E78 Brian Cameron on Global Surgery

Listen to this podcast on SoundCloud

Brian Cameron  00:00

You know every child thats saved from a ruptured appendix in Guyana. I mean every baby that’s born by an emergency Caesarean section in Uganda, you know, maybe the child that discovers a cure for cancer or a vaccine for the next pandemic or a way to stop global warming.

Chad Ball  00:30

Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We’ve had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been broad in range, whether clinical, social or political, our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do.

Ameer Farooq  01:31

Dr. Brian Cameron is a pediatric surgeon at McMaster University in Hamilton, Ontario. He has dedicated his career both to pediatric surgery and to global surgery, and has worked around the world in resource-limited settings. This was a particularly memorable episode for us because Dr. Cameron actually retires this year! And so this was really a chance for us to ask him about his career, his life story, and of course, about his passion, global surgery. Congratulations again to Dr. Cameron on his absolutely well-earned retirement. Can you tell us a bit about your where you grew up and your training pathway for those of us who don’t know you as well?

Brian Cameron  02:10

Well, I grew up in Hamilton, and I was the oldest son of the first pediatric surgeon at McMaster. And actually, it seemed that dad was always being called off to the hospital. So I was resolved never to become a doctor and certainly never to become a surgeon. However, obviously, that didn’t work out and he did inspire me. When I went to Calgary to train as a family doctor, Dr. Hugh Alley who you might have been aware of Chad, took me aside after my surgical internship, and actually told me that somebody just dropped out of the general surgery program, and I should consider transferring into surgery. So Tate McFerrin, professor, called me soon thereafter, and I was in. Some years later, after finishing general surgery, I did a pediatric surgery fellowship in Vancouver with Jeff Claire, who’s certainly the model of a global surgeon and Graham Fraser. And so I guess I could say, my, my profession is pediatric surgery, but my passion is global surgery. And I sort of ended up in this direction, both congenital and acquired reasons, I suppose. Yeah, it’s interesting.

Chad Ball  03:27

You bring up Jeff Blair. We had him on the podcast. And he was he was superb as well. You know, you mentioned the term global surgery. And I was wondering if you could define for our listeners what exactly is that? Because I think it’s in some ways, confusing, and in some ways quite, quite simple. So what does that term mean for you?

Brian Cameron  03:47

Yeah, you know that? That’s a really good question, Chad. And I think there’s actually been quite a bit of debate about, you know, what is the definition of international or global surgery, but I think it’s becoming clearer. And I think, thinking back to my into my own perspective, as a teenager, I was, I was quite inspired reading about missionary surgeons like Albert Schweitzer in Africa and Canada’s Robert McClure was a went to China. And, you know, I learned that there were great disparities in the world. And later, I’d learned that 10% of the world’s population has 90% of the world’s operations. So I thought I might be able to contribute something by being a surgeon in a resource constrained environment to help fill that gap of inequity. Along the way of life, I became a member of the Baha’i faith community. And I think what attracted me there was this vision that we are all one human family. So I think that that led into my understanding what is global surgery. So to come back to your question, I think my understanding global surgery has changed. Its not just one person going to do something as a surgeon, you know, we all know we can’t really do anything, just by ourselves, we need a team. And unless I, you know, unless we train others and build capacity, there won’t be anybody there to care of our patient care for patients in the long term. So I understand the field of global surgery really be about collaborating and partnerships, specifically in resource-limited settings. So that means in less developed countries, if you like. Being an advocate for change, developing medical expert expertise in population health, trying to model leadership and humanitarian service. So you can you can sense I’m sort of listing all of the candidates competencies, and I think global surgery really aligns with all of them. And then you know, this could take place in Fiji or in Guyana, or it could be a surgical practice amongst rural and indigenous populations of Canada, for example, who don’t have adequate access to surgical care.

Ameer Farooq  06:07

Yeah, Dr. Cameron, you know, as I’ve spent some time thinking about this, and doing a little bit of work, not nowhere, nowhere near, what you’ve done. But, you know, I have come to kind of dislike this term global surgery, because, in part, it sort of suggests going away somewhere, to participate in building the ability to do surgery or building access to surgical care. And I almost wonder if we need a new term, because I think that the issues that plague indigenous Canadians in, in Canada, in terms of having a prompt and timely access to surgical care, are just as problematic as the work that, you know, the patients in Mbarara, Uganda, in terms of not having access to prompt surgical care as well. Do you ever think that maybe we need a different term? Or or do you think that we just need to get people to understand it a bit better?

Brian Cameron  07:09

Yeah, you know, I think that’s a really good point, Ameer. And I agree, I think the conception of what is global surgery has changed to include aspects of surgical care, even within our own country or our own backyard. As you say, you don’t have to travel to do global surgery. But I think if I were to look at it as what does it mean to, quote, be a global surgeon, it’s a set of I think the set of skills and competencies that that are, are their understanding of population health, as I mentioned, apply equally to serve in underserved parts of Canada as they would in remote parts of Africa. I agree with that. But I think, you know, truthfully, if we look at the overall burden of surgical disease globally, you know, 90% of the need is in the low and middle income countries. And Canada really is, you know, pretty well off in terms of resources.

Ameer Farooq  08:19

I think work by people, like you and many others has really brought global surgery into the forefront. And it’s really made global surgery viable academic pathway, for example. And I think increasingly, funding agencies are recognizing that having access to surgical care, as you point out is really a priority for population health. But but can you sort of explain for our listeners, why is it so important when you compare it to other diseases or other potential public health targets, like, for example, controlling hypertension or diabetes? Why is surgery, in your mind, still such an important thing to target from a global health perspective?

Brian Cameron  09:08

Yeah, that’s a that’s a really good question, especially now when you know, COVID is really the only health issue that we’re talking about and spending money on at the moment. But this question comes up a lot. You know, people say, well, isn’t surgery expensive? I mean, aren’t infectious diseases and chronic diseases, you know, more important globally? And I would have thought the same thing, but actually the true answer surprised me and it would probably surprise many of your listeners to learn that a district hospital in Africa that provides basic essential emergency surgical care, I’m talking about, you know, managing injuries such as open fractures, being able to do Caesarean sections, emergency laparotomies for perforations, fixing hernias, I mean, pretty basic general surgery stuff. It’s actually more cost-effective to run that hospital in terms of preventing death and disability, then many public health programs including vaccines, so and how do we know this? Well, I mean, I’m not saying I obviously I don’t say I’m not saying I don’t support vaccination. But but the health economists, and these are people at the Population Health Institute in Washington and the, you know, the Marion Lopez who really have led this this development of measuring the Global Burden of Disease using disability-adjusted life years or DALYs. So these health economists have worked out a methodology using DALYs that proves that basic surgical care is a cost-effective component of primary health care. And, you know, surgical conditions globally, such as trauma, unnecessary maternal death, and even many cancers, obviously, are surgical. The overall burden of disease is at least 11%, minimum of the total global burden of disease. In fact, trauma alone causes more death and disability globally than HIV, malaria and TB combined. So if you look at where the burden of disease is, and the relative resources or lack of resources that have historically been put into surgical care, we’ve really got a long way to go to advocate for improving those numbers.

Ameer Farooq  11:26

Yeah, absolutely. And I point our listeners to some links in our show notes. I think the Lancet Commission on global surgery published in 2014, also does a really great job to kind of talk about all the issues and summarize all the issues that you’ve been talking about. And.

Brian Cameron  11:42

Yeah, that’s a good reference. Yeah.

Ameer Farooq  11:45

Yeah. I wanted to delve a little bit into your interests in global surgery and kind of talk about some of the early things that maybe led you into into getting interest into global surgery. Can you talk a little bit about maybe some of your early experiences, particularly I’m thinking as as a medical student, and, and what those experiences taught you and how this sort of shaped your interest in global surgery going forward?

Brian Cameron  12:13

Yeah, sure Ameer. I did med school at Queen’s in Kingston. And I got we, Pat and I, my wife and I got hooked up with a program called Canadian Crossroads International. And through them, we were able to go to Sierra Leone in West Africa for three months during my clerkship year. And so I was at working, doing an elective, really at a rural clinic in Sierra Leone. And I can probably tie this into the last question as well. But I was really shocked to see the number of newborn babies who were dying of tetanus. I mean, that’s something I’ve never seen in Canada. And obviously, tetanus is an infectious disease, but it’s a great concern to surgeons who treat trauma. I mean, I knew that, you know, mothers in Canada were routinely given a tetanus vaccine to prevent neonatal tetanus and their babies through passive immunity. And I was just shocked that these mothers didn’t seem to be getting vaccinated. And then I noticed that just outside the little house I was staying in was an abandoned Jeep in the front yard. And it was been there so long the grass was growing up through the roof of the Jeep, and on its side was written WHO maternal vaccination program. So I looked at this vehicle, I said, hey, what why aren’t mothers been vaccinated against tetanus, what happened to this program? And when I talked to the local hospital leadership, the answer really surprised me. But, you know, I’ve reflected on it since and I think I understand it better. They said that, you know, obviously, WHO funding had stopped and the hospital had run out of petrol of gasoline for its generator. So they had a choice, they had to choose to use the petrol for the hospital generator rather than for the Jeep for the vaccination program. So they keep keep the hospital going to perform emergency Caesarean sections, and save mothers and do other surgery. And, you know, it really upset me that the local hospital director had to even make that choice. I mean, we can’t imagine sort of setting that kind of priority in our own setting here. But it also showed me how, you know how complex priority setting can be when you don’t have much. And you know, in fact, they probably made the right decision in terms of the most cost effective use for that gasoline was to provide surgical care in the hospital. So I think that experience really it challenged me and inspired me and kept me interested in wanting to kind of get connected to this international surgery field.

Chad Ball  14:59

That’s an amazing story. You know Dr. Cameron, you’ve been so many places. You know, in particular, the stories you’ve you provided us already, but you’ve also been to Fiji. What what was that experience like? How was that?

Brian Cameron  15:15

I tell people I went to work to serve in Fiji. Everybody’s got a vision, which is true of the beaches. Yeah. beaches, sunny skies. And actually, it’s a beautiful country. It was really sad. We were so fortunate to go there. But so what happened was I did a years locum in northern Newfoundland at the Grenfell hospital after I finished my general surgery. And I’ll tell you, for any young surgeon who’s interested in learning about general surgery, go to rural Canada, I mean, and work with some, you know, some of the fantastic mentors that are working in those settings. And I learned a lot of stuff there, you know, including how to do open prostatectomies and pin hips. But anyway, I then found this job at the Fiji School of Medicine employed by their ministry of health. And so, with my wife, my two young kids, we moved to Fiji and I was one of three surgeons in the main national, it’s called them War Memorial Hospital. And we stayed there for four years. So after the first two years, I actually came back to visit Calgary, Chad and Professor Peter Cruz invited me to give a talk and about my experience, and he put the title of the talk, which was from surgical resident to dean in two years, which got a laugh out of everybody.

Chad Ball  16:41

Yeah, that’s great.

Brian Cameron  16:43

Because that’s exactly what happened. I mean, months after I arrived in Fiji, there was a coup, many of the elites and the expatriates left. And, you know, I was one of the few remaining faculty at this really long established like, 100-year-old medical school. So they made me the dean for a year. And, you know, we had so many wonderful experiences there. It really shaped my career. I mean, it shaped my priorities going forward in life, and obviously a wonderful experience for our family. But I think one particular story that sticks with me that, you know, sort of illustrates how we never know what impact we make just by trying to do our best for our patients. So I was a young, you know, new consultant there in Fiji, and I done a gastrectomy for cancer on a 50-year-old woman. And the operation had actually gone technically, really well. I was really pleased with myself. However, the next morning, I went to do rounds with the resident, and I’m looking around on the ward. And I said, well, where’s our patients from yesterday? Sorry, sir, she died last night. What? I’m sure I was shouting. I mean, why didn’t you call me? Well, sir, we never call the consultant at night. Well, I mean, you can imagine I was so upset as you can imagine. And I just was trying to hold the lid on my, my exasperation. But the follow-up was really the fantastic part of the story, which is that about 15 years later, so I’m back in Canada, and I get an email. And it’s from that very Fijian resident who found me on the internet. Doctor Sitiveni Vudiniabola, who is now the head of surgery at the War Memorial Hospital. So he found my contact, and he let wanted to let me know that they now had an intensive care unit. And he said, he remember, he remembered how upset I had been when that patient of mine died post up. And how I had kept my cool oh, honestly, that’s not the way I remembered it. But anyway, he wants to let me know that now. You know, a post op patient would not die because of inadequate care. And I thought, well, that’s that’s just there’s so many wonderful aspects to that story. And I think, you know, those are the kinds of experiences really, I think that can inspire any of us as surgeons to, you know, just want to want to keep doing it.

Chad Ball  19:21

It’s a truly beautiful story. It’s a great story. It’s it’s funny, because the first procedure I did as a staff guy in a different country, which happened to be Haiti was a partial gastrectomy as well as maybe there’s something to that or no. You know, what one of the interesting guests that we had on the podcast was Emilie Joos, and I don’t know if you know her. She’s a trauma surgeon in critical care.

Brian Cameron  19:44

Yeah. Yeah. I listened to her interview. I listened to her. That was a great interview.

Chad Ball  19:50

Yeah. Well, you know, as you heard, one of the things that we talked about in that I think both of us were really passionate and intent about was the concept of legacy and leaving, hopefully more behind them than you take from any of these places where you and I and Ameer and many others have been. Clearly one of the places that that you’ve returned to over many, many years is Guyana. So I was wondering if you could talk to us about Guyana, how that connection came about, and all the amazing stuff that you’ve done there?

Brian Cameron  20:23

Yeah, I mean, I’d love to. Well, Guyana is is an English speaking country, on the Caribbean coast of South America. So it’s just east of Venezuela. And they say that if you when you visit, well, I would say when you visit Guyana, you just fall in love with the people. And they say that if you drink the black water and eat the labba, you will always come back to Guyana. Well, so I guess I drank the black water, which is actually the water in the creek colored by tannins from the jungle leaves. And I did eat some labba, which is a fairly tasty, wild rodent, well cooked. So I just kept going back at least twice a year for a couple of decades. The very first time I visited Guyana, it was in 1995. And I was working with a health project coordinated by the local Baha’i community in a very remote region of the country. One of the poorer parts of the country with 34 indigenous villages. So the general socioeconomic status was was challenging. The small hospital had not had a full time resident doctor for years. Dr. Jamshaid Naidoo who was a Baha’i friend and a Canadian urologist had taken early retirement to volunteer services down there. And he was asked to move to this remote village of Lethem, which is near the Brazilian border, and he lived in a little house where he had to filter his water. I remember he used a car battery to power a small fluorescent light bulb. And that was it for you know, there’s no electricity. And he found a small hospital with basically a nonfunctioning operating room, which he developed and made it made things work over the over the next seven years. So he lived there for seven years. We would visit with surgical supplies and accompany him on outreach clinics. So eventually, I met a few of the surgeons in the main city of Georgetown, which is along the coast, population 300,000 or so. The population of the whole country is only about 800,000. So I did some teaching at their medical school and operated with them on some of their pediatric patients. But one thing they they complained that they would, you know, they would send someone away for surgical training. But they wouldn’t return. So, so they decided they wanted to start their own surgical training program. And that sounded ambitious. But then I found that a needs assessment had actually been done by Dr. Robert Taylor, who’s really a Canadian global surgery pioneer from Vancouver. Several years prior, and I had some links in the Canadian Embassy was able to find some Canadian aid funding. And so we started this partnership between CAGs  and Guyana, to train surgeons in Guyana. And over the next five or six years, I think we had at least the probably around 50 Canadian surgeons visited usually for two weeks at a time. And now 15 years later, the program runs independently. I mean really its been a success. That original cohort of a dozen surgeons are running the surgical services and the residency program. I mean, one of the cool recent things one of them actually spent, one of the young surgeons spent last year in Hamilton doing a vascular fellowship. So he returned there as the first country’s first vascular surgery, and he recently performed the first successful aortic aneurysm repair in the country. So the CAGs project has led to many partnerships that have built surgical capacity, a number of specialties there in Guyana. And I mean, I have to add that having my supportive clinical partners here at McMaster has really been essential to allowing me to do these ongoing visits to Guyana. So I’m really very grateful to them.

Ameer Farooq  24:43

Sorry I was doing the 2020 thing and trying to talk with while being muted. There’s there’s a there’s a number of comments that I want to make about the work that you’ve done. I mean, first of all, you’re such a humble person and I’ve gotten to see that firsthand. You know, some people might have been shouting all that work that you’ve been doing from the rooftops, but you you’ve just been quietly kind of plugging away and doing this kind of deep, long, long term kind of work for four years. And the second thing is that I, when I went to Guyana, one thing I noticed is that it’s kind of a unique place in that, you know, it’s not a very big country, as you pointed out. And it also has, it certainly has many resources, in that it’s not like a, you know, what we might stereotypically think about in terms of not having, you know, petrol to run the the hospital, it’s not like that. But certainly they have to work within some resource limitations. And in particular, you know, one of the things that was that bothered me while I was there is that you’d see all this, for example, laparoscopic equipment that was lying around, not being used that had been donated. Can you talk a little bit about kind of the unique challenges that perhaps Guyana faces in terms of delivering surgical care, kind of having to juggle all these different aspects to their situation?

Brian Cameron  26:13

Yeah, sure Ameer. And that’s, you know, it’s it’s always I love going there with somebody else. I enjoyed going there with you, because I see new things through new eyes. And that’s an that’s an interesting observation. And I mean, that’s a good thing to talk about. I mean, laparoscopic surgery, you know, it’s a good example of a new technology. And, you know, like everywhere in the world, it’s highly desired by surgeons in resource-constrained environments like Guyana and Uganda. But I think you would probably agree, I mean, what we’ve learned here is that here in Canada, you know, we take many things for granted. For example, stable electricity and gas supply in the operating room. I mean, we’ve got biomedical engineers, and we’ve got, you know, functioning autoclaves. But, and I’ve been there trying to do laparoscopic procedure in Guyana, when the power went out. And you know, when the power stops, the insulator stops. There’s no lights in the operating room, and you have the laparoscope in the belly, it’s pretty hard to do anything. So really, you know, to build a successful program, you really need the long view, as you said, you need patience, a supportive team. And really, you know, all those candidates competencies, we talked about leadership, advocacy, you know, our professionalism, all important. And really, it’s taken 15 years, we first introduced the fundamentals of laparoscopic surgery FLS course, training in Guyana, but 15 years ago. And it was about two years ago, we had a guy knee surgeon come to Hamilton, I think it was probably just after you had visited Guyana, Ameer. And he was here for a year in Hamilton, Oakville training as a clinical fellow focusing on laparoscopic surgery. So he has returned to Guyana and he’s actually got all the equipment working. We sent some more equipment back with some he’s doing you know, advanced procedures lap colectomies but I think importantly, he is training and supporting the nurses, the biomedical engineers that and training other residents and surgeons in the technique. So I think he’s been key to actually supporting the continuity of that program. And I think, you know, that relates back to your point that so often we think just donating the technology donating the equipment is enough. But, you know, I’ve seen terrible examples of, you know, your donate, somebody doesn’t have the right power supplies, somebody plugs it in and it explodes. Or, you know, there’s a lot of examples of mistakes like that, that have been made all through well intentioned efforts. And, but fundamentally, it’s about, you know, developing the human resources that will sustain a program, and and then you can add the technology, you know, in there.

Ameer Farooq  29:20

Can you talk a bit about what it was like to develop the Master’s in surgery or the residency program in Guyana? How did you, you know, logistically and practically go about doing that? What, like, what, what actually is involved, it’s in starting a residency program. I don’t think any of us even even think about that, you know, we just sort of slot into it. We don’t really think about the mechanics of actually setting up a program like that setting up the accreditation of it. So can you speak a little bit about mechanistically how that works?

Brian Cameron  29:53

Yeah, that’s, that’s a thoughtful question and and I hope it’s fair of me to reference back what we we did write two articles in danger of surgery that you can maybe link to this podcast to discuss some of the some of the, you know, the challenges and the successes, I guess, about the program. But, you know, just sort of thinking about some basic principles of why it succeeded. At that time Canada had CDA, so there was some aid funding, and that we use that initially to help support travel expenses for Canadian faculty going down, but we split it and so that the Guyanese were also able to pay some of their faculty to do some teaching. And, and to sort of develop a local office of postgraduate education and really would not have worked without Dr. Madan Rambaran there who was really the local leader, surgical leader who wanted to push this forward. So that was essential bit of funding, strong local leadership. And, and then the next piece was to recruit surgeons through CAGs who were interested in going to visit and, you know, the deal was you had to go for at least two weeks. We organized the structure to the didactic part of the program, in two-week modules, so that when you went, you know, you taught your module, it might be on thyroid disease, it might be on, you know, colon cancer. And we also were realistic initially about the length of the training. Most of these guys by this point, that guys, I mean, most of the young surgeons had graduated from medical school and worked several years as house officers. So in terms of technical skills, they were actually pretty good. And so we were really, I think, with these didactic modules, trying to cover a, you know, a course a curriculum in surgery over a period of two years, and then have a, you know, have a pretty rigorous exam at the end of that. And then, and that was all really the Canadian support really helped provide some outside validity and credibility for to the program. But it was always meant to train to the level of a local qualification that would provide competencies to, for the graduate to go to a Regional Hospital and practice safe surgery. That was basically the goal of that program. I mean, over the years, it’s it’s evolved, they’ve expanded now into a four-year program with a master’s degree. And the focus also has, you know, I think the subspecialties providing clinical teaching in the hospital have also really developed over the years. But I think, you know, the basic thing I learned from that was that, at the beginning of it, there was a lot of skepticism. There were actually the residents weren’t that keen and even signing up for it, because they didn’t think it would happen. But well, I think what I learned from it was if you can get something started, even though it’s not perfect, just get it started and get going and be consistent with it. And, you know, I was going back for initially, probably at least three times a year, and then keeping, you know, keeping in close touch with all the other visitors. So I think, you know, there a lot of factors that led to his success. And that, as I said, I think I would can’t underestimate the local, the couple of local surgical leaders, I should mention Dr. Deen Sharma, also in Guyana, who was really one of the visionary local surgeons that wanted to see this succeed.

Ameer Farooq  33:55

One of the things that I’ve always really admired about the way that you do things is that you’ve integrated the use of technology in places that you worked, but in a very smart, sophisticated and needs-driven way. You know, I think of the work that you and Abdullah Saleh have done in Mbarara in Uganda with developing an EMR and other projects that I’ve had the pleasure of learning about from you. Can you talk a little bit about how you think about integrating technology when we’re doing this global surgery workload? You know, because I think it’s it is very tempting sometimes to think, you know, we’ll come in we’ll, we’ll will modernize all the clinic spaces and make it all on EMR and you know, have the hospital pharmacy be on a computer software so they can keep track of their interval, inventory and all these kinds of things, but it often doesn’t work. So can you talk a little bit about how you think about that and, and how you introduce new technology into into a place that you’re working.

Brian Cameron  35:01

Yeah, that’s really a great question, Ameer. You know, where does technology fit in global surgery? Well, again, just to highlight, I mean, I should let your audience know that that you really helped us a lot with this geospatial mapping of trauma patient locations, which was part of this little project, partnering with Mbarara in western Uganda, and Dr. Martin Situma to develop help them develop a trauma registry, it was really spearheaded, as you mentioned, by Dr. Abdullah Saleh, who’s now a pediatric surgeon in Edmonton. And I think one interesting thing about that little project it started really with let’s do it, let’s help develop a trauma registry and get some handle on where injured patients are coming from and what their needs are in the emergency department and prehospital care. But then it actually evolved to helping them develop an EMR admission process, because Abdullah main problem was that there was no proper patient registration to get trauma records when patients came into hospital, so so it sort of illustrates that it’s important to understand what’s really needed, and not necessarily persist with what you think is needed. I mean, I think the jury’s still out on the impact of that particular project. But you know, we keep in touch with Dr. Situma, and he really has some awesome nurse research assistants there. I mean, I think one thing, it really is possible to do really high quality research when you have good partners. But other you know, I think one thing about visiting surgeons in a resource constrained environment, you think I come to understand that, you know, technology doesn’t answer all the problems, and it’s sort of, you don’t want to be somebody with a hammer thinking everything’s a nail. So you know, but when you go and visit surgeons working in that environment, you know, you learn how to better use, reuse, or adapt technology and new low-cost techniques. And, you know, there’s many examples of this is called reverse innovation. Where experiences gained in low middle-income countries are then transferred back to, you know, to high-income countries, because they’re good, adaptive, low-cost technologies. And you know, one example, actually is the widespread use of low-cost ketamine for pediatric anesthesia in Africa has been going on for a long time. And interestingly, this practice is now sort of coming back and being talked about by pediatric anesthesiologist here as being, you know, something new and interesting. So it’s an example of this reverse innovation idea that when we have partnerships, in low-resource settings, we often can learn as much as we give and, and certainly technologies specifically, can take off. I mean, for example, cell phones really took off much faster in Africa than they did here and, and their use of cell phones for transferring money, for example, now is way ahead of us. So there are some things we can learn with how to adapt technology.

Chad Ball  38:28

I think that’s so well said there’s so much we can learn. It’s interesting, hearing your guys’ experience about an electronic injury registry. Morad Hameed  and I from Vancouver, and obviously Calgary respectively, are deeply embedded with the University of Capetown, who just here trauma group and we obtained a grant at one point to essentially construct and then maintain electronic injury injury registry and the data we were getting both geospatial like you guys, as well as just bread and butter, demographic injury and patient data was unbelievable. But our money ran out and there was no legacy to that particular project. So it, it always reminds us I think no matter what we have done since that time, that it has to have some sort of angle to it should ensure persistence. And I couldn’t agree more with you, you know, Morad and I talk about it all the time that we get much more out of our relationship with them than I think they do from us. There’s no doubt even if it’s just a way of thinking. One of the other big big challenges for sure, you know, globally is has been COVID for me has been COVID-19. I’m curious how how or if that is altered global surgery as a as a concept in terms of delivery now and maybe even in the future from from your point of view?

Brian Cameron  39:52

Yeah. Well, we sure aren’t traveling much are we? Yeah, but we are zooming lots, actually. It is I think this one thing that is again impressed me about technology. I mean broadband internet, in, like, specifically in Guyana and in East Africa has really improved tremendously. And to the point, you know, where we can have really reliable online teaching, including with with video plane with trainees in Guyana and Uganda. And I’ve been involved with both of those groups in the last few months. And actually, just yesterday afternoon, I met with the current 15 surgical residents in Guyana, online to for a pediatric surgery seminar. And, actually, I was really excited that one of those surgical residents is a young woman from Lethem. And you will remember, that’s the first place I visited 25 years ago with Dr. Naidoo. And he would be so happy, he will be so happy actually to know that a local indigenous woman is now training as a surgeon in Guyana. And I think, you know, the other way that COVID has affected the world, I think, in global surgery, as a field is that, you know, COVID has illustrated how interdependent we really are. I mean, you know, what happens in Wuhan, and Italy, does affect what happens in Hamilton. You know, in spite of the antiglobalization skeptics, you know, we I think we’ve demonstrated, we can collaborate globally to develop solutions and, and, you know, that includes solutions to the disparities in surgical care. And, you know, the Lancet commission was mentioned by Ameer, there’s a number of other new initiatives that I think are continuing to stay connected in spite of COVID. But, you know, if we think of continuing to improve surgical care globally, I mean, every child that, you know, every child that saved from a ruptured appendix in Guyana, I mean, every baby that’s born by an emergency Caesarean section in Uganda, you know, maybe the child that discovers a cure for cancer, or a vaccine for the next pandemic, you know, or a way to stop global warming. So, I think that it’s really, I think, expanded our global COVID has expanded our global view. And I, you know, I’m optimistic that we’re gonna come through this with a changed, you know, many change perspective.

Ameer Farooq  42:33

You have a number of ongoing initiatives, Dr. Cameron, with regards to global surgery. You know, one, for example, that I’ll just mention is some of the work that you’ve now I think, handed off a little bit to Dr. Anise Barton with regards to weekly teaching for the residents in Guyana. But can you talk a little bit about things that you’re you’re working on, and and ways that people can potentially get involved if they’re interested in doing more global surgery work?

Brian Cameron  43:00

Sure. You know, I think that, you know, for any surgeon, young or old, who’s who’s, you know, being inspired by, by, you know, by so many people that are promoting global surgery in Canada, I think there’s really, no, I generally advise two things because a lot of it’s about learning, and there’s a couple of legacy projects that have been going on for a decade or two in Canada that not all the listeners might be aware of what they are. The first is the annual Bethune Round Table conference. And it was started in Toronto by doctors Massey Beveridge and Andrew Howard. And the cool thing about this conference is that it features invited surgeons, anesthesiologists, obstetricians from resource-limited countries, and they come to Canada and present their research and they’re sponsored. And, you know, it’s a fantastic medium for learning about other specialties involved in surgical care. And, you know, for networking with potential partners. It didn’t happen in 2020. But it’s scheduled online to happen at the end of May in 2021. And I think the second you know, thing I second educational opportunity that I point people towards is the graduate program in global surgical care at UBC. That was started by Dr. Robert Taylor, and not doing a self promotion, but I’m helping facilitate the introductory course, which actually has gone from September till now and we had 20 20 participants from across the country and and including one from Tanzania actually. And that, that course, it’s a graduate level course it’s really a great opportunity to learn about the core elements of you know, this new evolving specialty of global surgery. So, you know, those are a couple things I remain involved with. And, again, I would encourage any of your listeners to, to Google those and, you know, get connected. And then, you know, I think Vancouver UBC basically pretty well, every Calgary pretty well every academic center in the country now has a global surgery office or at McMaster we have what we call the international surgery desk. And it’s a way to network locally with your own faculty and, and residents and find out you know, what sort of projects are happening.

Ameer Farooq  45:42

Dr. Cameron, I had the opportunity and pleasure to meet your wife as well, when when we were in Guyana. And I was so impressed by how both of you and from what I understand your whole family adapted to, you know, your your traveling and working in many amazing places. What advice do you have, for people who have families or maybe have young children who are interested in in global strategy work? How do you sort of balance those two things?

Brian Cameron  46:14

Yeah, that’s a that’s a, you know, a fun question to end on, I guess that. And you talked about balance, and I think that’s always a challenge, isn’t it? Because as surgeons, we’re busy and we’re up at night. It can be tiring, it can be exhausting. And, you know, it can be at times because I kind of feel soul destroying at times. But, you know, I think the piece of advice I would I would have sort of thinking back I would like to have given them myself, I suppose, would be along the lines of that famous Bobby McFerrin song, you know, don’t worry, be happy. Do you guys know that song? I won’t sing it for you. But anyway, what does it take to be happy? And I know I think I learned recently that according to Immanuel Kant, it takes three things to be happy, something to do, someone to love and something to look forward to. So I mean, I absolutely enjoyed my pediatric surgery and global surgery career but I’ve also been fortunate to find something to do outside of surgery. Being part of the Baha’i faith community, I’ve sing I do sing regularly actually in an acapella men’s barbershop chorus on Wednesday nights. Obviously, we’re not doing much singing now and with COVID, but we do meet on Zoom and keep connected. You know, I’ve also so fortunate to find someone to love and it’s nice for you to you know, mentioned having met Pat, Ameer, I mean, we’ve been married for 42 years. She’s put up with a lot. And we are blessed with you know, our two successful children, their spouses, and now we’ve got four wonderful grandchildren. You know, and finally, I guess we using this Kant’s Immanuel Kant’s trilogy, I suppose I have something to look forward to. And I’m retiring from clinical practice next year. So I’m looking forward to enjoy my grandchildren, keeping active with cycling I’m I’m going to complete my traverse of the Bruce trail in Ontario in the next year or so. And I’m again once this vaccine comes out, I’m sure we’ll be traveling again in 2021 and I hope you guys are able to as well.