FPMRS webinar series. I'm Dr. Lewiki Gauf, and I'm going to be moderating today's webinar, the title of which is, as you can see, The Role of FPMRS in Global Health Going Beyond the, quote, Hole in the Wall. Our speaker tonight is Dr. Rahel Nardos, who was born and raised in Addis Ababa, Ethiopia. She then received a scholarship to attend Franklin and Marshall College, where she earned her BS in biopsychology. A Yale Medical School graduate, she then completed her residency in OB-GYN at the University, I'm sorry, Washington University in St. Louis. And following her residency and with support from the Worldwide Fistula Fund, Dr. Nardos spent a year as a staff surgeon at the Addis Ababa Hamlin Fistula Hospital, which we're all familiar with. She then came back to finish her fellowship and training at Oregon Health and Sciences University, and then served as a division head for Urogyne at Kaiser Permanente Northwest, and director of global health in OB-GYN at OHSU. There, not surprisingly again, she was recognized for her clinical work and leadership as the 2018 recipient of the Kaiser Permanente Distinguished Physician Award. In 2015, she joined the board of the Worldwide Fistula Foundation, where she currently serves as the chair of the programming committee to support capacity building and the care of women with childbirth injuries in multiple countries in Africa. As part of her leadership role, she has been involved in the creation and ongoing support of the first formal Urogyne fellowship program in Ethiopia. In 2020, Dr. Nardos co-founded and currently serves as the vice chair of Global Perm NW, an NGO that's based in Portland, Oregon, created to help build healthcare capacity in low resource settings. She joined the University of Minnesota in August 2020 as an associate professor in the division of Urogyne. There, she also serves as director of global women's health within the Center of Global Health and Social Responsibility. So as the chair of the AUGS education committee, I'm so proud and privileged to have you here tonight, Rahel. A couple of housekeeping issues. We're going to field questions at the end. We'll leave about 10 minutes for questions. Please type your questions into the chat feature. And then if you have any tech issues, please also type those in there. All right, and take it away. Thank you so much, Christina, for that wonderful introduction. It's wonderful to be invited to give this talk. And really excited to see a lot of people interested in this topic. So hopefully I can give you just a big overview of global health in general and just a conversation on what our role is within FPMRS in the area of global health. So I have no disclosure today. I want to start with one of my favorite quotes by a woman called Lila Watson. She's an Australian aboriginal elder. And you can see here, she says, if you've come here to help me, you're wasting your time. But if you've come because your liberation is bound up in mine, did I just lose you in my screen? No, there we go. Can you still see it? Okay, perfect. Then let us work together. And to me, what she is trying to say really resonates with my work in global health. What she's saying is that we're global citizens. And what happens to one of us impacts all of us. And we are as strong as our weakest link. And if we have learned anything from our current COVID pandemic, I hope it's this lesson, the lesson of interconnectedness and how what happens in other parts of the world really what happens in other parts of the world really affects us. So helping to advance the well-being of others should not be seen purely as a humanitarian mission or an ethical obligation. But really, the understanding that we all do so much better when we all achieve our fullest potential. And health is obviously a minimum requirement for achieving this potential. So I usually tell my own personal story in this context, because it's a really good window into understanding why addressing healthcare needs in low resource settings requires a broader population and systems kind of approach to global health. It also highlights the importance of the role of social and political determinants of health. So when I was growing up in Ethiopia, our communist government was engaged in a never ending internal conflict. And we were one of the poorest countries in Africa. But also, we owned one of the largest military arms, thanks to our affiliation with the Soviet Union at the time. During the Ethiopian famine of the 1980s, which the world remembers, I was a nine year old girl. And I remember food was rationed, the government actually wasn't sharing the fact that there was famine going on in parts of the country, but we knew that it was really difficult to get food and basic supplies. I was always coming down with gastrointestinal diseases as a child. So I was a frequent visitor of our neighborhood government hospital. And all the hospitals were owned by the government and run by the government. And the government controlled pretty much everything because this was a communist government. And I wasn't sure why I was getting sick. But I guess in retrospect, I'm thinking it's probably because the water wasn't very clean. Even though we had tap water, we were one of the only families in my neighborhood who actually owned tap water. And we also had toilets in our house, whereas most of my neighbors did not have even pit latrines. So I remember, you know, the families and the kids from my neighbors would usually use just the neighborhood alleys as toilets. And we used to play in those alleys all the time. And I remember my mom would go every weekend, she will come out with her big water hose and try to hose the alley down to wash off all of those contaminations. And, and so it wasn't surprising, I was coming down with sickness. And, and I also remember that every time I got sick, my mom would wake one of my brothers up early in the morning, five in the morning, she will have them go to the hospital and stand in line. You have to stand in line almost all day long to be seen by a physician. And, and so they hated that. And so the other thing I remember was that, you know, when I finally got seen by physicians, it was usually by general practitioners. And these are folks who go through their medical school education and one year of internship where they rotate through different departments. And then they are after that one year, they are left to practice in both urban and rural hospitals on their own. And again, in retrospect, I realized that I have never actually really seen a pediatrician ever growing up. And every time I went, no matter what my ailment, the person who saw me would give me multiple prescription for multiple shots of penicillin. I'm talking about two, three, four weeks of shots every time I've gone through maybe four or five rounds of those as a child. And so the healthcare suffice it to say was very suboptimal. And when I see images like this was people, this is an image in Ethiopia, was people waiting for surgeries. I think this was for cataract surgery. It reminds me of my childhood and those people in those lines, because their own healthcare system has failed them. They're in the situation that they're in. But as healthcare advocates and champions, what do we do in this situation? Do we accept this failure of health systems as kind of like a terminal diagnosis and provide targeted medical relief whenever we can? Or do we try to work with the local communities and institutions to rebuild and strengthen the system itself? Or do we do both? I think it's important to have a historical perspective to meaningfully engage with some of these difficult questions. So looking back on history of global halls, you've probably heard of a movement to decolonize global halls. So let's take a brief look at why this is coming up quite a bit these days. So in the early version of global halls, colonial medicine time, in the mid 1800s to early 1900s, the way we understood global halls started with colonial powers, you know, controlling the majority of the African continent. So the British and the French controlled about 95% of Africa. And at this time, the goal of global halls was primarily to prevent the spread of diseases and control diseases from spreading across colonial sites, and to protect the obviously the business interests of those colonial powers. So even when research field sites were constructed in Sub-Saharan Africa by the British and by the US in the mid 1800s, they were primarily intended to do research on tropical diseases, so that they can be better understood and protect Europe and US. And this has big implications on how large, you know, how large research centers in Sub-Saharan Africa, for example, are understood, or looked at even to this day. During this time was also the International Sanitary Conference, which is a an important landmark conference in 1851, that was emblematic of this time. And the primary focus of this conference was to coordinate the quarantining efforts of all this European colonial power nations. International health was seen as a, you know, critical to the security issue of Western powers. And until today, global health is often seen in the context of foreign policy and health security. So then comes the second period of global health. My good colleague, Dr. Shaili Prasad, who is the director of our center, calls this Global Health Version One and Global Health Version Two. This was the time post-World War Two, and mainly concerned with the health problems and challenges in low-income countries. And the main focus here was on preventing and treating infectious diseases, improving hygiene and water supply, and to promote child and maternal health. So it was more focused on actual, you know, low-income countries at this point. But you have to understand, after World War Two, the nations also divided into this big camps of Eastern Bloc communist countries and Western Bloc Western capitalist countries. And then there was those in the middle who were not aligned with either of those that were just roughly called the Third World. And the Eastern and Western Bloc countries were competing with each other to control some of those non-aligned countries, including shaping the health care systems. So the creation of WHO happened at this time. And there was a big push on single disease focus of global health, such as eradicating certain diseases. And this approach is still somewhat pervasive in global health today, although, you know, there are some pluses and minuses to this. Pluses are, you know, there have been good efforts made, for example, in eradication of smallpox, which was more of a vertical approach, you know, just single disease focus, or even that of HIV. But it has also been criticized in that it did not have that horizontal spillover effect of impacting other more pressing health care issues, building the capacity of local partners so that they're better prepared to actually withstand other health challenges. So that was kind of the criticism of this time. So the question still is, you know, are targeted interventions sufficient to achieve sustainable health equity? At this time, there were also some really exciting progress made. So, you know, this was the time when the ALMA-ATA declaration was signed by about 134 countries. And this was at the International Health Conference on Primary Health. And what this declaration did was to define primary health care as essential health care, and emphasizes the responsibility of governments to provide adequate health care for all people, while at the same time acknowledging, you know, responsibility and engagement of communities and individuals. It was viewed as a really big victory for low and middle income countries. Although achieving it in reality, has been an insurmountable task for various reasons. And one of the reasons for that is the spread of neoliberalism, which, you know, was a fall of the Eastern Bloc countries like Soviet Union, neoliberalism proliferated, where health was thought to be best achieved by market forces, right? So privatization of health care. In global health, what happened with this view was that following the legacy of colonialism, now you have neoliberalism, which ensured this persistence of this power differentials and disparities among stakeholders, namely the funders of those projects and the recipients of the funds. So that power differential was very evident in the way in terms of, you know, who controlled and who owned the decision making in determining research agendas, for example, or programmatic priorities and allocation of the funds. And at the same time, there was also structural adjustment programs, which came forth, they were put forward by the International Financial Institutes, namely, the IMF and the World Bank, what this were, they were developed to ensure that low and middle income countries restructure their economies to control inflation to repay their international debt and to also stimulate economic growth. So what they did was to provide loans and debt relief in exchange for specific conditions that those countries have to meet that include promotion of free markets and privatization of, you know, industries and economic deregulation and small government sounds very familiar, right? And untoward impact of this was that this policies of privatization of public services and cuts to public health and health infrastructure and education led to worse outcomes for a lot of these countries. So essentially the reverse of what Alma Alta declaration was aiming to attend. So then you have the last step of global health, which is kind of where we are now, you know, the global health also some people refer to it as planetary health. Where we're thinking about health in a more focused on people rather than diseases and dealing with reduction of health inequalities such that all people in the world have the right to health and well being and under this version of global health. You know, understanding of the social and political environmental determinants of health become really critical in the idea of a shared decision making with communities and focusing on building healthcare resilience through strengthening health systems. So that's kind of where we are. So what is global health, I mean in this new definition. This is one that have seen used in many places that I, I like as well area for study research and practice that places a priority and improving health and achieving equity in health for all people worldwide. So, the important words here being health and equity. So the definition of health by the WHO is actually bigger than the way we understand health care health is a state of complete physical, mental, social well being, and not merely the absence of disease or infirmity. And if you think about what determines health, actually direct patient care health care only accounts for about 10% of this. The rest is determined by social, political, environmental, genetic, and individual factors. And this is important to keep in mind, whether caring for patients in low and middle income countries, or serving local communities, particularly marginalized communities right here at home. Before we delve into the FPMRS which we will talk about in the second half of my talk, and global health, I want to give you a couple more relevant frameworks to consider. One is the idea of social contract. So the definition of this is the expectation that society has to all physicians to be competent, ethical and responsive to the health needs of society in return for what society provides physicians, that is, status, respect, autonomy and practice, the privilege of health. So, you know, I knew about the social contract, but I have never actually thought of it in the framework of global health. So, you know, I knew about the social contract, but I have never actually thought of it in the framework of global health. So, you know, I knew about the social contract, but I have never actually thought of it in the framework of global health, until I read Dr. Shiley Presid's, my colleague's paper on his interpretation of this in the setting of global health. So, what Shiley says is, in a majority of short-term engagements in global health, the society that assumes the risk and inconvenience involved in training will not benefit from the students' future service as health care professionals. And in this context, this is not just medical students. I mean, this applies to residents, fellows, or even physicians, especially early in our careers when we're still learning to be better providers or honing in our skills. So, what he's saying is, when we do global health's work, and we are operating on patients or providing clinical care, those patients are providing the opportunity for us to learn with the understanding that it will pay off in the long run, that we will be taking care of them as expert physicians, and this is an investment that they make. But how do you understand that in the context of short-term medical missions where, you know, if it's not a consistent and ongoing commitment and engagement, how are those people who have had the social contract with us benefiting from this? And it was a very powerful way for me to actually understand this. And I think, you know, one way to ensure this in the setting of global health is to prioritize local human resource, you know, building local human resource potential through training of local providers at the same time. And building healthcare resilience over a period of time, even if those engagements are going to be done over short periods of time, over a prolonged period of time. The second framework I'd like you to consider is the ethical and legal framework. And so, you know, the U.S. has a very strict rule on matters of professional licensure, for example, and standards of care. So healthcare providers from other countries are not allowed to provide care in the U.S. without going through a rigorous recertification process, and we all know that. There's no real way that this kind of global engagement is truly bidirectional because of some of those rules. Most low and middle income countries also have rules and regulations as well, even though they may not be as stringent and often may not be enforced, either because systemic challenges, shortcomings, and their vulnerable status, to be honest, when it comes to enforcing this rule. So what you have to understand that, you know, because we have this power differentials still that we talked about earlier, host countries may not feel empowered to hold us accountable in some of these things. So there's a built-in lack of equity in bidirectional training opportunities and enforcing accountability, but it's our job to find out what the rules are and regulations are of our host countries and to try to abide by them, even if doing so may pose logistical challenges or bureaucratic burden. This should be our default position. So these rules are there to ensure health care teams do not work outside of their scope of practice, which in global health setting is highly likely. Let's admit that, you know, if you're dealing with a disease that you don't routinely see in the US, for example, obstetric fistula is a good example. Even if you have the skills, to be honest, and you don't have proper understanding of the social, cultural, political context, you may sometimes inadvertently do more harm than good. So, you know, host community needs over our interests is a big part of this ethical and legal framework movement. And then, you know, there's even some suggestions by some of these movements, and I cited the paper where you can read about this, whether or not there should be some sort of certification process for short-term engagements in global halls to make sure that these organizations, NGOs, or whoever is involved in this work, have some sort of checklist of accountability that they've done their due diligence to. And then to follow a certain kind of ethical framework. So let's talk about FPMRS and global health within this context. Mishra and colleagues through AUGS did a survey of global health engagement and interest of fellows in 2015, which I was really excited to read. And they got about 58 fellows who responded to the surveys, and what they found was that almost 40% said that global health opportunities affected their decision to do fellowship, and about 26% said that it impacted their fellowship ranking. So there's a lot of interest in global health. Nearly three quarters of FPMRS fellows are interested in global health work during fellowship, and half of the fellows would like to integrate it in some way in their future practice, and about 85% would like to work with underserved population, whether it's local or global. And they also noted that there are some barriers to this, including elective time, 74% said that finance is a big one, and also just personal commitment and having the ability and the time to do this. So when asked the fellows why this is so important, one of the fellows, for example, said, I think that it's important to use my surgical skills to help those who are less fortunate. It's important to be aware of other cultures and to help them with their barriers to medical care. You know, one of the things I like to plug in here for you is to contemplate that, in fact, we have a tremendous amount of untapped potential and power to make a difference that goes above and beyond our clinical and surgical skills. We can actually do even bigger things and make a bigger difference. And that's always a good thing to keep in mind, because I think coming from a clinical and surgical background, we're kind of focused on those skills, but I think we need to start thinking big when it comes to global health as well. And that comes as we become more and more mature in our careers and experience. It's not something you get when you're a resident or a fellow, but this is something that we go through an evolution, I hope, where we start thinking about those bigger picture things that we talked about today. So, this is, you know, the current landscape of global health engagement. We don't actually have very good data on this. When I was the chair of the Global Health SIG, we tried to reach out to see who is involved and what kind of activities they're engaged in, and it didn't really pan out. I hope that we will do that sometime. But just based on my own personal conversations over the years and observations of programs out there, the current landscape, what I'm seeing is that there's definitely a lot of short-term engagements in global health, and a lot of this has to do with the fact that, you know, fellows and faculty have high-volume clinical and academic responsibilities, obviously, and aren't able to spend longer time on the ground. The limitation has also made it harder to integrate broader care models. So, for example, incorporating ongoing physical rehabilitation, community, patient education, and even caring for more persistent chronic pelvic floor conditions, such as post-fistula incontinence, prolapse, and non-fistula incontinence, has made it harder and less feasible or less attractive to do. The other thing I see is, obviously, more focus on surgical care, but particularly on obstetric fistulas, and less so in other pelvic floor disorders. And again, there's multiple reasons for this. One is, the big one is that, is the fact that, you know, governments that normally run a lot of the healthcare systems in low and middle-income countries have not prioritized investing in the care of women with fistula. These women are poor, vulnerable, and their care and recovery requires a level of expertise and extended care that they're just not willing to invest in. And so, this responsibility, historically, has always largely fallen to philanthropic organizations and their volunteer surgeons to handle. Unfortunately, you know, visiting healthcare teams are functioning within inadequate healthcare systems, and by virtue of the care model of short-term engagements, there is minimal continuity of care. And I, you know, I also believe that the focus on fistulas is obviously partly due to the severe and heartbreaking nature of this condition, and the power of surgery to really restore the dignity of these women. It's very rewarding work. But a third reason of perhaps why we engage in fistula care over some of these other pelvic floor disorders, like prolapse and other incontinence, even though those conditions are a lot more prominent and prevalent, is because we don't get to do fistula repairs much in the U.S., and it's, you know, it's an opportunity to learn how to do the surgeries. And this is also, this point is also the reason why some of the fellows in that survey that I mentioned admitted being conflicted about the perception of medical tourism. So, and the last thing I noticed is usually the affiliation exists between a U.S. NGO or academic institution and a non-academic medical center or hospital or district hospital in low- and middle-income countries. And that means that this kind of collaboration sometimes means that it intrinsically makes it difficult to really engage in training and capacity-building of medical students and residents and other people from those low-income countries, just by virtue of the type of collaboration. And, of course, this happens mostly because the level of personal organizational investment required to build these deep relationships, to understand the health systems, and to find local champions that can drive this on the ground is a lot. And political instability and bureaucracy and leadership turnover always makes this very difficult to be engaged in a long-term sustainable project. And also, I have to say, it requires a shift in our own vision of success in the global health engagement. Because it's easier, you know, and the vision of success by funding organizations, right? Because it's easier to report, you know, the number of women cured of their fistula in two weeks or in three months or in a year, even though close to 50% of them still continue to leak urine and are really having ongoing issues, than to, you know, talk about training health care teams and improving health systems, which takes years of investment and buy-in from many more stakeholders to ensure success. A lot of funding organizations aren't willing to invest in that. They want a quick turnover of success so that they can tell their, you know, donors that they've done this. Most of our organizations that we're affiliated with, they don't, they just don't make this investment. And I think part of it is just that even thinking about it in that way and pushing, but part of it is just there's this systemic kind of barrier to do those kind of engagement work, unfortunately. So I want to share with you my own journey through global health and how, you know, I'm still kind of maturing in this process, to be honest. And my experience is by no means a template on how to do global health, but it may shade some light into stages of maturation. And I will tell you that, you know, we have to go through this process of how we do things in order to actually learn how to do things better. And that's just part of the way things are done. So in 2007, after finishing my residency, I decided to spend a year at Hamelin Vistula Hospital in Ethiopia. And, you know, Dr. Hamelin in this picture, this was from, my gosh, 2007, I think. My son is now 15 years old. He's a teenager. And Dr. Hamelin sadly is no longer with us. She founded the Hamelin Vistula Hospital purely dedicated to fistula care, an impressive place. I had the privilege of being there with incredible local surgeons who I learned from an whole health care team and really learned how the care of fistula requires a holistic approach. When it's done in a way like this, it's really incredible. But like you know, like everyone who wants to help this population, I that's what I wanted to do to learn how to do fistula and maybe to be engaged in the long run in this service. One of the sound advice I got from my residency mentor, Dr. Lewis Wall, who is also the founder of Worldwide Fistula, was that if I wanted to be successful in a long term career in global health, I need to really invest the time on the ground and build relationships and really understand the health systems and the social, cultural, political determinants of health. And that's why I did this, even though I owed a ton of money from med school, and wasn't the soundest financial decision of my life. So, you know, I learned a lot of things there. And one of the things I learned was that the care of this woman, even the surgical care, but the whole care of this woman was very complex. And they had injuries beyond the physical that we see, obviously, a lot of psychological problems and social injury from the separation and divorce and all those things and the ostracization and the economic injury. A lot of these women are dependent on their husbands and when they get divorced after this kind of experience. Remember, a lot of them have lost their children, their pregnancy, their babies. It's a really a terrible situation to be on. And I remember distinctly, you know, on the last day, you know, I will do the surgeries. And it would be the day that, you know, I would remove the folic additives, and I will hold my breath as I do my diet test, backfill the bladder. And then as soon as everything, the hole is closed, I would be excited, I would celebrate, I would, you know, we would hug and everything. And then I would go to round on those patients the following day, and they will be in tears. Some of them will be in tears because they don't want to go home. And that's because, you know, they don't have the social support. They don't know how they're going to survive. They don't have the economic support based on what has happened to them. And it was very clear to me at that time that we fall short on a lot of things, that social reintegration, the economic empowerment, we're all part of the picture of giving care, but we weren't able to provide it. The other patients that really broke my heart was, like I said, you know, 40 to 50% of these women continue to have pretty significant urethral incontinence because of the level of trauma to the urethra and surrounding regions. So, you know, again, what happens to these patients in the long run, you know, we were celebrating closing the hole, but they have a lot more needs. So we all know the, you know, fistulas are very complex and it's a surgical expertise that you need depends on the type of fistula. So not everyone can, you know, if you don't have good, well-trained surgeons, if you have surgeons who are coming from all different places, kind of desperate kind of care, there's a high risk of breakdown of fistulas. And if that happens, the likelihood those patients will heal the next time they have surgery is much lower. So this is a big issue with fistula model care models right now. And like I said, they need a lot more than just surgical care. We used to have psychiatric nurses at the fistula hospital, physical therapists to work with them. Some of them needed a lot of nutritional support. I mean, as you can see in this picture, this patient came in with both rectal vaginal and vesicle vaginal fistula, and she restricted her fluid and food intake for a long time to avoid contamination because she doesn't have a way to keep clean. And really, when they arrive, some of these patients are in dire shape. If they've been squatting in one place for a long time, they have lymph contracture. So it takes a lot of physical therapy work. Some of them have nerve injuries, foot drops. So really, it's not just about the surgery. It requires a lot of rehabilitation before you can even attempt to do surgery for some of these patients. So having a comprehensive care plan and a long-term care plan is really important. Obstructed labor complex that Dr. Lewis talks about with these patients. Like I said, post-fistula incontinence is a huge issue. We did a study in Ethiopia where we looked at women with and without persistent incontinence after fistula, and what we found was that those who have leakage have moderate to severe leakage. A lot of them have very severe leakage. In fact, we tried to do pad tests. Originally, our plan was to do a 24-hour pad. That was not going to happen because they soak through the pad in no time. We changed it to every two-hour pad test. For the Ethiopia study, we actually aborted it because they soaked through it even within the two hours. So more than four grams. We did the same study in Uganda, and it was the same thing. The level of incontinence these patients have if they actually do have leakage afterwards is pretty severe. So a lot of work needs to be done. A lot of psychological trauma. So what we also found in our study with these patients was high level of suicidal ideation, whether they're leaking or not, you know, persistent leakage or not. It's like in the range of 20 to 30% of people who have had suicidal ideation, but the women who have persistent incontinence were two times as likely to report having made a plan for suicide and about six times more likely to have attempted suicide. So psychological and mental health care is really critical. I just want to briefly give you, like, this happens within the context of poor maternal health. I mean, in sub-Saharan Africa, one in 39 women die of maternal complications compared to one in 49 hundred in high income countries. So there's huge disparity in this. There are lots of social and cultural and structural determinants for this mortality. One is the barriers to seeking care, you know, child marriage, lack of education, not trusting the health care system for obvious reasons. And obviously, gender inequality, women are not empowered to make those decisions about when to go to have their baby in the house, whether to have it in the hospital versus at home. They're not the ones making those decisions. A lot of times there are delays in reaching care. Transportation is a huge issue. Ambulances are not easily available. And people have to pay a lot of money to contract cars to take women to hospitals. A lot of times they have to be carried. Receiving care is a big challenge, obviously, because of the quality of care. A lot of these women are told to go to health centers, which are not equipped to do either operative vaginal delivery or C-sections. And so that actually poses a more delay in their care. So, you know, if you look at countries that have maternal highest maternal mortality in those dark orange area, they're also the same ones that have a great physician shortage. And this applies to nurses and midwives as well. So this is another big barrier to care. I just took this picture at our university partners in Magale. These are all the learners, the medical students and residents who are rounding on patients. And you can see there's so many of them. So what the government in Ethiopia decided to do is to address the issue of health care, access to health care, they would just train a lot of doctors or health officers. And the problem with that is that the quality of training is greatly compromised. There's no way the students are learning at bedside in this kind of environment. And that has actually led to another problem in the fistula area, which is iatrogenic fistula, as they did a lot of task shifting training, you know, health officers and general practitioners to do C-sections instead of trained OBGYNs, the risk of iatrogenic fistula has gone way up as regular fistulas went down. And we're just replacing one problem with another. And that's a huge problem. You know, in fact, you can consider iatrogenic fistula as a sentinel indicator of health system failure in this country's large lots of pelvic floor disorders that are not being addressed. This is based on a meta analysis, a systematic review that was done on low and middle income countries. So there's a lot of need for a lot of us to be involved in this work. We've done some of this work in Ethiopia, we started with surgical services for prolapse in rural community hospital. And after doing this for about, you know, four years, at OHSU with my colleagues, what became apparent was that we were never going to provide enough services to these women, we need to invest on training local providers. And that's, you know, in 2015, there weren't Urogyne fellows in Ethiopia. So this led to us partnering with Worldwide Fistula and Macaulay University at Hamelin to start the first Urogyne fellowship training program, which also included partnership with the local Ministry of Health, the Ethiopian Ministry of Health, as well as outreach organizations who can mobilize the patients to come in to get care. We've, you know, graduated four fellows so far. And these are all Hamelin fistula surgeons who have now become fully fledged urogynecologists. If you want to learn more about it, we have a publication on that. We've seen the number of fistulas go down while the number of prolapse surgeries have gone up. The fellows have done well over 600, 700 surgeries by now on their own. And one of the great things during this COVID pandemic was even though we haven't been able to go to support their education, they have been able to continue to do surgeries on their own with support from their senior fellows and for graduated fellows. Research is a big component of this, and this helps improve the quality of care. This is Dr. Kim Kinney, our former fellow in Malacca, who is our Ethiopian fellow working together. And, you know, it helps us to keep track of how we're doing. This was a study on our own outcomes with vaginal versus abdominal surgery. So, you know, and the work we do goes beyond surgeries, you know, we do a lot of capacity building work and quality improvement and nurse education and physical therapy. And that's what happens when you engage on a bigger, more interprofessional level is you start seeing big systems issues, and then if you are affiliated with an academic institution and you can engage your colleagues in this work, it becomes bigger and you can do more kind of meaningful change. So I want to leave you with this last slide, which is really what I've learned over the years is that we always start at the lower rung of this ladder in our profession, which is the individual level engagement. That's where we feel the most comfortable as physicians, you know, one-on-one surgery, clinical care. But as we progress, we have to understand that we have privilege and power to do a lot more, but we're not using it. You know, as we kind of progress in our leadership, in our career, we can start envisioning going up that ladder to change systems and even bigger, kind of make bigger impacts at a larger level. And with that, I'd like to end my talk and leave it, you know, open it up to your questions. Thank you. Thank you so much, Rahel. That was amazing. Yeah. So there's a couple of questions. So I think we have some time, just a little bit of time. So for those who participate in short-term endeavors, do you think there's any way to turn that into something meaningful by perhaps having adequate handoff, partnership with local physicians for continued following up and updates and continued work in the same area so that you can get to know the patients and communities? Or do you just feel that these experiences are inherently flawed and not redeemable? And that's a good question. I mean, I think we have to work with what we have, like in terms of our ability. It's very hard for people to be engaged long-term, to be on the ground. But what we can do is, you know, part of it has to do with the model of, you know, for example, if we're working with an NGO, like what their model is. So you're right. I mean, it may be that you can only be there for two weeks at a time, a year maybe. But then if your other partners or other partners in other institutions who are part of this work can go when you're not going, you can complement each other. And that's kind of how we did it with the Uruguayan Fellowship Program. I could only be there a total of, you know, four weeks, maybe a year. But I was able to recruit colleagues through OGS, through OHS youth, my mentors. So we were able to send teams, you know, three, four times a year to go and spend a couple of weeks at a time. And this worked for our fellows, but we weren't the only one. So we complemented, you know, that work was complemented by other, you know, we had colorectal surgeons who came and worked with our fellows once a year. We had urologists who worked with them. So when we're not there doing Uruguayan, they were also getting education by other teams. But we needed somebody who coordinated, we needed a, you know, a fellowship person on the ground, who managed all of these groups and make sure that the education was happening. And it wasn't distracting from our partners other work. So we gave them a chance to do their own responsibilities. So we did this in partnership, we kind of scheduled it in partnership. So, so even when, I guess, the bottom line is, if you work across, you know, larger groups, and kind of, you know, get to see who else can partner in this project, you can actually do more of a continuity model, without you necessarily being on the ground. But it does require that teamwork. Yeah, yeah. And another question, what advice do you have for Uruguayan residents who are planning to work abroad to enhance their training as residents in the US, outside of electives abroad, which are obviously canceled now because of COVID? Are you is that is that question just right now, like during COVID, or just in general? Just in general, like outside of, and then one of the other questions are there any certificates or programs that you think are particularly adequate to set a solid foundation for individuals who are serious about investing the time in global health? Yeah. You know, I just joined the University of Minnesota, and they have a really great global health curriculum through the internal medicine department. It's not specific to Uruguayan, but they have OBGYN topics. I'm actually, I'm actually doing their, I'm helping them with building their OBGYN aspect of that curriculum. But it's a well recognized program. You can get a certificate after you take it. It's like a nine week global health program online for the most part, but it does require if you want the certificate, it requires you to be in person for two weeks where they do a lot of simulation and all that kind of stuff. So it's kind of focused on tropical medicine, but a lot of the content there is very relevant to what we do. That's just one example that comes to mind. I'm sure there's quite a few other online global health modules as well that we can probably research. Yeah. Well, since it's seven, I will end this by thanking you again so much. This was so informative and just such a great talk. For everyone else, our next FPMRS webinar is going to be held on Wednesday, March 17th at 7 p.m. Eastern time. You can visit the AUGS website to sign up. And again, Rahel, Dr. Nardos, on behalf of the AUGS Education Committee, thank you so much for this. Thank you so much for the invitation. All right. Thanks, everyone. Have a good night. Yep. Bye.

webinar

Dr. Rahel Nardos

Female Pelvic Medicine and Reconstructive Surgery

FPMRS

global health

Ethiopia

social determinants of health

obstetric fistulas

low-resource settings