 Good evening. My name is Doug Hanto and I am chair of the surgical ethics working group at the Center for Bioethics at Harvard Medical School. And on behalf of the surgical ethics working group at the center, I would like to welcome everyone to our first Harvard surgical ethics conference ethical challenges in global surgery. Over 900 individuals registered for the conference from around the world and we would like to thank you for getting up early, staying up late, and taking time off from work or leisure to join us this evening. I believe we have an exciting hour and a half ahead of us. First, let me go over a couple of housekeeping items. We will have a Q&A feature to which you can submit questions at any time during the lectures. These are found in the meeting controls at the bottom of your screen. We will not be answering questions during the talks but we will be gathering the questions and then Dr. Mara will be asking the panelists questions during the discussion period based on your questions in the Q&A. You can also continue this conversation on Twitter using hashtag HMS bioethics. If you have any technical issues, please use the chat feature to send a message to all the panelists and a staff member will help. If you are interested in upcoming events news or education programs, please subscribe to the Center for Bioethics emails at bioethics.hms.harvard.edu slash subscribe. In addition, the sessions are being recorded and they will be available on the HMS Center for Bioethics YouTube site after the conferences are over. So without any further ado, let me introduce our first moderator. Dr. John Mara is the plastic surgeon and chief at Boston Children's Hospital and an expert in cases of cleft lip and palate, craniosynostosis and cephalosil and complex HSEA facial cleft. Dr. Mara is professor of global surgery in the Department of Global Health and Social Medicine at Harvard Medical School. He is Boston Children's Hospital professor of surgery in the field of pediatric plastic surgery and director of the program in global surgery and social change at Harvard Medical School. He is a leader in global surgery and was one of three co-chairs of the Lancet Commission on Global Surgery that held its first meeting in 2014, and that led to the publication of the commission's report, Global Surgery evidence and solutions for achieving health, welfare and economic development. Thank you Dr. Mara for joining us and moderating the session. Dr. Mara will introduce the speakers for tonight's session. John. Thank you Dr. Hanto. Thank you very much. There's 90 minutes coming up and I'm looking forward to all three of our speakers and I will first introduce Dr. Bethany Hettgothier. Dr. Hettgothier is a biostatistician specializing in health systems and implementation science research in Sub-Saharan Africa. She is an associate professor of global health and social medicine at Harvard Medical School and of biostatistics at the Harvard Chan School of Public Health. She is the director of research in the program of global surgery and social change. Dr. Hettgothier. Great, thank you so much and let me just get queued up here. Can you see slides? Great. I really appreciate Dr. Hanto and to your team, the invitation. This is a unique lens to look at global surgery and so I'm excited to explore this with you and with my co-panelists and Dr. Mara always a pleasure to be in events with you and thank you for the kind introduction. I'm going to set the stage for the conversation tonight, really thinking about why we're in this space and should we be here and how do we operate in this context. So just as a bit of a background, the Lancet Commission in global surgery that Dr. Hanto referred to and Dr. Mara was a co-chair of was really some seminal work in outlining the needs, the global needs for surgery and it was really something that actually brought me to the field. I'm not a surgeon, I'm a health systems researcher, but this commission laid a compelling case for why we need to be paying more attention to the global surgical need more broadly. So just a few highlights of the commission, probably the biggest highlight five billion people around the world lack access and of course that's not evenly distributed. There are historically marginalized populations that are the most in need of global surgery. There needs to be 143 million additional procedures to fill the unmet need for surgery. 81 million people are at financial risk. They would experience catastrophic health expenditures for surgical care every year so it's not just about providing surgery, it's about providing affordable and accessible surgery to these populations. We need to invest another 350 billion into surgical and anesthesia systems to be able to address these deficits. And then finally just really making the case that surgery obstetrics and anesthesia are just integral parts of the health care system and so we really can't talk about primary health care, comprehensive health care, universal health care without really addressing these deficits that were outlined in the commission. So with that in mind, of course these are not evenly distributed these needs. And so this is showing you a graph of the global distributions of surgeons, anesthesiologists and obstetricians per 100,000. And the target for this is to have at least 20 per 100,000 to really address the deficits that I just outlined. And what you can see here is there are many countries in the world that are exceeding this target of 20 per 100,000. So the top density in this map is 85 per 100,000 in Sweden. And then there are many countries that are far far below this target of 20. So, Rwanda where much of my work is concentrated has 0.68 per 100,000 and Sierra Leone has 0.15. And so it's not just about addressing surgical needs everywhere but it's really about prioritizing populations that have been historically marginalized and finding ways to both both address the short term needs but also the long term needs of these systems to be able to provide the surgical services. So clearly there is a need for more global surgery and so then the question is, do we have a moral obligation to address this thing. So are we morally obliged to respond and I oftentimes think about my moral obligation from just a human rights perspective so health as a human rights. And I provide here quote from Paul farmer who was my department chair, and really instrumental and fine. The founding of the program and global surgery and social change that john directs and, and Dr. June while and Dr. Joseph and I are members of. And for this, just this quote from Paul really brings us home from being an area of moral clarity, you're in front of someone who's suffering and you have the tools at your disposal to leave you that suffering, suffering or eradicate it, and you act. So we really are from a human rights perspective have a moral obligation to use our skill sets to address the global surgery deficit. That's highlighted in the commission. The second platform for moral obligation is thinking about it from our complicity and benefits from systems in which we are complicit so you know the foundation of we are complicit in and benefactors the systems that contributes the global disabilities, and therefore we are morally obliged to try and reduce those deficits so I wanted to give you a few examples of that. This is a paper that was highlighting the the colonial error and how we globally have benefited from the colonization of Africa and also how we in that colonization really undermined how systems that were already in the way that people traditionally access care, and didn't invest in infrastructure as we were extracting resources from that infrastructure. So that is a historical complicity from which we benefited from. But there's even modern day examples of this and so here's an example about how we in the US benefit from what how this headline poses at stealing doctors from other countries and so when we think about this SAO density, and the fact that Rwanda and Sierra Leone are so far from achieving their density targets, we have to recognize that we benefit in our health care system from extracting the human resources from many of these countries. So if we feel compelled that we have a moral obligation to address the surgical need, my immediately I immediately start thinking is moral obligation enough to bring me to this space and to keep me in this space. And some of the extreme situations we find ourselves in when we are only compelled by moral obligation. So here's an example of a young American and it's a very extreme example but a young American who her in her own words it was very very profound feeling and experience kind of hard to even describe in words it was like something that I was supposed to do. So this is the young American who in Uganda started a medical mission to treat young Ugandan children, and actually under a series of investigations found that her lack of medical knowledge and medical care actually was to the detriment of these children led to many deaths and she's currently under many lawsuits because of that but she felt compelled to do the work. And I would argue in that moral drive probably had blind spots to her own weaknesses of how she might actually be causing more harm than actually trying to benefit the system she was trying to benefit. So this is a really extreme example. I'm going to just briefly put up one that's, that's really more something that we would see often and and Dr junior Wallace can talk to you more about, you know, the discussions around the ethics of surgical missions. So I'm going to just briefly put up mercy ships here as the screenshot example of short term short surgical missions trying to address some of these deficits, because I know one person personally who works for mercy ships who I know is constantly interrogating how he is in the space and the contributions the mercy ship so it's not that I think this this group is bad actually think it's a group that's under evolution and it's a really exciting evolution to do but it is a place of discussion and and through that discussion. But, you know, are you in mercy ships because of the moral obligation what are your motivations for being there. Clearly it has very personal benefits to individuals so here's an article talking about one of the patients who recovered and received excellent outcomes because of the care through mercy ships. And I'll just put these here just the revisiting of these surgical trips and again, the next week we'll speak more about, you know, these surgical missions and their contributions and the ethics of them. I wanted to highlight that Dr. Hunter came to me with a proposal of, you know, lay out the need for global surgery and our moral obligations and again I immediately think well it's moral obligation enough to bring us to the space. And I wanted to highlight some of the strategies that I employ or that I our teams tried to employ to really think about how do we operate in the space in a way that's contributing and truly aligned to our moral obligation but also not vulnerable to our different spots. And how do we successfully operate and that's the space that pun is intended for for the surgical crowd but I want to give you a few solutions or few options of how we think about our work. So the first is, even though it's oftentimes uncomfortable to really interrogate the space. And this is just a slide from two of our surgical fellows Dr. Alayande and Dr. Miranda, who talk about both the history of colonialism in in health systems and in just more broadly, and then thinking about how neocolonialism presents itself and they are challenging conversations to have, but having these conversations helps us better see our blind spots and know how we might try to counter those. This is another article I want to point you to that talks a lot about the power relations between the different key players and global surgery and global health, and thinking about how those power relations manifest in this space and again understanding how those power relations really help us identify our blind spots and counter them. Another second thing we try to do is not just interrogate the space but interrogate ourselves in the space so why am I here, and I want to point you to this presentation and by Dr. Alayande, he talks a lot about our identities and if we're just going to a community because we want to help solely for moral obligation. That's not enough to really do good work that we have to have other motivations, you know, how does this benefit me, how does this help my goals what's the alignment between my professional goals and the communities that I serve, how do I make sure there's better alignment good communication. So these are all things that we need to think about not just our moral obligation. Another part of interrogating ourselves in the space is thinking about why we do the things that we do and so these are two papers that I worked on is in the last few years, one that highlights how our academic affiliation so specifically me is the faculty in the promotion systems within academic affiliations really motivate what I claim to be bad practice so you know in a few years I'll go out for promotion of account the number of first author publications that I have and that promotional system manifests in the fact that folks who are affiliated with US high profile institutions. Other papers are less likely to include colleagues from the countries that research is about. They're less likely to include those colleagues and prominent authorship positions. And so there's evidence of bad practice collaborative practice that comes from those institutions so one of the solutions we put forth is, if we know that that drives less ethical collaboration or less equitable collaboration, then we really need to be addressing those promotion policies and trying to change those pressures so that we can be more equitable and ethical in that approach. Another thing I want to put forward is just adopting very pragmatic strategies to improve the practice of how we occupy the global surgery space. So this is just an example and it was one of the recommended readings for tonight of some of the very practical things that our team does to try and make sure that, yes, we know we have blind spots, yes, we know we're under pressures, but how do we try to specifically counteract that so we do a lot of trainings that are focused on global surgery and global surgery research. We do host PGS to see fellows at our project sites but we make sure that there's a joint learning plan that benefits both our colleagues in Rwanda for me in our PGS to see fellows. And we're really thoughtful about mapping out a research space and making sure that there's opportunity for everyone on our team to grow professionally in the work, and that again we don't have blind spots of people that we might exclude or not think about for opportunities, just because of the historical power dynamics. And then finally, and I think you'll hear this a lot throughout the evening is just really centering our work for and through our partners and so I love the work that I do in the global surgery space but it is at service to other colleagues and it's at the direct request of other colleagues and trying to make sure that I'm addressing their request and not just motivated by what I think is right by what I feel compelled to do by my moral obligation. And just in quick summary, you know just a very brief tour about the needs and global surgery. I do think we have a moral obligation to be addressing these needs and global surgery. I don't think that moral obligation is enough to bring us to the space, and then hopefully some very practical strategies that we can adopt to make sure that we're countering some of our blind spots if we just were to be in the space of moral obligation. So I look forward to the discussion and I'm going to hand it back to Dr Mira for the next speaker. Thank you so much that was fantastic and I certainly have a number of questions and I know our participants will as well. I remind the participants please you know keep your questions keep them coming. I'm watching the q&a board here and after our third speaker will have a chance to to answer all those together so I'd like to introduce our second speaker now Dr Michelle Joseph. Dr Joseph is an academic trauma and orthopedic surgeon. She is a professor in global health and social medicine at the program global surgery and social change at Harvard Medical School, and an adjunct associate professor at the university uniform services Walter read at the PGS SC she holds co leadership as our chief strategy and health equity officer, and she is one of the inaugural recipients of the American College of Surgeons Board of Regents innovative grant grant for DEI and anti racism. Thank you very much for the introduction. Good evening. Good morning. Good afternoon to all of you who are joining us this today. It's a pleasure to be able to be part of this panel. I'm excited to share with you some of this information and especially looking forward to the q&a that we will have at the end. So I'll get straight into this complex surgical procedures. As you've heard from Dr Head Gutierre, we have this moral obligation and you to go even beyond that because the consequences are great when we don't offer and provide the surgical care that is required. When we look at the economics of this, the consequences are great publications in global health policy, and those specifically related to surgery have modeled 12.3 trillion economic consequence for not providing surgery. The ethics around this have been discussed most recently in a BMJ global health publication. Focus mainly on the clinical care delivery, which will be the main focus of this talk, but also on the education component, the training components as well associated with the ethical delivery of global surgical care. Partnerships, as you heard from Dr Head Gutierre, terribly important, especially making sure that they are equitable. There is true collaboration and we're really honing in on the key matters when it comes to appropriate care delivery. So what do we mean by complex? Well today I'll talk to you about a definition of what complex means in the context of this particular work. The overarching challenges that we face, the challenges in the context of the Beauchamp Childress framework, but also how it can be adapted to global surgery at large. And then finally I'll touch on some of the solutions which we've already heard to some degree. So what is complex surgery? Well all surgery has a propensity to be complex and setting really matters, but there are some absolute factors. The surgical procedure itself may require highly specialized surgeons with skills that are rare, surgical equipment or implants that are expensive and not readily available at all centres. Anesthetic requirements, not only lengthy surgery, but complex in delivery. And then we have the relative factors, co-morbidities. And I call them relative because if you could imagine in a high income facility in a tertiary centre which is used to having patients who have significant co-morbidities but they are equipped both in resource and skill set in terms of the workforce, they're able to deal with these relatively easily. If you're in a setting where these things are sparse, then suddenly these co-morbidities can pose great problems to delivery of surgical care, creating a complex surgical procedure. In addition, adjunct requirements for care delivery, not just the surgical procedure itself but the post-operative care. And finally the facility capabilities. So when we think about complex surgery, you don't necessarily need to imagine the complex reconstruction of a hand or a facial trauma or facial deformity, but rather think about it in the context of these factors, absolute and relative. The overarching challenges that we face from the lens of the global surgery practitioner and by that I'm talking about those of us who reside in high income countries that refer to it as global surgery. Our perception of the challenges because we do not reside in these spaces day in and day out throughout our careers is the tip of the iceberg in terms of the knowledge. The delivery of this complex care really requires a good understanding of the root causes and they can be country specific or region specific. The nuanced complexities that you cannot simply gather the intel on through short term mission trip, but you're really reliant on those who are living and working in this space on a day in and day out basis. The geopolitical components to the delivery of systems strengthening when it comes to ensuring that surgical care is widely available and we are really reaching that unmet need and the stability in which this care is attempting to be delivered. If we were to summarize these overarching challenges, there are three main areas I'd like to focus on the feasibility of the delivery of this care. What is the power paradigm and that really ties in with the development of the partnerships that we really feel are important for ethical delivery of global surgery and the sustainability of them. So feasibility, we're really thinking here about the resources that are available and the time that is spent. And Dr. Jojen Waller will go on to talk about the actual pros and cons of the short term mission tips, but time matters. Time matters from a individual point of care delivery to a systems level. Understanding the barriers and facilitators at both of these levels is key to really acknowledging the feasibility of delivering complex surgery based on the definition I mentioned and defining who owns the responsibility of the patients care. If you can imagine the delivery of care for a patient, if you're only there for a short space of time, who picks up the potential complications that may happen? And therefore your ethical question is, was it wise to do the surgery in the first place? And whose responsibility should it be to pick up those issues should they arise? What are the clinical superior? We'll go on to talk about that a bit more later. In terms of the power paradigm, this is really embedded in the history, the colonial history, but also the neocolonial as well. And the disconnect between who makes the decisions at the table versus who is actually experiencing the attempts of delivering these complex surgeries on a regular basis. We have to try and redefine this. And when you think about the shift that is required in this power paradigm, what we're really talking about is utilizing this word equity over equality. What we want to see is that those who are making the decisions in this space and really driving what the priorities are need to be those who reside in country and are involved in the delivery of surgical care. And how do we sustain this? How do we just sustain this attempt at delivering feasible complex surgery? It does come down to funding and also independence so you're not relying on these short term missions and a shift towards systems building and education and long term partnerships whereby you are building up the expertise in country. Essentially, you want to aim to do yourself out of a job when it comes to the delivery of this healthcare type. So when we think about this in terms of ethical frameworks, one that we're all familiar with is the other four principles and how does this fit into global surgery and what are the challenges. So I'll briefly have this up, autonomy, beneficence, non maleficence and justice. And really what we're talking about here is how much should the patients have say in making their decisions. We want them to have that level of autonomy and this is for all patients doing good and promoting that while avoiding harm, maximizing the benefit of patients and society at large. Now what does this look like in the context of global surgery? Well, there are some issues that we need to talk about. There are certain barriers that suddenly come to the fore. Cultural awareness, language barriers that one may face. Are you truly gaining full consent when attempting to deliver complex surgery in these low to middle income settings? What happens when there is a ambiguity? Do you proceed in life saving urgent events or do you stick to the moral obligation of ensuring that the patient is making a fully informed decision? These are challenges that are not fully answered by the framework in its entirety four principles. Looking at beneficence, when we think about global surgery practitioners, if surgeons from HICS go into LMICS, there is always a chance that you may end up working outside of your normal scope of practice. So the ethical question here is would you want to deliver standard of care that is potentially what you may consider lower than the normal standard of care that you were delivering your home country? These are really hard questions to answer, particularly when it comes to acute emergencies. One would argue that you should remain within your scope of practice and maintain a good high quality standard of care. That would be the ethical code, challenging when you're in those environments. And who manages the continuity of care? How do you manage follow up? What are the long term potential problems? Well, there is always a potential for complications that may occur. The question you should ask yourself is was it the right choice to make to deliver that surgery knowing that there may be potential consequences that you will not be around to take care of? In addition, if you're offering high level surgery that requires adjunct support, HDUs or ITU services, are you exhausting resources from other areas that the facilities may offer in terms of health care? How do you balance that more ground between delivering to many versus fewer patients without forming these unintended consequences? And finally, the justice component. The ideal scenario is that we offer equitable access to all in need of surgical care. The reality is patients are selected based on the safety, based on the workforce that's available, based on the resources and the location, the facility capabilities. So if we go beyond using these four principles and think about things more in a systemic fashion, I mentioned the workforce density issue. The infrastructure is key. Systems may be isolated and not necessarily, there may not be the necessary communication between the tiers of surgical care that will be normally available or rather in the HIC setting that does not translate to the LMIC setting or the country or region that you are working in. It's important to ensure that there is a full understanding of the systemic challenges before embarking on surgeries that may actually end up doing harm. And finally, as I started the talk talking regarding the economic factor, there is this ethical and economic obligation to mitigate the economic consequences of not providing surgery. But at the same time, we need to ensure that there's a balance between working within the existing structures, but how do we improve them? So that some innovative work that's been used to tackle this difficult conundrum is to look at the prevention component to this. How do we mitigate surgeries that may not need to happen if we were able to work with civil societies or public health departments and organizations, NGOs who work in the space of prevention? And when I think of prevention, I really hone in on injury prevention because we know that that is an area that can be prevented with the right mechanisms in place. Standardization of care. Should there be a level of standards of specific procedures that are really governed by bodies within countries? And if that's the case, how are they followed and how are they put in, how are they put into place? There's a challenging proposition, almost one that falls into the realms of ideals, but standardization is important to ensure that there is some degree of protection for patients. The education and programs that are existing in this space are a good solid mechanism for really building up surgical practice in country. Long term educational programs really do promote the equity factor whereby we are ensuring that the skills reside in country and the surgical procedures are performed by those who live and work in these spaces. And finally, partnerships. We've spoken about this already. Dr. Gucci has mentioned this quite clearly that partnerships are really the key to doing this work well and developing ethical frameworks should be centered around these partnerships, having equity, the 80-20 split as your focus. So in summary, the overarching challenges of BAS, when you think about them under the guise of feasibility, the power paradigm and sustainability, there are mechanisms and metrics for us to really help us be our compass in guiding how we approach them. In terms of the key challenges, when we think about the Beauchamp and Childress Framework, consent when we think about autonomy, the practice and benevolence and the unintended consequences that can occur because of the will and desire to provide care, which may be out of our scope of practice, when we practice. And thinking about these things housed within the systemic challenges that we face. And finally, the innovation factor. How do we really harness these areas in order to make sure that complex surgery in terms of the absolute and relative factors can be delivered and really move towards meeting that unmet need in an ethical way. Thank you for listening. Thank you so much, Dr. Joseph. Boy, we're going to have a lot of discussion here in just a few minutes. We're getting some good questions from people. Please keep the Q&A coming. I'm keeping track of them. And as soon as we're finished with our third speaker, we'll get to those questions. So now for our third speaker, Dr. Rashi Jinjinwala. She is currently a general surgery resident at Beth Israel Deaconess Medical Center. And she has been a Paul Farmer Global Surgery Fellow in the program in global surgery and social change for the last two years. Now for her third year, she will be our chief fellow in the program. And after her chief fellow year, she will be completing her residency training in general surgery and she plans to continue her work in global surgery as a trauma surgeon and an advocate for health equity. And I would also add she has a master's in ethics, so she's well suited for this discussion. Dr. Jinjinwala. Thank you for the kind introduction and I'm really glad to be here with everybody. Big shoes to fill but I'm our third speaker for this evening and I will be talking about whether short term surgical admission trips still have a role in 2022 and onward. So I'm just going to start off with a case. So a 25 I will read this kind of briefly but a 25 year old American med student who's interested in global health and surgery decides to participate in a global surgery trip at the end of her first year of medical school. So she fundraises all year and in June she goes to Haiti for a week long surgical admission trip. While there she first assists on 30 ish her knee repairs hydro seal repairs and elective co-assistectomies as well as some emergency cases. She goes to Haiti for a week with a newfound appreciation of the burden of surgical disease and loan middle income countries, a renewed love for surgery and she has obtained technical skills that she would not acquire during the rest of her time as medical student United States. About six months after she returns from the trip, she finds out that one of the patients she operated on died of septic shock after an ability to arrange post up care. So, the question is, what is the problem, and what are the problems. As we've heard from Dr. had got these talk and also from Dr. Joseph talk, you're going to hear some themes kind of reiterated but I think that just speaks to the importance of them. The global burden of surgical disease disproportionately affects people in low income countries and low and middle income countries with disproportionate challenges and managing the surgical disease processes in these settings as well. So not only is there a lack of timely surgical access in many LMA C's, but there's also a catastrophic and economic burden if one is even able to access a surgeon or an OR. And many of the reasons for this is because of a global shortage of surgical obstetric and anesthesia providers. So, given the immense scale of this problem we have to ask as we often ask in surgery is perfect the enemy of good. So, you know in an ideal situation, low income and low and middle income countries would train and retain their own surgeons. Obstetricians and anesthesiologists to provide first class care to their citizens the same way that we expect in many high income country settings. So, you'll see a list on the left of numerous challenges since this ideal situation, many of which, as have been kind of alluded to in the previous talks are a result of colonialism and resulted in wealth disparities resources and education disparities. You'll see this graph to the right of the screen that describes the number of doctors nurses and midwives per 100,000 population in each continent with relation to the number of dallas or disability adjusted life years per 100,000 population. So that over 50% of the world's providers are located in Europe and the Americas, whereas 3% of the world's providers are located in Sub-Saharan Africa which has the highest number of dallas per population. So, notably you'll notice that the situation is such that there are just not enough providers in places where the burden is very high of surgical disease. Do short term surgical missions provide a temporary if not imperfect real world solution to the problem of inadequate access to immediate surgical care. You heard Dr Joseph talk about some of the challenges here and you heard Dr had got the ear talk about our moral responsibility. We sometimes, you know, need to think about it terms in terms of in a political philosophy approach as well. So if hind from countries are obligated to provide some sort of surgical health care to those in LMICs without sufficient training or resources. The question is, is a short term surgical mission a reasonable way in which to offset this responsibility with the middle ground of sorts, whereby surgeons can do good and offer some training provide some concrete life saving intervention, etc, without requiring a complete upheaval of their own life and practice. So while I won't delve completely into the world of political philosophy for this talk. There are many ways in which nations cover their socio economic investments. So on one hand you have countries that rely heavily on a status approach which they prioritize care to their own citizen over others and only focuses focus on emergency port for others when needed. However, countries on the other hand who rely on a cosmopolitan approach focus more on a global approach to welfare, emphasizing basic hope well for all welfare for all excuse me. But you know how much does this type of investment actually cost. And we talk about equitable distribution of resources. What do we actually mean by that. The organization management in operas operating operating costs of short term surgical missions requires billions of dollars per year. So what is the responsibility of high income countries that fund and support these missions and offsetting or displacing some of that overhead. And could they be better spent, it could that money be better spent in education and infrastructure in the areas in which short term surgical mission trips operate. So this paper gets some sample statistics from 601 respondent physicians, indicating an increasing participation by us physicians and short terms medical missions including the opportunity costs of lost time. When they're not practicing in their home institution or their home country average to an average total economic input for an individual physician pursuing a short term surgical mission for about a week on average exceeds $11,000. So composite expenditures for short term medical mission deployment from the United States are about $3.7 billion annually, and the resource investment in quates with a nearly 5800 physician full time equivalent so that is a lot of money. So given all this money that we're spending on short term surgical missions. What are the benefits and harms of this model. You know, we've talked about many concepts of benefit and harm, and we have to ask, who's benefiting and who's being harmed potentially by by these trips. So on the top right hand side of the slide you'll see a blurb, which is actually a group that sends high income country participants to medical mission trips. And I won't read the whole thing but I will just point your direction, your attention to the second paragraph which begins. You can expect medical mission trips to hone your knowledge skill sets and problem solving capabilities. You will provide plenty of hands on clinical experience and train you to deliver maximum care with limited resources. In the end, these trips will make you a better practitioner reinforce your passion for medicine and show current and future employers that your boundless capacity for care makes hiring or promoting you an easy decision. So that is, in my opinion, very biased benefit that is focused on entirely on the providers that are coming parachuting in, if you will, to provide what they believe is care but also to really gain experience and knowledge at the expense of others. So, is participation in a short term surgical mission a form of neocolonialism without any opportunity for redemption, or does the all an all or nothing approach minimize the benefits that a well run longitudinal and during short term surgical mission structure could offer so the other paper that you see here is a qualitative study of local healthcare providers in Port-au-Prince Haiti. And in this study, four themes emerged. So general perceptions, the perceived effect of these mission trips on the healthcare system, the perceived effect on healthcare workers and future recommendations. And in general, the study found that local healthcare workers appreciated the skills and knowledge that teams impart and they improved access to a surgical services for the poor. However, workers, volunteers working independently of local teams creates negative perceptions, it stresses out the local healthcare providers and also strains the hospital resources. So that's to be a broken record with my fellow panelists, but we really need to be working in collaboration with the teams that we aim to serve so that we can actually identify sustainable solutions. So here, a systematic review that was published, reviewed 16,000, 1600 studies, 41 of which met full inclusion criteria. The studies reported a minimum of six month follow up showing a follow up rate of 56% and really notably a complication rate of 22.3%, which I just want to reiterate is an absurdly high number compared to what would be deemed acceptable in many high income country settings. The amount of 20 studies reported on follow up also reported on sustainability characteristics, but the 12 studies that did not report on duration of follow up rate reported a complication of rate of 1.2%, which is kind of not not really a contextually located so it's hard to kind of know what that actually means. So if you think about the harms of a trip like this, you think of lack of investment and buying and local infrastructure, creation and setup and maintenance of new colonial reliance on external funding structures, and then inadequate care potentially given by inadequately trained or equipped providers to deal with the patients that they're seeing. So, if short term social permission trips are to persist, persist, what requisite standards or guiding principles should we employ as rules for engagement. So this is a set of seven guiding principles that was actually first first introduced in the world of pediatrics in 2007, but I do think that there are many of the themes that we actually focus on in our own work these today and also would carry forward. So you need to have first and foremost a common and specific specific sense of purpose in your mission that is based on a collaboration that is truly based on a community and its infrastructure. And as has been mentioned, most recently by Dr Joseph and her, her speech or her talk and education and cultural competency competency training for volunteers as well as strict rules for the scope of practice and emphasis on good communication communication and goal setting is absolutely crucial. We also need to focus on teamwork and building capacity for ongoing and sustainable interventions and then finally monitoring and evaluation frameworks for both short and long term outcomes, patient safety schedules and plans for follow up care, as well as referral networks to existing hospitals or clinics for post op emergencies or issues to create actually a comprehensive network of sustainable and long term care. So back to the first slide of our 25 year old med student. Where could this have been improved. So she fundraises all year contributing to that $3.7 billion investment that Americans pour into American physicians pour into this endeavor. Could that money have been better spent elsewhere it's possible. She goes for a week in which time she hardly has the opportunity to gain any sort of experience or context or develop stronger notable partnerships. She's first assisting on on all of these operations which is not within her scope of practice. She notably does develop a new pattern of appreciation for the burden of surgical disease and low and middle income countries and comes away with that appreciation which drives her career in the future. But she also came away with a bunch of technical skills that she probably shouldn't have even been having the opportunity to develop. And importantly, the patient who died of septic shock due to inability to arrange post op care that should not should not have happened so, you know, if you think about the answer of whether we should be still doing short term surgical missions in 2022. It's evident, you know that the global surgical burden of disease is massive and it continues to grow. And although sustainable capacity building and educational efforts are without a doubt the gold standard to which we should all be striving. I do believe that there is a space for an equitable short term surgical mission model for care for provision as a way to decrease the gap in surgical healthcare needs and healthcare delivery. But if we take on our communal responsibility, our charges to adapt and improve the imperfect offering that we have with simultaneous focus on building capacity. I must focus both on the now and the future since short term surgical missions should be integrated with monitoring and evaluation frameworks capacity building and longitudinal training programs, as well as bilateral partnership initiatives. Thank you very much. And I will turn it back to Dr. Mira for the discussion. Thank you Dr. Junwall. Thank you so much. And thank you to all three of our speakers that was fantastic. It's a lot to unpack. And I think it's going to take us about two and a half more hours so everybody get comfortable we're going to we're going to go through everything no I'm just kidding. We, we have a half hour and I'd like to get to some of the excellent questions from all of our participants so I think I'd like to start back with Dr. Gutierrez a couple of questions came in earlier that are really quite nice in their in your wheelhouse so do you have suggestions as to how to address promotion policies to embrace equity and collaboration and I know you do because I know you've spoken passionately about that. And I will tell our participants that Dr. Gutierrez is really a thought leader in this area and I've learned a great deal from her over the last five plus years and so Bethany I'll let you talk a little bit about that to everyone. Thanks. Yeah. I mean it's definitely an area that we are and we being a lot of folks who are on this call with my fellow panelists, but also I see some names in the participant list that I know are chipping away at this. For me, it a bit touches on Dr. You had a quote in yours about the medical mission of like, you know, this will help with your CV building and this will help with your future prospects, and I, you know, was oftentimes finding myself being like well, I need that first authorship and not thinking about my, the consequence of me pursuing my needs over. You know, the then residual consequence of my other colleagues and their needs both you know the person down the hall but also the person across the ocean from my global health work. And so you know your question is one that we've given a lot of thought to the Lancet piece that that I had in my slide we actually outline that was the product of a two day session where we have colleagues from around the world many universities in the US but also our collaborators thinking about, you know, what are our pushes and polls and our professional life that lead to these consequences and then how can we change them. And so there's some very specific recommendations in there so one, for example, is from a like promotion standpoint, you know they count the number first author papers, right and they will also not penalize me if I'm publishing papers to colleagues and giving them credit so trying to put in more checks and balances to really evaluate not just the research but the nature of how we collaborate and that's not just for global health collaborations that's for any collaborations and with community partnerships. And so there's some other suggestions there about, like thinking about our administrative burden so Harvard does not want me out of Boston for more than six weeks a year but if you try to really address and manifest these partnerships that both Dr. Joseph talked about, but that's not something that can just happen overnight it really takes time and trust and so you know that administrative barrier can can be a limit to that. So those we have specific recommendations now the question is how do you change the policies and we're doing some efforts through the consortium universities of global health to try and have broader position statements and then really sort of put the pressure on the universities to note that that the norms of global health cooperation are changing and they need to align the promotion policies to that. So happy to share that piece in the chat. If that's useful and you can also just find the title of that paper in the slides. Thank you so much and just so that our participants know that your head go to a has been a very strong advocate for changing those policies even within our own university and it's not easy it's a little bit like changing the direction that Titanic but she's not going to give up. Just one follow up question while we're talking about research because there was another excellent question that came to us about, you know how do you handle grants with with your partners and, you know, can can a PI from another country. Maybe a PI on a US grant and how do you navigate fairness around funding and who gets what. I'll start with that and then would invite others to chime in. There are some grants for which I am uniquely eligible and not my colleagues and vice versa. We really try and it goes back to that coming around the administrative barrier so especially pre pandemic and we're trying to resume them now to just be proximate have colleagues here may be there and spend a lot of our times just brainstorming. What do we want to be working on together. We have a long, long list of what we want to be working on together so that if a grant mechanism comes along that facilitates this common goal, but for which I'm uniquely qualified. I'm not applying because it's my idea for me, I'm applying to facilitate our teams work. And so, you know there's that aspect of it. The other aspect is, you know how do we broaden our teams resources are our skill base our expertise so that other people can be applying for grants so why am I qualified for a grant and maybe a colleague is it. How do we make sure that in the process of implementing this grant that we're capacitating that person to be competitive for the next one. And so it's always thinking about, you know, maybe you weren't competitive today, but you can be competitive tomorrow so let's just make sure that we're strategic and addressing that. Okay, thank you so much. Let's, let's switch to a workforce slash clinical question and actually I throw it to both our clinicians Dr Joseph and Dr ginger and walla have an excellent question here from tail egg and UC. In the last aspect of the discussion on brain brain. Will it be fair to conclude that all workers are stolen when some nations do not provide enabling atmosphere for staff to stay in their own country so Dr Joseph maybe you can offer a thought there and then Dr ginger and walla you can follow up. Thank you for the question it's a it's a great one, and it is a reality. It doesn't happen everywhere, but it happens almost in a systematic way in some places like and I'm happy to give this example. When I was in the latter years of my training. I remember being on call and having seen at least eight or 10 new doctors from Nigeria. And I wasn't I was just surprised they were in the our emergency department. So I got talking to them and understanding how it came about there was a national recruitment of four Nigerian doctors to come to the UK on a contract for 24 months and build their emergency medicine skills, but with a view to potentially enter into full time training. So essentially they're taking those who have the skills from places in need and that was a systematic program because of the doctors or she's that we have in the UK. So yes there is a brain drain but the incentives are so great and high that it's difficult to say no. And I think the other parts that question was. Is it because there are issues in their countries residing countries essentially not stable. So how do you balance that out. Well I think the answer is you support the systems that are in country to incentivize for doctors to stay but that's very challenging because what you're really talking about is financial support. And if an individual is to travel from that country to gain the finances that they would would support their countries by working in elsewhere, then are you splitting the difference. It's a really hard question. And ultimately when you speak to the individual who hasn't been paid for three months and can easily move country and earn a lot more money and continue their skills. It's very difficult to save that person no stay in your country and not get paid. We will build the system in time because long term partnerships take time to build systems it does not happen overnight. So yes there is a brain drain, but there's always there's always a reason to leave because of the challenges with the health care system within the countries in which they reside. Thank you so that you're doing well I you know Dr Joseph is talking about kind of active coaching and I obviously think none of us feel good about that but, but what about the more passive nature of this and should high income countries be erecting barriers so that so that low income country providers can't come to high income countries. One of the things that I was actually just scrolling through the Q&A questions and there's one question that I think was I was already going to talk about it so I'll answer it, which is that, you know when we say global surgery. And actually, the four of us have spoken about many times, and we'll probably continue to but global surgery just means surgery right like it means surgery just means people getting access to the care that they need. We call it global surgery because we are modeling it after global health because people hear things that they know. Anyway, reiterate those but global surgery happens in the United States and it happens anywhere else it happens in Sub-Saharan Africa happens in India and it happens in the United States right. So one of the question I'm alluding to in the chat was that do you see brain drain. Equivalent or, you know, are kind of related to physicians in the United States, not going to rural areas or areas that are under supported and financial or other mechanisms. And I do think that there is some sort of an equitable relationship there in that it's really hard to say no when you are working, you know, for decades of your life to train for something that's an act of service to others. And then to finally be given an offer that you think you can't refuse right to live in a place that you want to live with your family that you may or may not have been able to live near or with for decades for your training, you know, potentially to have some creature comforts that you weren't able to have in other places. And, you know, for sometimes what seems like potentially an uphill battle or a thankless situation that you find yourself in. So, I do think Dr. Mayer like when you were saying, you know, should we erect barriers. I don't know that barriers are necessarily the way to go about things in general. But I do think that there is something there in not only not only providing financial incentive for the more challenging of these types of jobs or positions but also being really thoughtful as high income country and hiring practice providers that who were we hiring and why but then I think the thing that gets really challenging is who made me the boss. So just because of a miracle of birth I happen to be born in the United States as opposed to somewhere else, I have now been given the the responsibility potentially to choose who does or doesn't get access to the same kind of education and training and opportunity that I have. Sorry, excuse me. But that shouldn't be necessarily the case so I think my answer is I don't think that barriers provide you know put up by high income country participants or practitioners is necessarily answer but it's more about incentivizing the way that, you know, benefits are distributed elsewhere. I don't know if that's a skirting your answer but No, I think that's I think that's very true. You know, Lars Gander who was one of the commissioners on the Lancet Commission did some research looking at clinicians who had come. I believe it was to North America but it might have been to all high income countries and did a survey and found that one of the main reasons for folks to leave their home country was just what the participant who asked that question brought up was that, you know, there aren't the local, there isn't the local atmosphere the local community the local, you know, folks to work with and so I think, you know, on one hand you're talking about the fact that people have agency and should be able to decide what they do with their lives. And then Michelle was saying look but what we should be doing is building capacity and building environments so that people don't feel like they have to leave so I think, you know it's not one or the other and obviously it's not going to happen my tomorrow but what I think is all the above. Back to research just for a moment, Dr had got the how do you enter into in a practical sense how you enter into relationships with your partners so that, you know, the authorship is is more fair because I know that's, that's been something that you've really focused on it and I think it's really important because it's so easy I mean I know from personal experience so easy to, you know, get working on a paper and you, you know, you crank it out and you know, pretty soon, the authorship is really not very fair so how do you get started and get off on the right foot. It's a great question. I mean it's definitely even for me a continued work in progress right like I do not pretend like every paper gets it exactly right. And it's complex so I would say the first and foremost one of the barriers that I realized I had to this and it was a bit. The point I was trying to make around really trying to understand who you are in this space was just realizing that I wasn't being honest with myself or my colleagues about what I needed out of projects right so you know I'm here to help I'm here to support this research project. And then I found myself clamoring for first authorship without even realizing I was doing it and realizing why I was doing it. And so, you know, for myself I try to really think about, you know, what do you need, what are your colleagues name. And it's there are our teams have 10 1520 people on them so really trying to balance, you know now as I'm more senior in my career oftentimes serving in that PI role where my responsibility is to think about every single individual, what their goals are, what their needs are what their skills are and really trying to balance opportunities for that. So as soon as someone comes up with an idea. It goes on our paper list. And the first person who gets priority for that idea is the person who came up with it. It doesn't always pan out that way but it's a conversation it's really thinking through, you know, so Dr. Joseph may have come up with an idea but maybe it was her 10th really good idea so thank you through like what are your priorities on this and then can we share other opportunities and it's a constant dialogue. And by constant I mean I probably spend two to three hours a week just navigating authorship some various opportunities I think just having open conversation again really trusting that you can be honest about what you need and that people can be honest with you. All of that and then just putting things in writing and really trying to stick to those commitments are some of the strategies we've adopted. And so obviously the you know the dialogue and the conversations important if you've gotten to the point where you have a hard and fast rule and you say look. I'm not going to submit a paper unless there's you know co first authorship with one person from our shop and one person from over there or co senior authorship or I mean do you get to that point where it's like hard and fast rules or are you still trying to work through it with conversation. So I never think of a paper in isolation, right I think about a paper in the full portfolio of work. So there might be a situation where we have a balance that that someone might look at that single paper and say it's in balance. I think about it as like the full body of work and you know who brings what skills to the table and some papers, like we do machine learning paper that really rely on an expertise of a colleague. MIT and so that might have more of his students on it. And then we do papers that are really about clinical protocols and that might have more colleagues from Roland on it so I don't think about a single paper. One of the challenges I put to myself is that at least half of my papers have one and first authors, at least half of them have or one and senior authors for my papers from Rwanda so it's more about the full body of work not a single paper. I would say there was recently an authorship reflexivity statement that is fantastic and so I think sitting down and for that paper thinking about how did I engage partners, how did I think about this opportunity in the context of other opportunities. And that reflexivity statement is actually something that our teams were adopting, not just for papers but for how we go through our day to day research. And I think because I do think it's a helpful reflection for my day to day and how I'm engaging my full team, no matter where they sit. Right, right. Okay, that's fantastic. Thank you. Dr. Joseph, you talked a little bit about power and power imbalance. I think a little bit more to that in the sense that, you know, let's say I go on one of these, you know, medical missions and I'm going to I'm all excited I'm going to do some class lip repairs somewhere. What what happens what what do you mean by power balance I show up somewhere and what happens actually. I hope that there was an ask to begin with, and that the need you were trying to meet was a request from a surgeon in country who wanted you to assist in these difficult cases. One would hope that that is the scenario however that may not be the case. And if it's not the case then what may happen is you are contacted via an NGO to perform X number of surgeries at X hospital within a very short period of time. You may not be familiar with the hospital built any relationships with the surgeons and your approach may be one that is consistent with a HIC facility or our environment but is not conducive to getting the best out of people in an LIC or LIC setting. You do the surgeries very skilled, but you don't have all the tools that you need, because you're not used to working in that environment. So suddenly where it would have been fairly simple for you there may be complications, but you have to go back home you have to get back to BCH you got to get back to your list. And also the time difference so you can't help in real time with all the complications that may or may not occur. So suddenly you're left with this real true desire and need to do the right thing to help to assist because with cleft palate cultural issues that may be stigmatization with someone who has a deformity. So it's not a unrealistic or inappropriate ask to allow someone to be integrated to society because you have fixed their facial deformity. However, the potential consequences may be far greater than the stigmatization they would have faced. That is a case example of what may or may not occur. And, you know, pushing that a little bit further Dr. Junjun while. So, you know, I show up somewhere, what happens in the in the hospitals in the surrounding region, you know, when I bring a big group of, you know, 100 folks down to some hospital, you know, within 100 miles of that hospital what what happens in the surrounding area. Well, I can actually give you a personal example of what happens. So if it wasn't abundantly clear the 25 year old medical student was me that I spoke about. And when I was on that exact trip actually people were traveling for miles, miles to come see the American doctors right jokes on them, there was one doctor, the rest of our medical students, which you know we have our place but they weren't coming to see doctors they were coming to see the American team, and not only were people traveling for days, sometimes to come and see us. They were also bypassing other clinics and other, and like other hospitals that were in the central plateau that were equally able to provide them with care that we were providing because we were doing blood pressure checks and, you know, prenatal for pregnant pregnant people. And that's something that many people could have done that they passed by along the way because of the word that had gotten out that the American doctors were coming. And I think I would just say one other thing about power imbalances that Dr. Joseph and touched on. A lot of times you have to think about, and this is something else we were talking about earlier today a little bit, you have to talk about if they think about what questions you're asking people. And sometimes you might be not asking the right questions and so when this at the start of that, the same trip. The organization took us, you know to go see some of the family members or some of the families that we were going to see later in clinic, and they were like oh why don't we do a vaccination survey to see how many of these children have been vaccinated. You know we go down the street and we ask everyone like oh you know have you been vaccinated and they're like yeah we've been vaccinated and I just asked them one of the kids I said when was the last time someone asked you this question. And they said oh last week when the last group came. So, you know, there is inherently this system that's set up to not only prioritize the investment that the HIC providers give and again, not to go back to the same situation but you see this in the United States as well right you want certain, some patients with a certain type of doctor they don't want a doctor that looks a certain way because they want. They think that the best doctor is the white male doctor, they don't necessarily I think the best doctor is the person who's taking care of them. For many reasons right but I think that all speaks to the same concept of being really conscientious about what it means to do a short term surgical mission trip and ask the right questions about like, like Dr. I mean, I hope there was an ask for you to come do that cleft, that cleft, you know, cleft trip. Is that something that's aligned with the community. And are you actually engaged as a person who is a member of the community, also, or trying to help, or are you someone who is getting the best show possible in order to elicit further engagement so there's a lot of things that come up with that power and a question that also you might not even realize if you're not asking the right questions. Well you hit on something and I hadn't prepped you for this but you hit you hit it on something perfectly in that. Over a decade ago, our team and one of the local teams I won't say where to give it away but did a little research project looking at what happens that surrounding hospitals when a local when a team comes to one particular and it's exactly what you just said but we also looked at the clinical throughput at those surrounding hospitals and what happened is the clinical throughput dropped at all the surrounding hospitals because everyone was coming to watch these folks come from from other places so there are definitely some unintended consequences that that you have to be you have to be aware of. But the impact of research just for a moment. If you had a magic wand how would you restructure funding like from USA ID and gates and Clinton and how do you make funding so that it promotes equitable research. That is a hard question. You know my knee jerk reactions they give it to all of our projects. I feel like I feel like sometimes the funding, you know, promote some of these issues and so how, how, how would you make the funding mechanism such that it's it's better and you know what I'll throw another part in there. That's related because you've been involved in you're involved in something in Rwanda said, what are some examples of building capacities and LICs and LMICs in lieu of short term mission trips like who is in charge of the development so how do we change the funding paradigm around research but even even capacity building you know to change the whole paradigm. You know that question is really the one in the chat and then I'll get to your questions well john really got me thinking and again I'm not a surgeon so I'm not doing these short term medical trips but a lot of my early career I'm a statistician a lot of my early career was teaching short term math courses and doing a three day logistic regression course and Dr. while I think you were the one commenting on this about oftentimes what I taught when I taught it and the like sort of the structure of it was all about while I have four days. And I have some motivation to be in this country. And so I'm just going to like reach out to the university say I'm going to, I can do this right and it was a very specific ask. That is very different now than how I try, then how now I try to approach it which is, okay, these are the skill sets that I have this is the timeframe that I have. You know, is there a value that I can contribute what are your needs what are so I work a lot now with the Africa Center of Excellence in data science. The courses are coming on your curriculum. You know, how can I help and sometimes they just in with, you're not useful to us now. Right. And that is like a perfectly fine thing for someone to say to me like your availability and your skill sets and your goals don't have any needs and our priorities and our infrastructure and have a long term friend and colleague and Chanda who just always reminds me like, you know, we, she was at the University of Rwanda we spend so much time bowing to the goals and the responsibilities of the people who are coming to teach three day logistic regression courses that we never teach our survival analysis course because we're just doing these other courses so I think there's a parallel there to, to the surgical mission trip right and how the approach right there. I think there are for those of you who are on the call. I think there are still opportunities for if you have two weeks and a very specific expertise. There are still opportunities for that, but it's about doing it in a way that's not orthogonal to systems and programs and finding the right way to do that. So to your funding question I mean I think there's a direct line to that right so if my colleague wants a survival course, don't just say that you're only going to fund logistic regression right or my colleague wants a two year training, don't only give funding mechanisms for six months. From the research perspective I always call it the button chair metric right funders want more butts and chairs they don't want better in deeper trainings and partnerships. You know I think those are things that come to mind with funders but I definitely think funders need to start adopting, you know that that reflexivity checklist that I think it's going to be shared with you. You know they should be asking grantees to be reflecting and really demonstrating their intentions in Apple and that should be an evaluation criteria for sure. Thank you. Thank you that's great. Go back to you again because you brought the issue of the 25 year old going down there. I've seen a question or two relating to is it, you know, even ethical for us to be going over down these short term missions and I'll make it more for med students because you know, why would why should we be sending a North American med student anywhere. What how do they help what what value are they on any type of a mission trip. Yeah so I would say we shouldn't. That was the only mission trip I went on and I had such a bad taste of my mouth afterwards from kind of everything. How it all went that I really threw that is actually one of the reasons why I chose to do my master's in ethics, because I knew I had these big questions and, as Bethany mentioned, Dr I got the I mentioned a moral obligation, I felt that moral obligation to do more, but I didn't know the best way to navigate that for myself and I think there was another question that chat about, you know, is there other ethical frameworks rather than Benjamin Chalderess that you could you know apply to these types of questions and I that's what I wanted to learn more about in in doing that master's program and so I would say to medical students, it sounds very fun to go somewhere with something and maybe learn how to do a technique that you wouldn't be able to see somewhere else but I would posit that there are places in North America that you can get the same experience and probably way closer to home than you think. I got that question a lot when I was applying to surgical residency, you know, I went to, I went to medical school in Atlanta, and there are lots of disparities within the city itself in Boston where I'm located now there is you know a lot of evidence for life and there's a lot of expenses these dropping. Once you cross the road from Madapan to Milton. That is not unique, right. It's not unique to Boston it's not unique to Atlanta it's true for pretty much anywhere that you have a city with people. I think that the advice I would give is to really reexamine the reasons why you want to do that short term surgical mission and why why you want to go to Uganda or Wanda or Haiti, rather than down the street. And if your answer is that you want to trip you should just take a trip. Well, I think people agree with you I've seen a couple comments in line with that. Dr. Joseph there. I've noticed a few comments and questions here about how do you use technology telemedicine etc etc. Is that a way that can help us, you know, establish better longer term relationships or help with equity I mean how do we use new technology to do this better. I think if COVID has taught us anything for us that are working in the global health and global surgery spaces that there is work to be done that can be done remotely and if you can capitalize on the technology that's available to you, while also being able to be utilized by our partners in the countries in which we work. I think it's important for us to really harness technology, not just in communicating but also in training as well. I would like to be able to deliver training remotely. How do you push the boundaries of what currently exists. I think one company which us at the program global surgery and social change are familiar with this proximity being able to deliver training in theater in real time without being able to be in country is really pushing the boundaries of technology but also allows us to have more of a hands off approach while still ensuring that training is being delivered in an effective way. I think more of us need to start using technology to the advantage of our partners rather than to the benefit and convenience of ourselves. If we shift our lens, I think we're able to push the boundary further. Another thing I'd like to mention is the intuitive foundation who are currently working on really being a disruptor when it comes to training, allowing access to those who typically wouldn't have the benefit of going to a medical school or being in those circles but being able to identify that they're bright enough to learn surgical skills and become surgical officers in their countries in which they reside by having the material readily available. Now there are a whole bunch of ethics around that you don't want anyone round in person doing surgery, but there's an opportunity here for us to bypass the traditional route in order to ensure that we are training up the numbers that are required in order to deliver the surgery that is needed in these spaces. All right, well, we have three minutes left so just in the short time that we have maybe in the order that the speaker spoke maybe I'll let each of you just offer a few final comments or if there's a specific question that you really liked that I didn't get to because there were so many fantastic questions. I don't want to go ahead and answer that but so Dr. Goathe if you have just a comment or two or you want to answer a question that I didn't get to please go ahead. There's so many great comments in the Q&A and questions, but I just want to express gratitude for the space and I've known Dr. Jean Joelle and Dr. Joseph for a long time and I think part of why I'm getting better and again not perfect is just these conversations and so to Dr. Hunter and the team just having this space and really pushing us to think more about this I think it's so important to have these conversations and and hope you continue it offline after these sessions for those of you participating. Thank you, Dr. Joseph a comment or two or a question that you wanted to answer that that I didn't get to. Well first of all I'd like to share my thanks as well it's a real opportunity to share the panel with colleagues but also to read all the fantastic questions in the chat there are so many that I would like to answer but one that really stands out for me and I think is important is there's not one framework that fits all in an ideal world you could have a four point system and apply it but that's not the reality these are nuanced and complex problems and complex problems require complex solutions so I think it's important for us to take things in the context of the circumstance rather than utilizing some frameworks only. There was a question regarding other any other frameworks are out there, and I would suggest the application is very much dependent on the circumstance. Thank you so much, Dr. Jun. Yeah, I guess I'll just speak briefly, as the trainee and on the panel. I would encourage all of the medical students and trainees who are here listening to really question the or undergrads even anyone who's thinking about a career and surgery and is motivated by global health. I would just think about ways to show your commitment to this space and this work without having to feel like you need to be traveling somewhere that's as Dr. address says in the chat instagramable. You don't have to, and if you can show your commitment to the communities that you want to actually work with, and in that will come through, and I think it is important for us to keep that moral compass. Despite what we might be swayed by because the same pressures that exist when you're a medical student or an undergrad or the same pressures that Dr. had got they was talking about that push push you to try and achieve something for promotion down the line and I think I personally am just working on practicing staying true to myself and my moral compass on that so I would encourage you to do the same. Well, so first of all, I want to start out by thanking all the participants for spending 90 minutes with us that was a commitment and I hope it was enjoyable. I'm seeing some very nice comments and I appreciate everyone's comments. Secondly, I want to thank our three speakers they put a lot of time into those talks as you could tell they were new, new lectures that they put together and we really appreciate what they did and then I want to thank the President for bioethics that fantastic venue, it's really an honor to be able to do this with all of you so with that, I'll hand it back over to Dr. Hanto and the crew and thank you so much this was really a wonderful opportunity. I'd just like to reiterate Dr. mirrors thanks to Dr. head got the a Dr. Joseph and Dr. Jo Joala for excellent presentations and discussion, and also particular to Dr. Mira for moderating discussion and doing a great job getting to many of the questions that were in the chat room, and thanks to all the participants and the questions. As Dr. mirrors indicated, the feedback we're getting so far is that people did really enjoy the presentations learned a lot about global surgery and some of the challenges that have been brought up by the speakers so we just like to reiterate our thanks and thanks to the Center for bioethics and their staff. Ashley Helen Kyle for their work in making this technologically work and for helping us learn how to manage the Q amp a we we couldn't have done it without without you so. To all the participants we look forward to hopefully seeing you next week. On Monday we will have our session will be ethical issues and gender surgery, and the moderator of that session will be Christine Mitchell who is the executive director of the Center for bioethics. So we hope to see you all here next week and Godspeed. Good night.