All right, well welcome. We are pleased to start off the 2526 academic year department of surgery grand rounds with our wonderful speaker today, Dr. Sister Misenga, who joins us from the Bugando Medical Center in Tanzania where she currently serves as the director. A nun in addition to a general and pediatric surgeon, Sister Misenga obtained her medical degree at the Catholic University of Health and Allied Sciences followed by general and pediatric surgical training at the Kilimanjaro Christian Medical University and sub-specialization training at the Pan-African Academy of Christian Surgeons in Kenya. A recipient of innumerable awards, Sister Misenga has inspired countless learners throughout her career, and we are fortunate to have her here today to discuss the development and expansion of pediatric surgery department at the Bugando Medical Center. Dr. Sister Misenga. Thank you for your introduction. Good morning. Yes, as I've been introduced to you, I'm here to share with you about the establishment of pediatric surgery at Bugando Medical Center. And this is the front view of our hospital, Bugando Medical Center. So I'm going to talk about introduction of Bugando Medical Center. I will also talk about the history of pediatric surgery. I'll also talk about the current state of pediatric surgery services at the Bugando Medical Center. I'll also share with you the improvement of gastrochysis management in our hospital. I'll also talk about observation and training programs as well as challenges. And I'll also say something about technologists. The hospital is called the Bugando Medical Center. We like it to abbreviate it as BMC. It is a tertiary referral consultant and in medical university teaching hospital in Northwest for Catholic University of Ohio and the NIH sciences. It is serves almost 23 million people. And this number is equivalent to one third of the total population of the country. I can say it is like 70 times the number of the children in this state, something like this. Yes, it has very capacity of more than 1,200. And most patients are referred patients from the nearby hospitals. And I'll also share with you the services which are provided by the hospital. We take care of the patients. We also do trainings to the medical students, to the residents as well as fellows. We also provide the concert and services. Sometimes from hospitals, they ask for support in different areas like in the area of administration, area of the patient care. So when they concert as we go and give them support, we call it concert and services. And we also do research of course in collaboration with our friends and collaborators. So the history of Pediatric Society area is services at our hospital. Before the year 2021, we had no Pediatric Surgeon. Now you can imagine the hospital was built in 1971 in those years, almost 50 years, no Pediatric Surgeon in the hospital. So pediatric patients were managed by general surgeons. Especially they were emergency cases. They were managed by general surgeons and the department of general surgery. And specialized procedures were not done. Specialized procedures like a pull through, piece up, track your software, your facility, repair. They were not done because there was no Pediatric Sadi own for doing this kind of procedures. And minor surgical cases were managed. We had only two options for the measures. Minor surgical procedures were done there, especially margins for, let's say for congenitronorectoma formation if our babies having impoverished anus, a procedure like a colostomy formation. These ones, minor procedures were done by general surgeons. But specialized Pediatric Sadi co-procedures, we had only two options for them. By then, one is to refer them to our national referral hospital with quality mohembirities in the restaurant. And the second option is to wait for the surgical camp. Now, about the first option, the hospital, which is called the mohembirity, is far from our hospital. It takes almost 16 hours by car to travel from our hospital to the mohembirity hospital. Now, they need to have money. They need to have time. And when they go to the hospital, they are not familiar with people. They are not familiar with the environment. And when they go to the hospital, it means everything stops at home. So they can't involve themselves with the economic activities. So it was hard. Sometimes if you tell them to go to mohembirity hospital, they say yes, but they don't go. They go back home, which is really difficult because of their economic status. Now, the second option, surgical camps, we were receiving collaborators from the US, specifically since the national children's hospital in Ohio. They were coming once in a year, and they were staying with us for a week. Now you can imagine the workload we had. They were very selective because children were mainly waiting for definitive surgeries. So they were selective for few children. And the rest were left unoperated. So we had indicated the operating room for children by then. So we were using operating rooms, which were used by other departments like Genoa Sajary, Urology, and other departments. Motoric therapy was high, and this is due to the absence of specialized periodic surgical care. You can imagine if you don't have team for surgical, periodic surgical care, it is difficult to have good outcome. So patients were accommodated in the shared words with Adat. We were mixing them together in the Adat word, in the Genoa Sajary word. And in the year 2021, now, the first periodic surgeon finished studies. And that was me. I came from my training center. I was in Uganda for periodic surgery training. I also did it in Kenya. So periodic surgery unit was established. I started it to establish the unit. Now you can imagine. You come back from school. You are the one. You are alone. And you are junior. I was junior in the field. So I have no one to consult or to ask something, especially when I faced some challenges. It was a really, very difficult situation to me. I had to organize the world. I had to organize the entire team to have the nurses, to have the junior doctors to work with. So all these things were not there before. I can't imagine. I can't explain clearly how situation was difficult. Specialized care, where now they were started to be done on daily basis. I was doing, I was working in the clinic attending outfessions. I was working in the world, doing world-run, reviewing post-operations. I was doing calls. And I was doing surgery. So this is how the situation was by then when I came back from school. So with strong support from local and international collaborator from US, BMC built a Pediatric Psychic Center for North-Western Tanzania. As I said, I came back in 2021. So at that time, Pediatric Psychic was one. And I had one junior doctor registrar. This is the doctor who just finished his MD training. And then I had 13 nurses. And I had dedicated Pediatric Psychic Center operating room, which was equipped by kids, or as one of organization from UK. And in 2022, now we hired one Pediatric surgeon because it was not possible to continue working alone for more than a year. I had to inform administration to hire someone from whenever to come and work with me. In the country, we had very few Pediatric surgeons. We couldn't move Pediatric surgeon from one hospital to our hospital. We had to hire one from Ethiopia. And he came when we became two. And we added one junior doctor. They were two plus 13 nurses. And then from 2022 to 2023, we moved from General Sajary Ward to another ward, which was dedicated for children. Because initially, when I started to work, I was admitting my patients in General Sajary Ward. So we moved from the General Sajary Ward to the ward, which was dedicated for Pediatric Sajary. So in 2023, if you see the number 2.5 is difficult to understand, to say I have 2.5 people is difficult. But that's how it was. Now, my mentor, Dr. Monika, she mentioned me when I was training in Uganda, I had to consult her and ask her to come and support us because we had a very, very difficult situation. And we wanted someone who is senior to advise us on how things should be done properly. So she came, she joined us. So we were at 2.5 Pediatric Sajans. She was coming every other month. So in a year, she was working with us for almost half a year. I'm very thankful to her. And then we had three registrars and again 13 nurses. In the year 2024, now, one Pediatric Sajan joined our team. And we became 3.5 together with Dr. Monika and the other one who came from Ethiopia and the new one. And we added one registrar they were four. And we had nurses again. And Pediatric Sajary became a separate department. Initially, it was just a unit. And in the year 2024, it became a department. Now in the year 2025, in this year, now, Pediatric Sajans, the one who came from Ethiopia, he went back to Ethiopia. Now we are 2.5. So Dr. Monika is still working with us. And we really depend on her. She's senior to us all. And we have one Pediatric and Astrologist. We have one Pediatric Sajary fellow. We have just started to train because we think without the training, the life would be very difficult for the pediatric Sajary patients. So we said we have to find a way. Though we have few, we have extremely busy. We have a lot of patients. We have students on the floor. But no way, we have to train so that we can increase number of Pediatric Sajans. So we have fellow right now. And we also have four registrars. And the number of nurses has increased. Now it is 23. So the department in infrastructure and team, Pediatric Sajary, what it has five rooms. And we have much distributionally team. We have two full-time Pediatric Sajans. And one part-time Pediatric Sajan, as I've said, this is Dr. Monika. And we have one Pediatric and Ashesiologist, one Pediatric Sajary fellow. We also have four general doctors, these registrars. We have 18 nurses. And in the ward, and these six are in theater. Three is scrub nurses and three. NASA, nurses, they are all in theater. So the current is touch of the Pediatric Sajary service in our hospital. Currently, Pediatric Sajary Department offers comprehensive training program for medical students. As I've said in the previous slide, we train medical students. We also have general Sajary residents because I said our hospital is medical university teaching in hospitals, so we have a residence. And we have fellows who are pursuing their training in a Pediatric Sajary department. So these are the strategies we used. The Pediatric Sajans were successfully trained, and they recruited it to expand the Pediatric, the department is clinical capacity. And in the year 2021, stuff underwent clinical attachment and specialized training at Simuhinbili National Hospital. This was done for the purpose of orienting them and enabling them to know the field of Pediatric Sajary. Because they were working in the general Sajary department, they knew nothing about Sajary, a Pediatric Sajary. So we had to take them to the hospital where pediatric patients are managed to have an exposure in this field. So in the same year, again, a dedicated Pediatric Sajary unit was formally established, and we shifted, as I said, we shifted from general Sajary ward to a different ward, specifically a located for Pediatric Sajary. And the Pediatric Sajary Repatimenting Handles and other radioph 300 consultations monthly with approximately 60 Sajaries. The place is real bizz. And we have almost all Pediatric Sajary conditions. As you can see here, we have an rectum of formation. An ultum of formation is the leading condition in our department. And we had made three to five patients in a week. We also have other Pediatric Sajary conditions like gastro-skissing, as you can see, the number of animations per week. We also have Hashfand disease, intestinal atrhesias. We have unfollowed cells. I remember when Dr. Monica came to our hospital for the first time, we did 15 unfollowed cells repair in one week if I'm not mistaken, yes. So we also have children with the umberi pohania, Pediatric Sajary Quadsumas. The leading one is within tumor. We get them with intersception. We also have phyrologic stenosis. Interceptions are so many who are coming with intersceptions. And unfortunately, when they come to us, we can't do a non-operative option. We have to go for operative option because they come late. By the time when they are at our hospital, the bowels are already gangrenous. So you can't do a non-operative procedure. You have to operate. We also get them with the biorealic stenosis, tracheosophageophystula, any cloaca, x-rophy, and other conditions. As I said, we have almost all pediatric surgical conditions in our hospital. So in 2021, a fully equipped pediatric operating theater was installed by Kisora to support specialized surgical procedures. And this helps us a lot. It reduces surgical waiting time. Instead of waiting for general surgery room to use it for pediatric surgical procedures. Now we have our own room. It is simple for us to plan and do our surgery according to our plans. In 2023, a neonato care room was specifically designed for managing the psoriasis cases was prepared. And this improved outcome of these newborns. And in the year 2023 again, pediatric surgery unit was officially upgraded from the unit to department. And we have now head of department. And we have inshaginas and the other staffs. So gastrochysis as one of the top 10 pediatric surgical conditions before 2021. I feel bad to say this, but this is the situation. Before 2021, I can say 50 years after building the hospital. Because the hospital was built in 1971. Up to 2021, 50 years, mortality rate was 100%. Now you can imagine in this very short period from 2021 up to 2025. I said I gave you the number that we have attended a good number of patients. So if we go back to our record, I think we shall find many, many babies with gastrochysis who died without getting proper service. So between 2021 and mid 2025, the MC attended over 687 cases. We have so many patients. Unfortunately, we don't have enough space to admit them. And I want to share with you about contributing factors to high mortality. I know you would like to know what are the problems, which cause this high mortality. So the problems are many, but some of them are resource constraints. And then is and and the system factors. So maybe I start with the patient factors, open hospital factors. Let's presentation. They normally come late to the hospital. I can give you an example for gastrochysis babies. They pregnant pregnant mothers are supposed to be diagnosed prenaturally and advise to go to deliver their babies to the place where many people of gastrochysis is done. But this is not the case. Mothers go to deliver their babies without knowing the situation of the neonate. Now you can imagine when they go to deliver their babies in their lower level hospital. And they have to move from their lower level hospital to the next level hospital till they reach to us. By the time when they come to us, if you go through their medical reports, refer later you will find they have already gone through the two or three hospitals before coming to us. So let's presentation contributes so much to body outcome. So the case of the gastrochysis is large defects. You know, we don't have silo bug, but thanks God that sometimes we get from our collaborators. When Dr. Monica comes, sometimes she brings silo bugs, but we don't have varieties. You remember the ring is should differ. The diameter dimensions should differ. But for us, we have few. So sometimes when you insert the silo bug, if the defect is big, they pop out. So it becomes difficult to manage babies with the like defect because we have very limited silo bugs. And gastrochysis cases with the complications, some they come with the complications. I think we all know that it's home money associated with the anomaly in the gastrochysis. But that one is not bad. It's bad if they come with the vanishing gastrochysis. And sometimes they come with gangrenous bugs. Now you can imagine. Once you have complicated gastrochysis, outcomes is expected to be bad, especially in our setting. And sometimes they come with a population. In this instance, out plus perforation. So you can imagine some babies, most of the babies, they come with sepsis because the referring hospitals staff or workers who work in the referring hospitals, they don't know how to take care of these babies. So they end up coming to us with infection. The infection is the leading cause in neonase in our setting. So any other questions, is there a session prior to referral? Babies are supposed to be resuscitated before referred to the higher centers. But unfortunately, they are referred to our centers without having a line, without being covered to prevent hypothermia because hypothermia cues. Without being given IV fluids, so resuscitation is not done at all. I'll share with you these few photos. The first one shows vanishing gastrochysis plus gangrenous bugs. So situation here, we have almost two complications, gangrenous bugs. And we also have vanishing gastrochysis is already complicated. Gastrochysis, it is very difficult to take care of this kind of neonase. And the second one, what is heard then between the blood dotes are hollow. So it's perforation. So if you come to this slide, you'll see the first one, you can see the bilia's contents within the silo bug. Meaning what, there is already perforation. And here, the second photo is the air, meaning there is a foration. So once we have complicated gastrochysis, it becomes very difficult for us to manage them. Gastrochysis itself without having complications, it is difficult. Now you can imagine when you add complications. It's not simple at all. It is very rare to have associated anomaly apart from atrizia in gastrochysis. Atrizia is common, but very rare to have other congenitum anomalies like what we are seeing from this slide. And then the next photo there, you see the baues are notifiable. And then if you look at it carefully, you will see some gauzes around. So the baues are covered by gauzes. And these gauzes infection, because gauzes are not sterile and they are transported in a in a prop, not in a proper way. So they easily get infection. These are the principles of anomalyneotrotransportation. They're supposed to have an engine seat for the compression because they're baues. They don't work properly. GI contents are not pushed distally, so they can evolve into aspirate. They can get a specific pneumonia and they can easily die. They're supposed to have an engine in situ, but it's not done. They're supposed to be covered to keep them warm. And sometimes they need oxygen, this newness. As I said, stabilizers and it's very important. They are baudes. They have more water in their boat, but they are not given any fruit. So by the time when they come to our hospital, you'll find them, they are already hydrated. So it's really, it's really difficult. Yes, other contributing factors to high mortality, and this is under a subsequent strain, and they have a manutrition. They say, you know, when they come to the hospital, we give them high deflits. We don't have neonatal total parental nutrition. So they end up having manutrition. And we also have lack of asylum bugs. They are not meant for actually in our country, but you can't find them even in farmers. So we depend on donation. We also need to take them to cover the intestine once. The serial reduction is done once the intestines within the abdominal cavity. When the asylum bug is removed, we have to cover the defect with the take them. We also depend on donations. Absence of antibiotics sometimes, you know, most of the parents, they don't have worth insurance for their babies. So they don't have money to pay for the antibiotics. So it becomes difficult. Even if they have infection, maybe you already have cachariza, but the parents don't have money to pay for antibiotics. So it becomes difficult and it contributes to their body outcome. Systemically factors, let's refer. In some conditions, like intersceptions, they may think maybe it is just the area they continue saying the baby. By the time they recognize it is no longer the area it is intersception. It's already too late and the power is gangrenas. So let's refer. Like the standardized protocol for management of gastrochisis, gastrochisis in neones, where it makes and managed together with the other neones, despite of their critical conditions. In their referring hospitals, it's difficult to separate neones from others, because no one knows how to take care of these kind of patients. Also lack of appropriate close monitoring. And neones needs very close monitoring, because they can change at any time. Yes, impacts and outcome. So survival rate improved up to 15% by 2022. And then now it is 56%. We are happy, especially when we consider that we came from 0%. We went up to 15%. And then now we are at 56%. We are not satisfied. We wish to have good outcome more than 90. We wish to be there. So some of the contributing factors to outcome improvement, including the infrastructure expansion, as I said, removed from one ward to another ward. And this reduces risk of infection when neones are mixed with the other risk of infection increases. Dedicated in the room for neones, as I said, we have a single room with 10 baby cats for neones. At least that room has a lot in improving outcome of these neones. Human resource empowerment, as I said, we took stuff from the hospital. We sent them to the hospital, to get an exposure, to learn from the experienced doctors, experienced nurses, and come back to the hospital to take care of the baby. It has contributed much to this outcome we are having right now. And installation of monitoring equipment, we depended on the donation. And use the office standardized care protocol and the management. All these have contributed much to the improvement of outcome from 0 to 56%. Infrastructure expansion, I think you can see this photo shows the dedicated periodic cellular operating theater. And the one with the blue cup there, Systema Senga, I was doing an operation. And human resource empowerment, we also have dedicated gastrochysis in neonato-imagine scale room within pediatric surgery ward. And we also have dedicated continuous monitoring gastrochysis in us and doctors. We have doctors in the gastrochysis room 247. And additional, we have trained stuff. The training was not for more training, but it was a clinical attachment. But it was helpful for our patients, and it was helpful for our hospital. Equipment installation, at this moment we have radiant warmers, we have emergency surgical trays within the ward, and we have monitoring equipment, availability of supplies like cello bags and tagadams from donations. So these modifications have significantly improved outcome of gastrochysis babies. Now, at least we can talk about gastrochysis survivors from 2021. And these are some of gastrochysis survivors. And this is the day of gastrochysis awareness day, 30th of July. We celebrated and we were all happy. Because before 2021, stuff thought that it is not possible to help a gastrochysis baby to survive. That's it for their attitude. That's what they knew. So we had it to change their attitude. We wanted them to know that it is possible for gastrochysis baby to survive. And through training, through working together, finally we managed holding this baby on our hands as survivors. So this is our plans for further improvement. As I said, we are not satisfied with 56%. We wish to have higher percent. So our plan is to have a constant cello bag supply. And we have a plan of having capacity building to continue, doing capacity building to whoever was joining the department. And early detection. This is the problem. Early detection, especially in the referring hospitals. And our plan, another plan is to support on the culture identi-dautics. It is difficult, but we have to find a way to support them. Because if we don't support them, they will die on our hands. We know there are problems that they have infection, but we can't give them antibiotics. So we have to find a way to so that we can give them antibiotics and improve their outcome. Another plan to have more space. This place is too small. It's not enough for all cases. We are very selective. We admit there are a few children. And the rest, they wait till others are discharged. Till others are operated and it is discharged. Infectual prevention and control. It is also one of our plans to make sure that we reduce infection and the improvement of outcome infection is the leading cause for death in our neonness. We also plan to do research. And we wish to have neonato-toto-parental nutrition. I don't know when this will be implemented, but at least it is in our plans. We have challenges. Despite the progress, the department's phases challenges such as delayed refa-lo-as-as-as-as-a-saving their previous lives from peripheral hospitals, especially to babies requiring special care, and they are a little bit more likely to be able to get some of those healthy, healthy vaccines, like gastrochysis, and other babies within testinobstructions. If they say for long in their lower level hospitals, especially these babies within testinobstructions, they can vomit and aspirate. And once they have aspirated pneumonia, they can easily die. They can be delayed or inadequate treatment for children with complex erotic or congenitumal formations, such as bladder extrafy and cloaca extrafy. What we have in the hospital, we have general errorogists. We don't have pediatric errorogists. There was a time when we received one pediatric errorogist that Dr. Evalene and she did a lot of cases. She was naturally she stayed with us for short time for one week. Another challenge in the adequate monitoring equipment in the gastrochysis room, and in the adequate bed warmers for gastrochysis in illness, as we all know, hypothermia kills. And another challenge is limited space, and the shortage of research efforts for ongoing gastrochysis research. I applied for FANT from AFSA, and we managed to get FANT, but we got FANT for one third of the area we wanted to go for capacity building. We wanted to go to the low-lying hospitals to teach them about the principles of neonatal transportation. We wanted them to know that it is important to insert an NG. It is very important to cover babies so that they can be warm, to give them IV fluids, which is needed for their bodies, and the other things, but we couldn't get enough money, but we still put it as a challenge, maybe one day we can make it. And we think if we do training to the referring hospitals, especially in the area of neonatal transportation, when they are referred to us in a good condition, it will be simple for us to take care of them and then to have a good outcome. Yes, I would like to thank you for coming to this association for listening to me attentively, but in a special way, I would like to thank Dr. Monika. As I said, she is my mentor, but since she works in Boston Children's Hospital, I would like to thank Boston Children Hospital Administration for allowing her to come and join us, to come and work with us when we work together in practice big, rather than having a single person working alone in practice may not be big. So I'm very thankful to you all, and I acknowledge the DMC administration, because it was very supportive, especially when I came back to school, when I talked to them about hiring a poetic surgeon. I was almost not sleeping. So I'm also a very thankful to Arab Corrubo Lettels, including Dr. Monika and others, thanks to Boston Children Hospital Administration. Thanks to Global Heifig Programme for this program we have. The first one is Clinical Observorship. We, two of our staff came here for Clinical Observorship. One was a theatre nurse, and the second one was a pediatric anesthesiologist. They came here under Global Heifig Programs Support. So I'm very thankful for that. And Global Support has also supported us in NASA, for Dr. Rebecca. Dr. Rebecca, I mean, Rebecca, who is a nurse, she came to our hospital to teach us, to teach our staff on how to research patients in ICU. And we noted the impacts is big because the outcome is much, much better if you can prepare this situation we are having now, and the one before she came to the hospital. And we also prepare contracts to support research, collaboration, and the Global Heifig Programme. And I'm very thankful for that. And there is a plan of having much disciplinary spinal bifida, clinical development in our hospital. I wish to have this because right now doctors work individually. They don't work together with the other department. So I think this will also be fruitful to us. And then we expect to have pediatric urology support. And the Global Heifig Programme. So I'm very thankful to all of this. So thanks to you again, and I would like to use this platform to welcome you to Bougain Medical Center. Whenever you have time, feel free to talk to Dr. Monica, to talk to me. And I'll be happy to host you in your hospital. Thank you so much and welcome to our hospital. And this is the end of my presentation. Thank you. So Dr. Monica, may you come here to help me to ask some questions. I know you will be helpful to me. Sister, if I say yes, we can express her incredible. Thanks to you for what you've done for an enormous number of children. It's stunning what you've accomplished as an individual in such a short amount of time. You're so gracious to acknowledge the help of others. I had to honor spending some time alone with sister standing yesterday. And she describes a little more of what she does. And her pathway in 2021 she finished her training. She will give me only pH of surgeon for the entire part of the country. And with less resources than here. Then they made her head of all surgical services, essentially surgeon and chief. And now two months ago, they made her essentially what we would think of the COO, the hospital, the president of the hospital. She's running a show of this 1200-bed hospital and is still operating and running clinic. It's truly astounding what you accomplished. I have met few people with the capacity that you have, your special gifts clearly. And one of them is gratitude because what you've expressed to me, which we know is true, of how Monica Linger has helped you and your country and the children is gracious and factual. And we are most willing to help support her in supporting you. And I think most of us probably feel pretty small right now, considering what you've accomplished. We had zero survivors for gaseous pieces. And you guys have brought it to be in a very short amount of time. I would have took them a very long time to happen here in well-resourced places. So it's stunning. And we're proud to be a very tiny piece of supporting you all from Monica's personal efforts. So thank you. I will turn it over to Monica to run the rest of the, I wish you all the questions. If you want to comment first. I would like to give a brief comment that it's been inspiring and encouraging to work with Sister Masega and her example of tireless enthusiasm for looking after these children when you know we talk about burnout here, but the potential for burnout there is really like unbelievable and the impressive way that people are able to maintain compassion and continue to strive for excellence, even with the limited resources is just like really so inspiring and it's a joy to work with her. I'm really up here because our accent is very difficult. And so I'm like going to say it in English again with a slightly more easily understandable accent. So please ask any questions. Santisana for excellent talk. As many of you know, and as you know, I've been working at Moombioli Hospital for 23 years and I always, your talk was not just the content, but the format was a great reminder to me of how much I enjoy working with folks in Tanzania because as we've noted, not only are you faced with a daunting task, but you have tackled it with such a lot of all encompassing but humble manner and it's just inspiring to be honest. And I guess my comment would be to say to Steve, how many faculty surgeons do you have now? Couple dozen and several surgeons seems to me of every one of those people took two weeks. We could increase the FTEs at Wagonga to at least four and a half. Maybe five pediatric surgeons, right? So I'm sure that they'd be more than willing to encourage your folks to come visit and work there. I think we have people interested in and actually Monica has facilitated some assistance saying that it says some people here, children have been over to help and to train and to do some research and hopefully increase pick lines and pn and things like that. And we've learned in retrospect, we're also specialized and we think we do these great things and then Monica comes back and shows these cases. She's definitely, oh my gosh, she has everything on there because they do with what they have. And so yeah, we'd love for our department to be able to contribute more. So my, but I do have one question, which is as you will know, the US government has pulled back foreign assistance in many different countries. Can you comment on whether and how the reduction in the pet far programs or USAID programs have affected your practice in your hospital? I don't, I can't speak to it, but I can say that one immediate impact that I noticed because I was there when the funding cuts were announced was that we somebody had a needle stick injury in the operating theater. And there's significantly higher rates of HIV there, even amongst children. And the first comment was, we don't have any more testing for HIV because that was part of the pet far program and we have no more pet kids for. And I think that's a great way to get access if you had a needle stick injury and it was all of a sudden very palpable. That was on a, it wasn't my needle stick injury, but that was on a very personal basis. I was like, wow, all of a sudden overnight, the availability of just testing and prophylaxis. Now that's not actually treatment for the patients with HIV. So I think you can probably comment better on that. Yeah, maybe I can add something in the department of where the HIV patients are managed. That's where the effect is too big because we can't get support right now. And we were informed officially that we have to continue ourselves. You can imagine we were getting support, 100% support now we have to take care of these patients. It's difficult. So obvious, the progress will not be good. Thank you for this talk. Very inspiring, wonderful efforts all around. We clearly work in a very resourceful environment here in Boston in the US. I was wondering, and you know, with both of you, if you could discuss a little bit about maybe some efforts that are being done or that are sort of in progress to potentially reuse or recycle things that to reduce waste that you've, you know, being a surgeon here in the US. And after you are frustrated by some of our excesses and things that are used in Tanzania that can help or that are being done currently. There's, there's a dichotomy to my practice because I use staples to do appendectomy and, you know, I, I don't have any difficulty using resources when I'm here, but it is. It's particularly jarring and I think some of the things that the hospital has started to do is to collect supplies that are not being used or no longer needed or maybe expired, but, you know, expired tape or, you know, there's a lot of things that are perfectly functional and valuable. I use a lot of expired sutures even because if you don't use an expired suture, you might be using a, oh, silk or like a, you know, a two-o-micro-lonabalynastomosis just doesn't work. A lot of donated supplies are used for that. I think the resource use in the OR there, you see that at the end of a case they have two basins, like that's it for the entire garbage for the entire case. And this is a laparotomy. It's not, it's not a small case necessarily. And, and I think we have a lot to learn from just maybe seeing how things are utilized there and finding a balance because much of what we do is for infection control and for preventing sepsis and things like that. And that's obviously very important, but I think that there's practices and opportunities to learn from other places that are using things in a much different way. Just when it comes to silos, they put their silos inside X and reuse them until they break. And, and the silos that I get are actually donated by bentek and their ones with like small little holes or something like that in them, but they're perfectly fine. And so there is a lot of like opportunities and things that we can do. And I think some of them are starting to happen here at the hospital and that's really, really great. They're starting to collect things on multiple units. They haven't yet expanded to the operating theater to really collect the supplies there because it was too daunting to start there. So I think this year's the year that they're going to really start collecting the supplies, but that is a part of the program. Yeah, I just want to agree with the others in an incredible inspirational talk and I think many of us have a new appreciation of what can be accomplished. The question I had specifically was with the epidemiology, which is, which is fascinating with the list of the common conditions you treat appendicitis that didn't even crack that list. And then you have anorectomyal formations and gastroskeases cases have done all defects. And I was wondering if you can maybe provide a little bit more information about what the catchment area is for that number of gastroskeases. And also has there been any efforts to better understand why those rates are so high are their environmental factors or their other factors to think about from a maybe from a public health standpoint to try to figure out upstream. You know why are there such why are there such high numbers of those defects and then what can you do to better understand what those factors may be. But thank you again for an incredible inspirational talk. I think the catchment area is around 10 million children and so when you think about that, the, that's more children than all of Canada, that's about like seven times the number of children in Massachusetts. So to huge catchment area and the obvious congenital anomalies are referred, you know, we're the only pediatric surgery site in that whole vicinity. So gastroskeases is really obvious and those patients all come. I actually think 18 a month is probably reasonable for 10 million children. I'm sure many of them are coming. And in rectum affirmations or something that becomes quite obvious. Occasionally we see five year olds who are girls with with a low imperfect a nice but you know a lot of neonates is really an obvious thing. And they can survive because they can get a colostomy. So I think that some of the differences that they are survivable conditions. If you have something that's not obvious like an intestinal atreja or billi area atreja, things that are confused with other presentations. If you ask people in referring centers, they don't realize that billious vomiting is a surgical problem. So they treat them for neonatal sepsis and then they die and they think that they died of sepsis. And so the understanding of referral places is quite poor. So I actually think as the knowledge base and understanding grows in the referral centers. Things will even out with the neonatal presentations. I have never done an appendectomy in 15 years in Africa other than for labs procedures or collectamies. And I think there's two things like we barely operate on anyone. I don't I almost never operate on anyone over 12 who doesn't have a congenital anomaly or cancer. But like those patients can be looked after by the adults. And appendicitis can easily be looked after by general surgeons. So that's who really looks after those patients, I think. But also their diet is extremely high in fiber. And I think that that's a there's a different incidence of appendicitis. But it is very striking that the most common emergency surgery that I do here. I've never done once there. Thank you. It's incredible. We are running out of time. I don't know to we all have to have the opportunity to hear more about how you scale what you've done. You went from zero to three and a half to a half. That requires training, collaboration, dedication. We scale trying to think about how many people have like in a focused area and how many total faculty we can have. We're working to do that. Which you've done is just just stunning. I wish we had a whole nother hour to hear more from you. But I think I can speak on half of the department in our hospital. How grateful we are for what you're doing. How hard you've worked for an entire population that most of us will never meet. I wish I had a daughter, who knows it well. And I'm for you are giving an outlet for for Dr. Linger to contribute in such an incredible way. We're in awe of your work. Thank you very much.
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