So our last speaker of the morning before our panel discussion is Mr. William Harkness, speaking about matchmaking and global pediatric neurosurgery. So apologies for the slight delay, and I hope this will be a bit of light relief before your lunch and before the panel discussion. I'm going to talk about matchmaking in global pediatric neurosurgery, and to give you an update from pediatric neurosurgery and what we've been doing in global neurosurgery. I had the privilege of being with you last year, and during that meeting I introduced to you the idea of global neurosurgery for children. Just very quickly for those of you who weren't here, global neurosurgery for children has followed on from the work of the Lancet Commission. As you know, the Lancet Commission said that there were 5 billion people in the world who lacked adequate access to surgical care. And more importantly, they demonstrated that it was cost effective to invest in surgical care. They didn't specifically refer to children, but naturally, as in many countries, 40 percent of the population is actually in the pediatric age group. Investment in children, specifically, must lead to a much greater improvement in economical terms. The Lancet Commission outlined the numbers of different areas in which we needed to concentrate, and this really talks about the infrastructure required to be able to carry out effective surgical care. Not only that, it also talked about the different levels of hospital involved, and obviously when we come to pediatric neurosurgery, we're primarily talking about this first level district hospitals and in higher level, tertiary and quaternary hospitals as well. With regards to the procedures involved and were addressed by the Lancet Commission, sadly the only neurosurgical procedure looked at was burr holes and recommended. And clearly that's inadequate. When they looked at the access to hospitals, you can see the distance between hospitals in low income countries was clearly much greater than in higher income countries, really highlighting the problems of access. And finally, when we look at the deficiency, the darker the red color here are those areas where the problem is worst in the world. And if we match that with the map of pediatric populations, the highest pediatric populations correspond to those areas where surgical care is most deficient. You will probably be aware of this paper from Dr. Park and Dr. Dempsey and Dr. Johnson looking at global neurosurgery, and they addressed the issue of what had been seen and discussed in these reports. And primarily the problem is that neurosurgery has not been looked at adequately. The people who have been contributing to these reports have mostly been orthopedic and general surgeons and not neurosurgeons. And really the issue is that we need to take account of that, and we need to be producing evidence of what we should be doing to improve surgical care for patients with neurological conditions. However, the problem is that none of these papers and none of these reports have mentioned children in any way. And that was really the basis for why we felt we needed to be doing more. So last year during my presence of the ISPN, I was able to travel to many countries and to try and get a view of what had been going on. And one of the first things we did last year, as I say, was I attended the AANS meeting in Los Angeles, which was hosted by Professor Boop. And the main theme of the meeting was, in fact, global neurosurgery. And I met with a number of interested individuals who you can see there, Dr. Park, Dr. Johnston, Dr. Johnston, Tony Fegazi, and others. And we decided that really we needed to find out what was currently going on. We needed to have some index procedures for benchmarking so that we could see how we could contribute to the literature as to how we could improve surgical care for children with neurosurgical conditions. And finally, we needed to bring some or facilitate some mechanism for bringing people together. And so the first thing we did was to develop a questionnaire. And this questionnaire was formulated immediately after the meeting. It was distributed and analyzed. We presented it at the ISPN meeting in October of last year. And it's now been submitted for publication. And the other thing is that we've proceeded with this plan that I'm going to describe a little bit later for matching centers. With regards to the questionnaire, what did we get out of it? As I've said, this was conceived after the meeting in Los Angeles. It was put together by this young man, Michael Dewan. And it was distributed to a number of pediatric neurosurgical organizations around the world, including general surgeons as well. And we got 500 responses from 78 countries. And you can see it was both adult and, as we've heard, in many, many countries, pediatric patients are looked after by surgeons who do both adult and pediatrics. And we also had non-neurosurgeons responding as well. And you can get an idea of people's case mix. But look here that non-neurosurgeons are doing a very significant amount of pediatric neurosurgical operations. And that's primarily pediatric surgeons who are dealing with myelomeningoceles and hydrocephalus. What about the estimated number of pediatric neurosurgeons by country? As you can see, these dark areas are the ones where the supply of pediatric neurosurgeons is plentiful. But then if we look at the supply in Africa, parts of Latin America, and Asia, you can see it's very poor. And therefore, you can see that the numbers of neurosurgeons, pediatric neurosurgeons for the pediatric population can, in many cases, be zero. What about the perception of neurosurgeons as to whether or not there were adequate numbers of neurosurgeons? You can see, again, the general feeling, particularly in Africa and Asia, is that there are inadequate numbers. As regards proximity to a neurosurgeon, on those who are receiving elective neurosurgical care, many of them are having to travel long distances. And even patients who have got a requiring urgent neurosurgical care have to travel long distances as well. And when we analyze this according to the World Bank classification, low income to high income, you can see over 80% of patients are having to travel more than two hours to access any form of neurosurgical care whatsoever. The next thing is bellwether. Bellwether was a term that really, until I got involved in global neurosurgery, I didn't really understand it at all. And it comes from the old English of one sheep having a bell. And that was used to lead the flock. And basically, it's used in the context of global surgery to define a surgical procedure that's required and can be used as benchmarking. And in general surgery, these are the procedures that have been decided on. To be able to match surgical sites in low income countries and meaningfully interpret their capability of providing a surgical service, we looked at 15 different procedures. And I'll just very quickly say that here you can see this is a VP shunt. In red, the non-neurosurgical responders. And it's deciding whether or not, at what level of hospital these procedures should be carried out. Cutting to the chase, we discovered that it was felt by most people that these were the sort of bellwether procedures that we could use in pediatric neurosurgery to assess people's capability to provide an effective service. What else came out of the questionnaire? Well, we looked at the need for equipment in different scenarios. And you can see that there are many places that, particularly here in Africa, where there is a great need for equipment and training. And we've heard today about endoscopy. But if you look across all of the global regions, there is a huge deficit, both in the equipment and the training, to provide that sort of service. Finally, we just asked a very simple question about whether or not they had a functioning drill. And this shows you that 93% of neurosurgeons said that they got a functioning drill. 70% of non-neurosurgeons said they did. But if you turn that around, there's a very significant number of people who are trying to operate on children but don't have the adequate equipment. And therefore, I think it stresses the importance of having basic surgical skills with a Hudson brace and a jiggly saw. At the ISPN meeting in Denver, we managed to draw together a number of different people from Africa, Malawi, Nigeria, Nepal, Bangladesh. And we had a discussion about how we could influence things. And Ezio Di Rocco and Michel Zerra also shared with us their experience of doing humanitarian work. And we finished that up with a discussion. And as you've heard, unfortunately, Graham Feagin can't be with us. We had a good discussion about particularly sub-Saharan Africa. And you can see on the left here, the statistics really are frightening. There are less than 15 fellowship-trained pediatric neurosurgeons in sub-Saharan Africa and a population that already exceeds 1,000 million. So we've got a real problem. We've got to do something about that. The good side is that there are neurosurgical training programs developing and improving and increasing in numbers in Africa. But as I say, there is more work to be done. We had our third Global Initiative for Children's Surgery meeting in India at the beginning of this year. And I think it's important to stress that as well as working with our adult colleagues for global neurosurgery, we really do need to work with pediatric surgeons as well, as many of them are providing the sort of care that children need, both with head injuries, hydrocephalus, and myelomeningocele. And at this meeting, I carried out a workshop of basic neurosurgical skills for general surgeons. And you can see, using a Hudson brace and a jiggly saw, demonstrating how you can turn a craniotomy flap. And many of the general surgeons, I think, were really quite enthusiastic about improving this type of training and education. And we finally produced an optimal resources document to try and help people lobby, both administratively and politically, to get greater resources for children's surgery. So finally, the thrust of my talk really is all about collaboration. In our questionnaire, we discovered that many people would potentially like to collaborate, but they really just didn't know how to go about it. And particularly, you can see in the resource-poor areas of the world, there was a huge desire to have meaningful collaboration. This society, combined with the Congress of Neurological Surgeons, did a survey, which was published just after the meeting last year in Los Angeles. And you can see that this was to ask people about their experience in global neurosurgery for children. And if you look at the number of different agencies that are involved in trying to coordinate this work, you can see why many people just don't know what other people are doing. And in this report, they said that 40 percent of respondents said that one of the reasons why they couldn't collaborate is that they really just didn't know who to hook up with. So what is there out there? This lady is a pediatric surgeon in Seattle, no, not Seattle, Portland in Oregon. And she spent the last 10 years putting together a collaborative website for pediatric surgery, but was finding it very difficult to maintain. It was hugely labor-intensive. And so we decided we needed to adopt a different approach. And this is where I'd like to introduce you to the inter-surgeon website. I've got some little handouts for you so that everybody knows how to get onto our website. But this shows you what happens. You get onto our homepage and there will be a map. And these are all centers that want to collaborate. And plus means that there's more than one person at that location. And in fact, this is for Rwanda and the DRC, Democratic Republic of Congo. And if you click on the button there, you'll see my friend Luke Malemo, who's actually a general surgeon. And he works at the HEAL Foundation in Goma. And you can get all the information about him, where he is, what he wants to do, and what sort of collaboration he would like to have with you. But that's one part of it. The other thing is we actually are trying to bring people together. And the idea came from sitting in the meeting last year in Los Angeles and thinking, well, actually, what we need is something like a dating site. We need to try and bring people together to try and create partnerships, long-lasting partnerships. And so we map people together by those that request help and those that are offering help. And we map it in terms of these areas here. Now, as you can see, we're not mapping this at any great depth. And we all know that there are problems with dating sites, too. So these two individuals may map together. They're the same age, and they both love a night out, perhaps particularly in New Orleans. So there are issues with mapping and matching. But we're really trying to improve that. And we can only do that with your help. So we've been running for six weeks now. But what happened in the first month? Well, we had 350 visitors to our website. We got 66 people who became members. And they were representatives of 26 different countries. We had 13 offers and six matches. So that was, in one month, 26 different countries. Since then, we've now, and this is the data from last night, we've now had 500 website visitors. We've got 86 members. 35 countries are now represented. We are still waiting for more people to post offers and requests so that we can help match. So finally, I'd just like to thank the ISPN, GICS, and the University of Alabama at Birmingham, who have provided help and resource, both physical and financial, and to three private donors. I'd also like to thank Jim Johnson, who's my co-founder of Intersurgeon, for the work that he has done and is continuing to do. What next? Well, we're a beta site. You will see when you go onto it. It's still under development. And we need your responses to how easy you find it and any suggestions you'd like to make. We are appointing trustees and registering as a charity in the UK. And it's important to understand, all of this work is being done pro bono. So none of us have got any financial gain from this. We are defining now a schedule of costs to be able to maintain and continue the development of this website. And we're hoping to introduce additional specialties. Obviously, adult neurosurgery and general pediatric surgery are the next ways to go. But we've also taken out the interphysician domain name. And so I'm hoping in the future, we will also be able to go out into medical specialties as well. Fundraising is really important. So we are going to, as I say, this is going to be a free service to everybody. So we need funds to maintain that. And so if anybody has got access to funds that they think might be appropriate, please come and talk to me. And out of this, one of the things that is clear, and as we've heard from Femi from Nigeria, people want to get involved in research. And one of the things that projects that we've been thinking about and discussing is possibly head injury training and teaching. So that we can make sure that children who don't have access to neurosurgeons can get proper neurosurgically trained treatment in remote areas. And that's something we're going to be working on too, I hope. Continuity. This work started with my predecessor at the ISPN, Graciela Zuccaro. And it's going to be continued with Graham Feagan, my successor. And so I would like you to visit our website, feedback to me anything that you have, and have a look at intersurgeon. And just so you know now, if I hit intersurgeon now, oh, no I won't. Well, it'll give you an idea. You can just go into the website and look at it. And oh, here we go. So this is in real time now, and that's what we've got. So that's what our front page looks like today. Thank you. Oh, sorry, you can't see that. Oh, well. You can do it on your mobile devices. And so put out your phone. Just do intersurgeon.org, and that will get you into it. Thank you.

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