 And now we're going to move on to Dr. Mifflin. Unfortunately, there are no cables up here, as there usually would be. Does anybody know where the cables are? Good morning, everybody. I wanted to talk to you about the experiences I had in Zambia. Since Dr. Teske and Dr. Mifflin and Dr. Ambarri were so gracious to allow me to go and spend two weeks there in August of this year. This is a picture of the hospital that I went to. This is taken from on top of a water tower that's near the hospital. The hospital itself is in this grove of trees here, which are mostly mango trees and such. And this is the Malaria Research Center, which has also been built at the hospital, which is a little newer. So the trees aren't as full. Just to give you an idea of where this is located, it's located just outside the city of Choma. If you go straight south, you'll find Victoria Falls. And about straight east, you'll find the capital, Lusaka. Macha Hospital is a hospital composed of five wards. This is a picture of men's ward. There's a women's ward, a TB ward, obstetrics ward, and a pediatrics ward as well. Macha has a total of 206 beds and is served by three doctors. Macha Hospital was originally started by the Brethren and Christ Church, and this is the Mission Church. It's now run by the Zambian government, but two of the main doctors are still missionaries of the Brethren and Christ Church. One of the main doctors is Phil Tuma. His father started Macha Hospital in 1956, and he's a pediatrician. He's looking at a growth chart here. And the other thing Dr. Tuma does is he's the malaria researcher there. And his efforts over the last 20 years in malaria research have reduced the amount of malaria by about 90% in the area. So he's really done a great service. The other main doctor is Dr. John Spurrier. Dr. Spurrier is who originally introduced me to Macha Hospital. And Dr. Spurrier, I would say, is the most complete physician I have ever met. He trained in ER, but I've seen him do just about everything that a physician could possibly do at one time or another. And this slide was to remind me just to give a little introduction when I first came to Macha. As you can see, I'm a little bit far away from the eye here. This is when I was a fourth-year medical student, and I'm closing up a C-section that I had done with Dr. Spurrier. I first went to Macha Hospital when I was a first-year medical student in the summer of 2001, and since have been back now six times total. So this is a rough example of my itinerary. Week one, on the way over, I met with Molly Beddingfield in London. This was the cause of some disappointment because her daughter is... If I can get this to work. This is her daughter, and the single guys on the trip were a little disappointed that her daughter was not actually involved with the meeting. However, what she does is she's the founder of Global Angels Foundation, which raises money for children's projects throughout the world. And so I was meeting with her. She's become interested in Nepal, and I was meeting with her to talk with her about whether or not there could be some coordination between her efforts and what Jeff Taven and Himalayan Cataract Project are doing in Nepal. Then after that, we arrived in Africa, and I say we. I went, Dr. Embodied joined us a weekend, but I went with a general surgeon who I went to medical school with and a maxillofacial surgeon and dentist. I did two days of eye clinic where I saw about 90 patients each day. A lot of patients with trochoma, some corneal foreign bodies, some corneal ulcers. I had the interesting experience of seeing a corneal ulcer doing a scraping, walking over to the lab, reading a book about how to do a gram stain, doing the gram stain, putting it on the microscope, seeing gram positive rods, and then going back and treating the patient. Which is something I have not had the chance to do here. Then I spent a day going through all the equipment that we would need for cataract surgery and repairing what needed to be repaired. Then I spent a day doing surgery and anesthesia with the general surgeon and helping him and the dentist to do the things that they needed to do. I spent a day working on some other projects that I had been doing in Zambia over the last 10 years, and I'll talk to you a little bit about those as well. Then a quick trip down to Livingston to see Victoria Falls and pick up Dr. Ambody. When he arrived in Macha, we did pre-op exams on Monday. Saw another about 90, 95 patients and signed up about 40 for surgery. I did surgeries on Tuesday and Wednesday, post-ups on Thursday, and then on Friday took Dr. Ambody to Lusaka to fly up and also to our university teaching hospital with Dr. Grace Mutati, who is the chairman of the ophthalmology department there. She also worked with us on Tuesday and Wednesday and learned some techniques from Dr. Ambody, including capsular rexis. Did we? Yeah, so we did extra-ocular surgery, but not intraocular. Just briefly, cataract makes up a large percentage of blindness in the world, glaucoma. So we attempted to address cataract. We didn't do any glaucoma surgeries. We did remove some corneal foreign bodies and treated ulcers. Treated several cases of glaucoma and didn't really encounter any river blindness and did encounter some cases of childhood blindness that were beyond our capabilities at the time. And just a reminder, this comes from the Himalayan cataract project. The life expectancy of a blind person in the third world is roughly a third that of a person with sight. So it's not just a matter of restoring sight. You know, these are...working to restore sight in the blind in the third world is saving lives, too. These are the procedures we did. We did about 19 cataracts. I did three horizontal tarserotomies for glaucoma. I removed two...or I'm sorry, Dr. Ambody removed two conch tumors. I removed two lid tumors. Dr. Ambody did an open globe on a patient who had had an open globe for roughly two to three weeks. And I removed about five corneal foreign bodies. So this is Dr. Ambody in PREOP, examining one of the cataract patients. As I said, we saw about 95 people worked from about 8 a.m. to about 8 p.m. And the next morning the patients came for surgery. And we're all... Not every patient was able to actually have surgery because of, for example, one patient was unable to lay flat. And so there were a few patients who were unable to receive surgery there. This is me doing a horizontal tarserotomy, trachoma. I think Dr. Ambody can attest that trachoma was rampant, even in teenagers to patients in their 20s. Just about anybody who presented with an itchy eye turned out to have trachoma. So it was something that we saw over and over again. And in the elderly, quite a few patients have marked tracheosis from trachoma. This is Dr. Ambody doing surgery with Dr. Grace Mutati, and he's teaching her some things. In particular, we were able to teach her capsular rexis. And that's important because the University Teaching Hospital had just received a shipment of a FACO machine, which they were going to begin using, but had not yet unpacked when we arrived. So this was something that, this is a skill that she will need in order to use those. And so Dr. Ambody was able to teach her that this is, again, Dr. Ambody doing some teaching in a break between cases and then back to more cases. I think, again, Dr. Ambody would be able to attest that the surgery days were long and busy with very difficult cataracts and really quite a challenge. Among the challenges are doing conch tumor removal under the exceptionally bright light of a direct ophthalmoscope. You can see the cataract microscope here, which had been functioning quite well up until halfway through this case. I'm briefly taking a photograph and then returning to my screwdriver and wrenches. I did manage to get the microscope back functioning to finish this case. And this is the microscope. So it's an example of how working in the third world you sometimes have to wear multiple hats. And I was glad that I had been an engineer as an undergrad. Yeah, that was a good one. Doing an open globe under topical anesthesia was difficult as well. Another difficulty, this is a photograph from three years ago where I'm with my kids in Zambia as a fourth year medical student. This is Sidney and he was the nurse who was trained in the ophthalmic scrub nurse. He died of renal failure about a month before we arrived. So that complicated things as well because I ended up being the ophthalmic scrub nurse instead. And then the other challenge that we faced was actually just exceptionally difficult cases. This is a patient we chose not to do any surgery feeling that it was probably just beyond our ability with the equipment that we had. But this is a 15 year old girl with light perception vision who from the history I believe got chemical burns from a bush medicine treatment for conjunctivitis. And you can see that the cornea and conjunctiva have completely epithelialized or keratinized, I'm sorry. So if anybody has any ideas on how to fix this well in the third world, please let me know. So I'm going to make a little transition here. Five things that I will not miss about matcha. Toilets without seats. I'm really tired of that after two weeks. Equipment failures, mosquitoes, so many mosquitoes. Geckos. One of these things while I was taking a bath dropped off the ceiling and landed on my back. I'm okay with geckos but not when they jump me from behind. And again equipment, equipment failures. So at matcha they have a book called primary surgery. It basically walks you step by step through every surgical thing you could ever encounter. And so I just wanted to read a quote from it because I think it introduces the next part of my talk well. You may be cherished, supported and praised and congratulated by your Ministry of Health or you may not. You may be in a health surface which is steadily improving or one which seems to be getting steadily worse if that were possible. Expect that you may be cut off from the rest of the world for four months of the year. Matcha has great Wi-Fi most of the time. Not great, well we were there. On top of everything else AIDS may now be endemic in your district. But finally your greatest blow may be that your predecessor who was promised that he would be posted to your hospital for only a short time never ordered any stores or planted any cabbages. This last line or planted any cabbages is actually very significant because a lot of things that happen at the hospital revolve around things like planting seasons, whether or not patients can travel to see you at a certain time, whether or not patients have money to travel and so on. So if you have somebody who needs to be referred you may not be able to refer them because they won't go because it's planting season or there's countless things that are social that affect your ability to provide care. And so one thing that I've always believed is that if you're practicing medicine in the third world you have a responsibility to think about more than just cases and clinic. And so this is how I actually became involved with doing more than ophthalmology in Zambia. This is a little girl named Mercy. When I first arrived in Machia as a first year medical student I got off the van and somebody ran by and said, do you know how to take a blood pressure? I said, yeah. They said, all right, you're anesthesia, come on. And this girl had just arrived. Her hands were burned so severely that from the first joint down was just charred in black and bone. And I spent two months changing her dressings. This is the result after the contractors from the scars. And when I got back to Boston for medical school they emailed me these pictures and said, can you do anything to help out? And having spent two to three months changing this girl's dressings without any anesthesia, I kind of felt responsible. And so I decided to ride my bike from Boston to New York City and back and get people to sponsor me to do that to pay for this girl to have surgery. This is her hand after the surgery. It's not a normal hand by any means when you burn your fingers off. But she has a thumb that works and two fingers that work is able to feed and dress and clothe herself. And this is her several years later. And it was very gratifying to see what you could do in the life of one person. And that led me to discuss with Dr. Spurrier about what else we might be able to do. The obvious big problem there was HIV AIDS. Zambia falls squarely in these dark red countries which are 15 to 34 percent HIV positive for adults. At Macha Hospital the first summer I was there. I had roughly two to three patients of mine die a day from HIV complications. This is a picture of the HIV, one of the HIV sections of the women's ward. And I was part of helping Macha Hospital start an HIV treatment program which grew so rapidly that it gradually was taking over the entire hospital. And they asked me if I could help them build a building to house the HIV treatment program. This is that building and it now treats 6,000 people in a three month period. And this is the mother of a friend of mine there who actually was one of the first ten patients and is still healthy and doing well nine years later. And this also shows these are drawings and colorings from HIV positive children. The HIV treatment program there has managed to reduce the transmission of HIV to infants from 60 and 100 infected mothers to about two to three and 100 infected mothers. So that's a huge advancement there. What I do now with the HIV program, these are bags of seeds and this is the agricultural development officer at Macha Hospital. And it became clear in the literature that HIV patients who were treated with antiretrovirals but in fact didn't have enough food to eat, still didn't do well. So what I've been doing with Macha Hospital is running a nutrition program for patients with HIV to make sure that all the patients who come through the HIV clinic actually have access to adequate nutrition. We provide seeds and training in agriculture. This is a family planting. I believe these are peanuts. And so we also we aim to provide protein. So peanuts are a good source of protein. Carbohydrates and fats and oils, these are sunflowers. And this is in coordination with CHAS, the Church's Health Association of Zambia. We also provide agricultural training. This is Daphias and this is the general surgeon who went with us, Andrew Steven. And this is one of the teaching plots where he shows people how to arrange crops and rotate crops and what to plant near what and so on. We also have a livestock program with, those are the she goats and the he goat. And we've provided nutritional training. This is a nutrition student, master's student from Kansas State and one from Tufts University who went and helped train Daphias in nutrition and also went into some of the rural health posts and trained people there and taught individuals who then went on to train other people in how to eat balanced diets instead of just corn and so on. And of the crops, so from the peanut crop, when we provide, we provide seeds to two to 500 patients per year. And their expectation is that they'll provide us a bag of peanuts. And those peanuts are used, this is a peanut butter maker. And so they're used to make peanut butter which feeds malnourished children in the pediatrics ward and gives us a good source of protein for kids there. This, I threw this slide in for two reasons. One is that as with any trip overseas there are beautiful things to see and Africa definitely has the best animals in the world. The other thing is that doing things in Zambia can sometimes feel like you're trying to move one of these animals. And the best example of that is the dental clinic. This is Dr. Paul, the dentist who went with us. We've been trying to build the dental clinic in Macha for the last five years. And for lack of being able to keep a dentist at Macha and lack of being able to find somebody to actually just connect a few things, we haven't been able to get that done. And so there's definitely frustrations involved with working overseas, but there's also great rewards. These are five things that I'm going to miss about Macha. Some of you may know that when I was a kid I lived on a banana plantation in New Guinea. I miss fresh bananas grown in my backyard. I miss Coca-Cola and glass bottles. The Coke in Zambia is amazing. I miss going into the villages and having people provide us Guatu, which by the way tastes absolutely terrible, but it's the hospitality that counts. I miss good friends and I miss my commute, which was roughly from here to there and took about three minutes to walk. So I'd like to thank the people who went with me, Dr. Paul, Dr. Andrew Steven, Dr. Bala and Body. I'd like to thank Tina Zarek upstairs for helping to get things together for the trip, for Dr. Teske for giving me time off of my retina rotation and Dr. Mifflin, for Dr. Tabin and Dr. Oliva from Himalayan Cataract Project who helped us and for Alcon and Dutch Ophthalmic who helped get us some supplies. And this last is a picture of the sun setting over Chobe Park in Botswana. Dr. Heer. For a nice presentation, I've found in a lot of virtual trips that they always wanted a fecal machine to get the expense of fecal training and consumables. Why not small student extra cap? Why are they getting a fecal in the sun? They're getting the fecal at the University of Teaching Hospital in Osaka. So the remote setting will not have a fecal, but the big teaching hospital will have one. That'll be the first fecal machine in Zambia that I'm aware of. And right now are three of the roughly 12 ophthalmologists who do small incision. And there's a reasonably good effort to train people there. They've sent one each of the ophthalmologists out to India or Europe to learn plastics and neuro and glaucoma. So each, Dr. Mutadi basically took the 12 ophthalmologists and said, okay, you're going to learn plastics, you're going to learn glaucoma, you're going to learn this. And so they've made a good effort to do that. Dr. Hoffman? Yeah. I think we've done that all incision extra caps for the rest of the citizens. And that's an attempt we've done at Ghana as well to try to build a sustainability model. And when we got to Ghana this last year, the new chief of the hospital that just returned from Germany, where he had surgery, Alan's been teaching the local folks a good fecal. So hopefully it can capture those individuals. I think that's, you know, it's just kind of an ongoing process to make the program self-sustaining. That's a great presentation. Thanks. Any other questions? Dr. Arambati? Yeah. It's, you know, it's been a fantastic experience for me over the last 10 years, going there six times total. I've learned a ton and hopefully I've done some good as well. But it's something that, you know, when you do stuff overseas, don't expect it to go perfectly. Be willing to be flexible. But it's well worth it. All right.