2016 – Ewen Harrison

Ewen Harrison: James IV Travelling Fellowship 2016/17
University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
Countries visited

• South Africa
• Nigeria
• Kenya
• Malawi
• US

Over the last three years I have been lucky enough to be involved in the establishment of the GlobalSurg Collaborative. This is a grassroots organisation which encourages training surgeons around the world to get involved in surgical research. The collaborative is expanding and is forming an international surgical trials network with particular support for surgeons in low- and middleincome countries.

From small beginnings, we have now gathered data on 27,000 patients in more than 70 countries focusing first on emergency abdominal surgery and subsequently on surgical site infection. The aim for my James IV Travelling Fellowship was to strengthen relationships with surgical leaders in Africa and the US and explore how we can expand our efforts in global surgical research and training.

Groote Schuur sits high looking out over Cape Town. It means “Big Barn” from the Afrikaans but no one ever calls it that. I was made very welcome by Ed Jonas who is the Head of the HPB unit. With the festive period just coming to an end, there had been less elective operating going on. We spoke about Ed’s career in Sweden,his recent return to South Africa and his extensive experience in HPB surgery. We discussed some interesting patients with advanced disease he had been coaxed into operating upon in Kenya. Our conversation on hepatocellular carcinoma in Sub Saharan Africa was particularly useful for me and an area of future research collaboration.

Richard Spence (right) and myself at Green Point.

Professor Elmi Muller, Head of Department and Transplant Surgeon, is well known internationally for her work developing kidney transplantation for HIV positive patients using HIV positive donors. We had previously met at the European Surgical Association in Edinburgh, where I had wielded a blade for “Address to a Haggis”, the poem recited before eating the famous Scottish delicacy. The transplant programme in Cape Town continues to expand and I was pleased to meet David Thomson and Tinus Du Toit to learn more. We discussed the evolving understanding of the selection criteria for donation after circulatory death donors, something we have also been exploring in Edinburgh.

Groote Schuur is of course a world leader in trauma surgery. I spent a day with Professor Pradeep Navsaria and Sorin Edu who showed me round the busy department. By UK standards the numbers are vast: 12000 patients assessed in the unit each year, 400 with abdominal trauma, the majority of which is penetrating (85%; one third of which is gunshot injuries). The volume of trauma puts understandable strain on systems and the hospital as a whole. Data collection and analysis is a primary research interest of mine. As such, I was particularly interested in the development of the Trauma database in Groote Schuur (Nicol, JAMA Surgery, 2014) and the challenges faced in ensuring on-going, high-quality, prospective data collection. This is an area of potential collaboration.

Groote Schuur was founded in 1938 and is famous as the site of the first human heart transplant by Christian Barnard in December 1967 – of great interest even to a liver transplant surgeon. The museum at Groote Schuur describes the endeavour and contains many interesting artefacts. Tragically the 54-year-old recipient Louis Washkansky died 18 days after surgery when a pneumonia was thought to be rejection and the immunosuppression was increased. The original consent form (below) is a little light on detail by modern standards and not signed by the operating surgeon.

Consent form (left) and operation note (right) for first human heart transplant.

Sandie Thomson is a fellow Scot and Professor of Gastroenterology. We had a wide-ranging conversation about many issues in medicine and his great work in endoscopy training and education. We also spoke about the “Rhodes Must Fall” movement, initially directed against a statue of Cecil Rhodes at the University of Cape Town. Student and staff protests were successful in persuading university authorities to remove the Rhodes statue from the campus. The worldwide protests had the broader goal of highlighting what has been described as the perceived lack of racial transformation in many educational institutions. An issue which my own institution has renewed its commitment to address this year: www.ed.ac.uk/equality–diversity/about/strategy–action–plan

Victoria Hospital | New Somerset Hospital

I was pleased to be able to visit two of the smaller hospitals in Cape Town. Mark Hampton is Head of Surgery at the Victoria Hospital in Wynberg. It was established in 1890 with 14 beds, became a General Hospital in 1923, and now sees 330 outpatients a day and 3000 emergency patients a month. Mark does an amazing job as a true general surgeon and I spent an enjoyable day going around the wards with him. The New Somerset Hospital is another smaller hospital in the Western Cape and Heather Bougard (Head of Clinical Unit) and Fazlin Noor (Consultant General Surgeon) took me round the general surgery wards. The deprivation in the catchment area of these hospitals was clear and as in all cities, in stark contrast to wealthy areas I had visited on the waterfront.

Cape Town from Table Mountain.

It is true that Cape Town is a dazzling jewel set on the ocean. It felt safe and catered well for visitors. AirBnB was good for accommodation and Uber for transportation.

Yet profound deprivation is close at hand. I had a wonderful experience and was impressed by the dedication of the clinicians in the face of limited resources. I was heading to Nigeria, but would return to South Africa on my final stop in Johannesburg.

Nigeria

Lagos
Lagos University Teaching Hospital (LUTH)

“A man does not wander far from where his corn is roasting” – Nigerian proverb.

I arrived tired after an overnight flight to Lagos, Nigeria’s former capital and the largest city in Africa.

Its growth is rapid and I was surprised to discover it is now the fourth largest city in the world with 21M in the metropolitan area (after Shanghai, Beijing and Delhi). Lagos is a sprawling wealth of humanity where I was made to feel very welcome. I am deeply in debt to Soji Ademuyiwa (Chief,

Paediatric Surgery Unit and Associate Professor) who went to great personal efforts to host my visit. Soji is a key member of the GlobalSurg Steering Committee and led the team in publishing the GlobalSurg paediatric dataset.

Soji Ademuyiwa picking me up at the airport (left). Soji Ademuyiwa, Justina Seyi-Olajide,and Felix Alakoloko at a local art gallery (right).

Lagos University Teaching Hospital was established in 1962 and is a tertiary hospital affiliated with the University of Lagos (UNILAG). I was honoured to meet Professor Chis Bode (Chief Medical Director) who well-known internationally for his work in paediatric surgery. He now leads the hospital but stays in close contact with clinicians. Professor Bode is a great advocate of surgery in Nigeria and is particularly keen to increase the capacity to deliver laparoscopic surgery. We spoke about this in detail and he was particularly interested in our work showing the benefit of laparoscopic appendicectomy in low- and middle-income countries (Surgical Endoscopy in press).

I was pleased to be asked to speak about liver surgery to the group and had a good conversation with Professor Sulieman Giwa (Head of Department) about the challenges of delivering HPB surgery.

It was also good to meet and speak with Prof Joseph Adeyemi (Dean Faculty of Clinical Sciences), Professor Fasanmade (Chariman Medical Advisory Council) and Professor Daramola (Deputy CMAC).

Soji is very progressive and is supporting the establishment of the REDCap data collection tool in Lagos (projectredcap.org/about). We have used this tool extensively and I was able to discuss some of the details of the proposal at the University. Soji has gone on to successfully run a community study of paediatric surgical disease (SOSAS Nigeria) using REDCap.

I was overwhelmed by the hospitality shown to me by the team during my visit. I am particularly grateful to Justina Seyi-Olajide, Felix Alakoloko, Seun Lapido-Ajayi, and Olumide Elebute for the kindness and they showed me. And in particular for introducing me to Nollywood, Nigeria’s popular film industry. I can highly recommend “The Wedding Party” which we watched at one of the local cinemas. I was pleased to meet Soji’s wife Iyabo Ademuyiwa, who also has an impressive research career.

I had interesting discussions about international perceptions of Nigeria and its portrayal in the media. Certainly, the UK coverage focusses on Boka Haram, described as an “Islamic extremist terrorist group based in northeastern Nigeria”. The consequence of the Boka Haram campaign is catastrophic, with at least 20,000 people murdered and millions homeless.

(www.cfr.org/nigeria/nigeria–security–tracker/p29483).

Yet many I spoke with were saddened that Nigeria was branded a “terrorist country” as a result, discouraging inward investment and travel. “What about most of the country not affected by Boka Haram?”, I was asked. “Should the UK be branded a terrorist country due to the actions of the IRA or Islamic terrorists?” My own perceptions have undoubtedly been coloured by the media but only by visiting the country did this become obvious to me.

Nigeria is the most populous country in Africa yet ranks 152 of 188 in the United Nations Development Programme human development index (HDI) of countries. Another common misconception relates to Nigeria’s oil industry. If Nigeria has such oil wealth, it is said, its people should be rich and its requirement for international development aid low. Yet for many years Nigeria’s oil industry has been plagued by corruption and mismanagement. The World Bank has estimated 80% of the energy revenues in the country benefit only 1% of the population (globalcitizen.org/en/content/oil–in–nigeria–a–cure–or–curse). Most of the produced oil is directly exported limiting the economic benefits to the local population.

Soji Ademuyiwa, Justina Seyi-Olajide, Chris Bode, Seun Lapido-Ajayi (with daughter), Myself, Iyabo Ademuyiwa, Suleiman Giwa, Felix Alakoloko, Charles Ememonu, Seyi Olajide (left). Statistical support always available at LUTH (right).

Lagos State University Teaching Hospital (LASUTH)

LASUTH is the teaching hospital close by and is operated by Lagos State and affiliated with Lagos State University. Although I did not visit the hospital directly, I was able to meet up with Mobolaji Oludara (Consultant General / Laparoscopic Surgeon) who had previously visited me in Edinburgh. LASUTH also contributed to the GlobalSurg project and Mobolaji is keen to develop more HPB capacity in Lagos.

Daniel K. Ojuka, University of Nairobi (left). Prof Fred Were, Dean of School of Medicine, University of Nairobi (right).

Soji Ademuyiwa showing me the operating department(left). Presenting to the residents about the importance high quality data in the delivery of surgery (centre). Meeting Professor Chris Bode and colleagues in Lagos (right).

I very much enjoyed my time in Nigeria and the hospitality was second-to-none. Lagos is a large busy city which is difficult to navigate and I was glad that my hosts (and in particular Felix) provided all the necessary transportation.

It is a country with immense drive and the clinicians I met are talented and passionate in equal measure. I look forward to great success in our future collaborations.

Kenya

Nairobi
Kenyatta National Hospital / University of Nairobi

“Sticks in a bundle are unbreakable” – Kenyan proverb.

I landed in Nairobi at dusk and it was pleasantly warm. The taxi driver smelled of an aftershave from my youth and we chatted pleasantly as he took me to my accommodation, an apartment block named “Habitat” and reminiscent of a 1960s sci-fi movie.

My visit to Nairobi was perhaps the most unusual of the trip. Unusual because the hospitals I visited contained virtually no patients. A long running dispute between doctors’ leaders and the government regarding pay and conditions resulted in a strike lasting 100 days.

I was hosted by Pankaj Jani, Vice President of the College of Surgeons, East Central and Southern Africa (COSECSA) and Vice Chair of the Executive Committee of the G4 Alliance. Through the University of Edinburgh, we run a successful surgical distance learning programme led by James Garden. With 500 students on courses at any one time, 140 students in total have been from SubSaharan countries. I had many good discussions with Pankaj about how we could expand this. There is a clear opportunity to work together with COSECSA to build surgical distance learning as an effective means of increasing the skills of young surgeons in the region. I was pleased after my trip to report back that we had been successful in an application to the Commonwealth Commission for Scholarships to support training surgeons in the COSECSA region.

Daniel Ojuka looked after me well during my visit. He showed my round an almost empty Kenyatta National Hospital, Nairobi. I could imagine the large Emergency Department full of patients and noise. But it was almost silent, with only 3 lying on trolleys in the middle of a large empty space. “Where are all the patients going?”, I asked Daniel. “Who knows”, he replied.

On the wards, patients who could walk had long since done so. Nursing staff were looking after those who could not leave, many of whom had not seen a doctor in weeks. Medical students were also absent – “why would they come if there are no patients and no one to teach them”, Daniel said.

The doctors have been forced to work in intolerable conditions, on call at all times and receiving a salary of $400-$850 a month (www.bbc.co.uk/news/world–africa–39271850; www.aljazeera.com/news/2017/03/kenya–doctors–strike–deal–government–

170314084246054.html). The Department of Health reneged on a new contract (the 2013 “collective-bargaining agreement”) which would have increased salaries, as well as committing to the employment of thousands of new doctors and addressing drug and equipment shortages. There was intimidation of doctors and threats of mass firings as the government sought to force clinicians back to work. Following my trip, doctors returned en masse after a new deal was signed. It remains to be seen whether conditions for doctors and patients will improve as a result of this.

Nairobi Surgical Skills Centre

I was greatly interested to learn about the unique challenges facing surgery and training in Kenya.

Despite these difficulties, I was impressed by the Nairobi Surgical Skills unit which is supported by Johnston and Johnston. This has surgical simulation facilities equal to anything I have seen elsewhere.

I spent an enjoyable morning being shown round the suberb facilities at the Nairobi Surgical Skills Centre by Edwin Bore and Danson Muchiri.

Mombasa

COSECSA Annual Conference

The College of Surgeons of East Central and Southern Africa has become an important organisation in the delivery and assessment of surgical training in the region. The Annual Conference combines college exams and graduation with a scientific meeting and grows in size and stature each year.

I was grateful to Denis Robson (J&J) for the invitation to speak about data and Measurement and Evaluation at the specially convened NGO Workshop. This sought to bring together NGOs, clinicians, advocacy groups and policy makers to generate ideas that could be translated to tangible projects.

I was pleased to meet Miliard Derbew (COSECSA President) together with Declan Magee (Royal College of Surgeons of Ireland). The RCSI together with Irish Aid have contributed significant resources COSECSA. The meeting is a great opportunity to network with the many dynamic individuals working in the region. In particular I was pleased to catch-up with Professor Eric Borgstein (Professor of Paediatric Surgery, University of Malawi), who I would be visiting next.

It was an excellent opportunity for the Edinburgh team to meet up with current students and graduates from our surgical distance learning programmes. We were able to receive valuable faceto-face feedback and make plans to expand our scholarship support for the students.

James Garden, Denis Robson, Ian Walker, Vicky Young, and myself with the University of Edinburgh surgical distance learning students at COSESCSA.

As I left for Malawi, I thought a lot about the doctors’ strike. Many patients had died who should not have. It is sobering to reflect on scale of the difficulties delivering high quality healthcare in Africa, compared to the day-to-day troubles we face in our own jobs. Which sounds a little trite when written here. Still, what is the purpose of a Travelling Fellowship, but to allow us to reflect on our own practice. And yes, to realise how good we’ve got it.

Malawi

Blantyre
Queen Elizabeth Central Hospital

“You cannot pick up a pebble with one finger” – Malawian proverb.

The sun was bright and the air cooler when I landed in Malawi. My wife had previously worked for a year in Queen’s so this was my fifth visit. I was looked after fantastically well by Professor Eric Borgstein and his wife Sophie at their house.

As I left the airport, my driver spoke at length about the worsening political and economic situation in Malawi. Maize is the main staple and the price had risen significantly in recent months. It would go on to rise in part due to the “armyworm” plague affecting Southern Africa. This new threat is common in South America where Brazil spends $600 million each year in control measures. It has tragically been recently introduced to Southern Africa where it is threatening food security. Eric’s own maize was treated on the day I arrived by sprinkling ash down the maize stems to suffocate the worms.

Malawi has been a keen GlobalSurg partner, though we have struggled with obtaining ethical approval for projects. It has been well supported by Eric Borgstein, Emma Thomson (Consultant Paediatric Surgeon) and Patrick Noah (Consultant General Surgeon), as well as Professor Nyengo Mkandawire (Professor of Orthopaedic Surgery and Head of Surgery).

One of the most exciting projects going on in Blantyre was the building of the Mercy James Institute for Pediatric Surgery and Intensive Care at the Queen Central Hospital. Otherwise known as the “Madonna Unit”, it went on to be opened in July 2017 and was funded by the singer Madonna’s charity “Raising Malawi”. This beautiful new building sits amongst the existing hospital and is a vision of how care can be delivered when the funding and drive is there.

Professor George Youngson, Joe Mackie, and David Tipping were there from the Archie Foundation. A charity based in the northeast of Scotland, they have expanded to support the establishment of paediatric operating theatres in Africa, with a new unit in Uganda, and support for the Mercy James Institute in Malawi.

It was good to speak about GlobalSurg and data to the doctors in Queen’s at their morning meeting. There is real enthusiasm to get involved in collaborative international projects. I spoke to the to the residents about data collection and common HPB conditions and learned a lot about their local practice in return.

Eric and Sophie were perfect hosts and had me making guacamole, gathering up escapee turkeys, and learning which end of a croquet mallet was which.

Professor Eric Borgstein, Joe Mackie and David Tipping (Archie Foundation). Coffee beans growing in Eric’s garden.

Johannesburg

Charlotte Maxeke Johannesburg Academic Hospital (Jo’burg General)

“Abundance does not spread; famine does” – Zulu proverb.

I enjoyed being shown the lab research unit in Wits and discussing opportunities for further collaborations. I spent an enjoyable morning being shown the department by Prof Damon Bizos (Head of Surgical Gastroenterology) and Leanne Prodehl (Consultant Surgeon). Prof Bizos has contributed extensively to surgical training models and research, and I was interested to discuss this in detail.

Chris Hani Baragwanath Hospital (BARA)

The Chris Hani Baragwanath Hospital is the 3rd largest in South Africa with 3200 beds. Jones Omoshoro-Jones and John Devar were impeccable hosts taking a great deal of time to show me the facilities. Seventy percent of the 150 000 admissions each year are emergencies, with 160 gunshot wounds per month. This staggering figure reflects the violence of Soweto and the extensive expertise in the surgical management of trauma in ‘Bara’ reflects this.

Given my interest in technology and data I was pleased to meet Mike Klipin, who is leading the establishment of a new electronic patient record. Irma Mare and the software developers showed took me through their work. I was inspired by the progress this small team had made and impressed with the vision in establishing this. Irma and I will continue to collaborate on data projects though the REDCap consortium.

Research department at Wits (left). Prof Damon Bizos, Head of Surgical Gastroenterology, Wits (right).

I had not expected Johannesburg to be such a green city and had not previously heard of the concept of an urban forest

(edition.cnn.com/2010/WORLD/africa/11/18/johannesburg.urban.forest/index.html). Perhaps it was all the trees that made it seem friendlier than I had been expecting. The Gautrain from the airport is fast and efficient and I was grateful to my hosts for helping with all my transport.

This was the last stop on my Africa leg, before making my way to Los Angeles. I left feeling very positive given all the inspiring people I had met. While there is much to be optimistic about, the extent of the deprivation and lack of healthcare facilities sometimes felt hopeless. In the absence of stable corruption-free government, how can sustained improvements be made?

My focus will be to support the expansion of healthcare infrastructure through research programmes. Randomised controlled trials are not a particular priority for Africa. However, the grant funding for well-designed clinical research addressing local priorities, can perhaps help capacitybuild while answering important research questions. This is the philosophy of the NIHR Global Surgery Unit, which has arisen from the GlobalSurg project. It will establish 5 autonomous Clinical Trial Hubs in low- and middle-income countries with an aim for these to become independent during the lifetime of the initial grant. The UK government and others are keen to channel international aid monies through well-established networks such as ours, in an effort to ensure support gets directly to where it can be put to best use. Our first Hub is due to open in Johannesburg later in 2017.

US

Las Vegas
Society of University Surgeons (SUS) / Association of Academic Surgery (AAS) Academic Surgical Congress (ASC)

“If you aim to leave Las Vegas with a small fortune, go there with a large one” – Anonymous.

I had only twenty-four hours in the UK before I was flying to the US. I was astounded to have complementary continuous wifi on the Irish airline, Aer Lingus, on my flight across the Atlantic. Ireland were playing Scotland at rugby which most of the cabin were streaming with enthusiasm. I had to keep my partisan support muted for fear of causing an international incident.

I was honoured to be invited by Rebecca Minter (SUS President) to the ASC to deliver the BJS Lecture, “Crowdsourcing Surgical Data”.

The meeting has a great atmosphere and an emphasis on high quality, relevant plenary sessions. It was a great opportunity to meet new colleagues and catch-up with old friends. Rebecca and I are Editors on HPB and I thoroughly enjoyed her great Presidential address, “Passion, Integrity, Resilience”.

Caprice Greenberg has had a fantastic year as President of the AAS, culminating in her address “Sticky Floors and Glass Ceilings”. Caprice has recently visited Edinburgh as a James IV Travelling Fellow.  It is with sadness that I think about being out for dinner during her visit together with Professor Ken Fearon, who died earlier this year with a great loss to us all in Edinburgh and beyond.

I was also hosted by Taylor Riall (President-elect SUS), who I knew from her work on patientcentered outcomes – an area I have also been working in over the last five years.

I attended the SUS Global Academic Surgery Committee meeting chaired by Ben Nwomeh. Ben and I know each other from Twitter (!) and have both been supporting Soji Ademuyiwa’s paediatric surgery project in Nigeria. The committee is enthusiastic and promote excellence in surgical education, research, clinical care, and collaboration.

Tom Weiser (Associate Professor of Surgery, Stanford) is a great supporter of GlobalSurg and is coming to Edinburgh as a Visiting Professor for one year from August 2017. His research focuses on the role of surgical care in the delivery of health services in low- and middle-income countries. Tom has worked as part of the World Health Organization’s Safe Surgery Saves Lives program during which he performed seminal work in quantifying the global volume of surgery. He was instrumental in the creation and implementation of the WHO Surgical Safety Checklist which most of us use in the operating theatre today. Tom and I have a number of opportunities for collaboration, particularly relating to surgical infections. It was great to discuss these and get things moving forward.

Steven Yule (Assistant Professor, Harvard Medical School) is another Scot and an academic psychologist now at Harvard. Steven’s interest is in the impact of behavioural skills on team performance and patient safety, particularly in the operating theatre. Steven developed the NonTechnical Skills for Surgeons system while in Scotland which is now the gold standard tool in this area. We spoke about opportunities to gather data on non-technical skills using our crowdsourcing approach. We have good quality data on use of the WHO Surgical Safety Checklist and looking at non-technical skills would be a useful additional element to the data.

It’s a great meeting with a particularly positive atmosphere. Of course, the Strip on Las Vegas could not be more far removed from Blantyre Market, Malawi – it is like the capital city of an alien civilisation in comparison. Yet there was one prominent common theme: healthcare inequality. I had many conversations about the future of Obama’s Affordable Care Act and what may follow. The Trump presidency had only begun a couple of months earlier and while no one was very sure what would happen, many were worried. Looking down from my hotel room to the Strip, it was difficult to believe that capitalism is having an existential crisis (time.com/4327419/american–capitalisms–greatcrisis). Yet it seems that a commonality between the UK, US, and Sub-Saharan Africa is a profound lack of confidence in the best and most equitable way in which to fund healthcare provision for the societies we live in.

Susanne Warner (Assistant Clinical Professor, City of Hope Hospital, Duarte) (left). Gala dinner at AAC (right).

Los Angeles

City of Hope

“Health care is a big deal” – Barak Obama.

I drove to Los Angeles through Joshua Tree National Park, which really is like an alien landscape. The final leg of my fellowship was to City of Hope Hospital in Duarte. Yuman Fong (Chair and Professor, Department of Surgery) is an HPB luminary and James IV Traveller (1999). Yuman and Nicole were the perfect hosts at their house in Los Angeles and gave so much of their time to take me out and show me aspects of LA I had not seen before.

City of Hope is a Comprehensive Cancer Center with a strong research pedigree. It originally opened in 1914 as a TB sanatorium consisting only of two tents, one for patients and one for staff. Given the poor prognosis of TB in the pre-antibiotic era, it was called “the city of hope”.

Yuman Fong is an inspiration. He lives life at 100 miles per hour and has as many ideas in that time. We have common research interests in HPB but particularly in wearable technologies for diagnosis and follow-up in surgery. I hope we can bring some of our transatlantic patient follow-up ideas to life.

I spent an enjoyable day with Gagandeep (Gaugs) Singh (Chief, Division of Surgical Oncology, Head, Hepatobiliary and Pancreatic Surgery) watching a tricky open distal pancreatectomy then discussing parenchymal-sparing hepatectomy. He is an advocate and had some good examples of colorectal liver metastases involving hepatic veins where a resection could be performed preserving the vein.

I met Susanne Warner (Assistant Clinical Professor, Division of Hepatobiliary Surgery) at the ASC and so it was great to watch her do a difficult left hepatectomy for cholangiocarcinoma, down to but not involving the confluence. Susanne and her husband also have an interest in humanitarian work and I hope we can work together in the future.

I was particularly keen learn more about how the team viewed the indications and use of the robot in HPB. Yanghee Woo (Associate Professor, Division of Surgical Oncology) has tremendous skills with the device and I was interested to discuss it with her.

I am so grateful to Yuman and Nicole for their hospitality. From making gluten-free muffins in the kitchen (a family business bensmuffins.com), to the La Brea Tar pits and Hancock Park, the Huntington Botanical Gardens, and the LA Philharmonic, I had an amazing fantastic time.

Conclusion

The James IV traveling fellowship has been an extraordinary experience and I am immensely grateful to the James IV Surgical Society. It has been great privilege to have the opportunity to visit and speak with surgeons working in environments different to one’s own. This is particularly the case given the challenges faced in many countries delivering safe, timely and effective surgical care. Despite the differences, the world is becoming smaller and there are many similarities, with great opportunities for shared learning.

The ethos of the GlobalSurg Collaborative is one of global community, that “we are all in this together”. I am left feeling this is definitely the case and that the community of surgeons working across the globe to improve the lot of the surgical patient is real.

The process of establishing GlobalSurg Trials Hubs around the world continues apace a worldwide RCT examining simple interventions to reduce surgical site infection in place. The GlobalSurg team plan to return to Johannesburg as part of the launch of this later in 2017.

Finally, there is great opportunity in expanding surgical distance learning programmes, which in themselves, contribute to a global surgical community. Our successful efforts in expanding scholarship opportunities for training surgeons in Sub-Saharan Africa should act as a springboard for further an expansion of funding in these areas.

Callan, number one son, exicited to be riding an ostrich in South Africa (far left). Finn, number two son, happy despite the prospect of a long flight (centre left). Reading “The Gruffalo” (cenre right). Liv, Callan and Finn on Table Mountain, Cape Town (far right).