fortunately we ran a process evaluation. And the first thing to realize that there's a program theory. And so the program theory was this. If there are high risk patients and they identify proactively, then we can allocate the resources for surveillance to those patients. Then we can identify complications earlier and in that way we can decrease failure to rescue. But they're all the assumptions that you make done that pathway. And so why didn't it work? Well, we couldn't determine if we actually provided more care. We couldn't determine if we identified complications earlier or if we could appropriately escalate care. So there are all these places where the assumptions or the program theories got the potential to break down. And when you look at implementation fidelity, in other words, the ability to provide increased postoperative surveillance, these are things that come up. Those who successful have got good leadership. They got teams that work across the health care force. So I'm saying between the management, the doctors and the nurses on the ward. And then the interventions get tailored to the context on the ground. And finally, the inadequate research funding means that clinicians care the time was taken away from care. And they could also have impacted on performance. So these five interventions didn't decrease mortality. And the real message is that for anything like this to work to improve quality of care, you need interventions to be co-designed with local health care staff to ensure that it's sustainable and adoptable. And if you look at the systematic review on a host system delivery and improvement, you see that the factors associated with success are related to people. It's about engaging stakeholders, teams, communication collaboration, patient's and fitness. And so if we want to improve quality of care in these environments, we need to do this. We need to get evidence and processes together. And then we still need to ensure that we have all the soft skills necessary for people management. And if you look at the can meds approach. Really what they talk about is collective competency. And I think you know, these stepping stones for education to get. Low resource environments to provide the best care talks about this collective competency because of the concept of touch sharing. And so the tens and an end service is a good example. The parts of project is a good example. And the messages that came through and I just do that you need teamwork to improve implementation fidelity. So if we look at adult surgery in Africa, we started off with a pilot study in South Africa and then we went on to a continental study to look at what was happening. So a signal which was you try and so is likely to die in Africa and it's probably failure to rescue. And then we went on to do a trial. Which failed and we learned a big lesson in a whole lot of other things that we didn't understand. And so where do we go from here? Well, interesting in the process evaluation, we asked a whole lot of questions that the question that was most. Positively answered was people still believe that we will reduce mortality by increasing post operatives of adults. And it's probably because almost all the days are going to stop. And we know that twice as many patients die after surgery, even though the complication rate is the same. So really there's this despite what happened with us was to do this. This real need for as pushing forward with this quality improvement project for these high risk patients and co designed within the local context. So if you're looking at quality of care, epoch, high resource environment and SS to speak to roll of leadership, senior support collaboration and teams. And really they speak to the need for this soft skills education to improve quality of care. So if we're going to make quality of care better in this environment, this is how I see it. I think it's built around this sort of onion concept. And so these are signals that come in the first thing is the values. It's your values as an individual and it's the values of the as a team. So for example, if if the nurse is working really hard and each other. If you do this increase post operatives balance here and we decrease the work on the lower patients, the second increase your workload. But if the nurse is working really hard and they perceive it as being more work, it's not going to work. So that's the individual values and then the team values about how are we going to contribute to a greater public health in Africa. And then the thing about leadership and teams, so you have to break down the hierarchy. This message comes through so strongly in epoch and associated and about communicating across these different strata of teams. Only once you can get the values right, then you can start to work on these processes. The processes that one are trying to put in place for epoch and associated. And then when that fails, it's failing sometimes because there's a lack of education in how you do parts of the processes. And as we education gets bolted on to help people understand the processes and where to go. And only after that the resources you need, you know, if you want to do it better, you might need better resources. And so I think the improved quality of care, this is sort of the strategy and hard. It all fits together to improve surgical outcomes. So in adults in Africa, we move into a QI project and peeds. This is what we've done. So we've done the equivalent pilot. So we did steps us in South Africa. I think it was about 64 hospitals around that number. And we in the process now recruiting sites for SS speeds. I think the first country to recruit will be in a year in the next couple of weeks. So the last thing. So we're going to use political leverage. And I think we have to take a lesson from HIV advocacy. So what happened to say in that picture is like a aqua certainly he started the treatment action campaign. And really what they did is they educated society. They educated it them about the treatment efficacy of anti retroviral and that is your right to access them. And then the political leverage and campaigning there by people like Jackieachman to the treatment action campaign resulted in this massive financial aid. So the US presidential emergency fund for age relief. It's a pit for fund and the global fund. So if you look at donor funding in 2019, there was $40 billion global funding for health. 10 billion was for HIV. That's how successful their political leverage was a quarter of all donor funding in 2019 winter HIV. And we need to do the results. We got lots of evidence of treatment efficacy for surgery. We know people should have access to surgery to be honest. The vast majority of population I think do not realize that they're not getting access to surgery they need. And we need to form a coalition with healthcare workers, patients and civil society to leverage for this. And we need data to do this. We got good data in Africa. We're working on establishing a minimum data set to provide data for low resource environments. So if you want surgery to have a right for place and global health, we need partnerships, government, donors, providers, civil society. We got to advocate for structure through regulation. We have to advocate for appropriate financing of health. We need to look at quality of care and we need to think about what are the resources you need and what are the processes. And we need education reform. We have to work on things like soft skills and collective competency. And then we have delivery politics and we have to communicate this message here and medical meetings, public and authorities. So in conclusion, if we're in a group of our outcomes, we have to report the travesty of surgical outcomes in low resource environments. We have to demand implementation of insights in our countries. We have to advocate for global health funding planning. We have to focus on education quality and processes. And we have to create a culture of collective competencies and soft skills. And then we should advocate and demand for safe surgery for everyone. Thank you. Bruce, thank you. That was amazing as always. I think we've got a few minutes if anybody would like to ask any questions. I have a comment and a question. I can start. When you talk about this stuff and listening to other people who are doing some really amazing work in this sphere, talk about really evidence based solutions to some of these things. I'm always struck by the implementation side and how that really seems to the more I do this seems to be everything. That we know how to teach people how to do surgery and anesthesia and sort of the technical aspects of those things. But it's taking these solutions that we develop through trials and really scaling them. And I know you've spoken a lot about that obviously, but that's something I'm just constantly struck by. I think great. Your point is really important. Especially for me coming from that background predominantly have been interested in cardiovascular outcomes. So you come from this very strong evidence based background where you're doing drug trials. That sort of thing. So in reality, they pretty much simple interventions. You know, if you can give a tablet and it makes a difference. But the reality is the first thing is the biggest difference in all relative risk reductions are going to come from changing some processes. And that's why at the beginning I spoke about things like Florence nightingale. But the difficulty is they complex interventions. So it's not just giving a tablet anymore. You're changing like a whole lot of things and a big message here. I think for us as an instance insurgents is a lot is happening on the surgical floor. And if ever we go into you know to try and hone these skills on implementation as people in the period of space. I think we should be working on the skills and on the surgical floor because that's where we're going to build these experience and communication, particularly between surgeons and nurses and a need to manage us. Thanks for the great talk. One of the things that you mentioned was funding. And the thing that I think about is with many countries in Africa, they were dictatorships. And are there ways to get the funding to healthcare because often it gets siphoned towards the military or other things like this. How have you thought about why have you implemented any ways of actually getting the funds to be desired process or investments. So John, thanks for a good and hard question. When so the short answer is I don't know how to get around this is a real problem and you've seen it. We've probably seen it both in high and low income countries is the whole thing with PPE and COVID. I became an opportunity to make money for people. And you could see it in Africa as well. Suddenly tender, pruneers navigating the way PPE moves and how people get access to it, etc. So yes, I think it's a very serious and genuine problem. I don't know the answer, but I always feel if I'm going to talk and I want to talk about things that I believe we need to do, I'm going to talk about them optimistically. Otherwise, I'll never be able to talk about this. The reality is we don't need a lot of money in Africa. When you see the numbers, you actually don't need a lot of money. But like you said, just as you get to the right place, I don't know how to do it. I have free someone else might not know how to do it. The other thing I'll say is kudos to you for the work you're doing. When I think about the size of that continent, I mean it's three times the size of the United States building relationships across the continent to do what you've done is remarkable. So. Thank you. Yeah, thanks. John said, I think it says that I didn't speak just because of time about the network itself, but it says a lot about the condition investigators in the environment, because you know they are very few. But they're doing this with no funding, they're doing it because they believe in it. They're doing it is because they feel in part to make a difference. So really the people in the network are amazing. There's probably about 1,500 clinician investigators that we all work together with now. So it's good. John, I just wanted to you asked about funding and one thing that's pretty exciting that's happening right now, at least in terms of US funding is there's a group of NGOs and a PGSSC was involved with this lobbying the house and Senate appropriations folks to put into action. So we had a group of organizations that were involved in the process of appropriations language that was put in for USAID last year. It was the first time that USAID appropriations language had specifically addressed surgical care and developing robust surgical systems. So we got the appropriations committee to agree to actually put that in the budget. Now how much is going to be in the budget remains to be seen, but I think that's a successful first step at least from US government. So that's amazing work you constantly. Congratulations. We'll see. Just one last question. Are there any specific things you think we as an institution department could do to support these efforts? And there's certainly I'm sure there's lots and a lot of difficulties is with skillsets and limited skillsets, but it's probably a bigger discussion that we could have outside the meeting, but certainly I mean this I think there's lots of opportunity. So thank you. Thanks for thinking about it. It looks like there's a couple of questions in the chat. So one is are there any specific pan African initiatives similar to South Africa safe project or Oxford's any P.A. Sim courses to bring anesthesiologist not pot of graduates to pace with closing the gaps and failure to rescue. So the issue is that's a have a good question. If if I interpret the question correctly, it's asking are there failure to rescue projects educational projects, which might be similar to safe. I'm aware of, but in learning learning all these hard lessons of failure and how you have to move on to what is implementation. A big component of the first part is educational material to make sure everyone's on the same page everyone's working from this believes the same hypothesis because otherwise it's going to fail. So I think the question really is actually as stimulus for maybe is we should be looking to take the educational component bigger. That it becomes part of just education like safe officer said be this. So thank you. And then Dr. Mizrahi asked about can you speak to the involvement of francophone African countries in ASUS 2. Yes. So we do have quite a lot of francophone participation. So when we saw it and then ASUS we had predominantly angrippin and francophone and and then ASUS 2 we even built out further and and now we got all our documents are also in Arabic and Portuguese. So I think that's not as not a tremendous barrier and blamwich for the network. What's been amazing is we've got like thousands of WhatsApp groups in that and it's all with you know quick Google translates on your phone for quick communication is actually amazing. So quickly people can communicate just with things like Google translate if you all believe in the same thing. So yes, we've got good francophone participation. So we have questions for Dr. Picard. All right. Well, you know on behalf of both the departments of surgery and anesthesiology I want to thank you Bruce for. I've been an amazing amazing talk on some you know truly amazing work. Very impressive that that you guys are doing and thank you very much for taking the time to come and enlighten us. I really appreciate it. Thank you. Thanks, Craig and thanks a lot of you. Pretty nice of opportunity. Cheers everyone. Bye bye. Bruce, talk to you soon. Yeah, cheers.