All right, it's 1046, so I think we're going to get started. Hi, everyone. My name is Dr. Ninia Tamayo. I'm the current chair of the International Rehab and Global Health Community. So welcome to our community session called Humanitarian Rehabilitation in Conflict Zones, Lessons Learned and Future Strategies. We're really excited to put this on. It's a pretty hot topic, as we know. So we have a great panel of speakers today talking about their experiences in disaster rehab, specifically, with respect to conflict zones. So I'm really excited to introduce them a little bit later. Just some housekeeping things. If you missed our community session, this is our 2024 year in review newsletter. So if you want to know about what our community is up to, please, we also have a QR code. You'll read all about our group's trip to Namibia and some of our projects and initiatives. So if you would like to be part of our listserv, yes, we still use FizzForum. However, there were some requests from individuals who may not necessarily be part of AAP Menar, but want to know what we're doing. Again, our goal is to sort of break our silos with respect to global health. If you could scan that first QR code and get on our listserv, we would really appreciate it. One of our missions is to create a directory for medical missions. So if any of you are involved in trips in other places in the world, specifically physiatry-based, please also scan this QR code and put in your information, because we want to create a vetted resource for medical students and residents, especially since that is the most requested topic. So if you know of any colleagues who could fill this out, please send it to them as well. And if we have any program directors or attendings who are part of residencies that can take observers from other countries, the next QR code is for you. And for any private practice docs who are willing to take on observers or IMGs from other countries, that last QR code is for you. So we'll be passing the QR codes around as well. OK, so I just wanted to start with our why. Why did we do this? Besides the fact that it's been a very hot topic. But historically, rehabilitation medicine really lags behind when it comes to delivering humanitarian emergency response aid, especially in conflict zones. The funny thing is physiatry grew out of conflict. So back in the early 20th century, really the need for physiatry was because of all the wounded soldiers that came out of World War I and World War II. And the hope was to have them recuperate and return to duty. And as the 20th century went on, we saw that there was a greater benefit to rehab compared to prolonged bed rest. So the main thing is that physiatrists as frontline health care workers or as part of an emergency response team has only recently been accepted. We've usually seen emergency medicine, surgery, primary care medicine leading the charge. So there's really been a need for physiatrists being part of the frontline, especially because we know that early rehabilitation has positive benefits. And because of all of this, rehabilitation has really been seen as a second priority. So Article 11 of the UN Convention on the Rights of Persons with Disabilities has a mandate. And it reads that rehabilitation should occur during the early disaster response with the goal to continue months and potentially years beyond the conflict at the community level. And so we wanted to identify or define what a conflict zone actually means. And it's defined as a designated area where the rights of neutrals are not respected by the belligerents during an armed conflict. And this can refer to a region, country, or area within a country where conflict is prevalent. And according to the Geneva Academy, as of 2024, June, I think 2024 was this data, there are more than 110 armed conflicts ongoing in the world. So it's not just the stuff that you see on CNN. But even in the Middle East, there's 45 other armed conflicts. In Africa, there's 35 armed conflicts, Asia 21, Europe 7, and Latin America 6. So there's clearly a need, especially for physiatrists who have training in disaster rehab to show up in all of these places. So despite the mandate and the statistics, our role as physiatrists in conflicts and disasters remain underdeveloped. And some of the challenges include lack of specific skills in major trauma, and of course, the systemic challenges in conflict zones, including obstruction of humanitarian access, infrastructure damage, or health system constraints. And because of this, the field of disaster rehab has really emerged to address all of these inadequate issues and challenges. And so today, I'm really glad to bring in a group of panelists who can answer some of these questions. I'm going to lead it to, or give it to Dr. Gina Libby, who is another member of our executive board, to introduce our questions and our panelists. Thanks, Dr. Jemayo. Thank you, everyone, so much for coming. Yes, so one of the things that we're hoping our group, as we keep going over the next few years, we, oh, one second, go back to the other one, if you could. There we go. Okay, let me just finish up this and then we'll keep going. Yeah, so some of the groups are, some of the questions our group is working on, hoping to answer over the next few years, and if you want to be a part of this, let us know. You know, we're really focusing on one of the knowledge gaps, right, that we have related in providing rehabilitative care in conflict zones. What are initiatives, what are programs that are currently in place in disaster zones for specifically, for disaster-related rehabilitation? What are those challenges and barriers providing rehab services in specifically those areas of active conflict? And then what can we do to help sustainably and effectively? So it is my honor to introduce our amazing panel to you. We are very excited to be introducing these three speakers. First, we'll be listening to Dr. Amanda Mayo. Dr. Amanda is an assistant professor of physical medicine and rehabilitation at University of Toronto, medical director of Sunybrook St. John's Rehabilitation Hospital, and amputee physiatrist. She has an interest in digital prosthetics and orthotics fabrication to improve access to devices both at Sunybrook but also in areas of conflict and low resource. After Dr. Mayo speaks, we will then have the pleasure of hearing from Dr. O'Connell, who's live in Ukraine right now. Pretty, yeah, really excited that she's here with us in person all the way from Ukraine. So Dr. O'Connell is a professor of physical medicine rehabilitation at Dalhousie University Faculty of Medicine, medical director and research chief of the Stan Cassidy Center for Rehabilitation and clinical research director of University of New Brunswick Institute for Biomedical Engineering. She serves internationally in rehabilitation and disaster response, including Haiti, Ukraine, and Nepal. Currently, she is in Ukraine with an international spinal cord injury team. She chairs the International Spinal Cord Society Emergencies Committee, co-chairs the Emergencies Workstream of the WHO's World Rehabilitation Alliance, providing technical guidance for rehabilitation in the humanitarian space. She actually helped lead the WHO Emergency Medical Team Spinal Cord Injury Initiative. And once again, super excited that she's live from Ukraine. And she'll be back in a little bit, so she will join us. Yep, she'll be back for our Q&A section. And then our third speaker, we have Armine Babikian. She's an award-winning occupational therapist and founding director of a multidisciplinary organization, Therapist for Armenia. She leads humanitarian and development initiatives aimed at strengthening Armenian rehabilitation services in emergency, post-conflict, and low-resource settings, and is a member of the World Health Organization Armenia Rehabilitation Task Force. She is currently a PhD candidate at University of Toronto, where she researches sustainable development of Armenian rehabilitation and centering lived experiences of service users. So, big round of applause for our wonderful panel who will be speaking today. And Dr. Amanda Mayo, I'll let you take over. And thanks for having me. It's been a pleasure to come to APMR, much bigger and better than CAPMR, I have to say. So yeah, I'm going to speak on improving limb loss rehab in a conflict zone, and specifically Ukraine, and going to sort of really approach on the topics of collaboration and innovation using technology, adaptive practices, interdisciplinary teamwork, and community partnerships, both, you know, on-site, on the ground, but also in Toronto, where we've had a lot of community support. And so, I always look back, like, how did this start? Like, why me? I'm not Ukrainian, I have to disclose. I'm the only sort of team member on my team that isn't Ukrainian, but they came to us because we're Canada's largest trauma hospital. So, we have those trauma skills, and we actually started, like, physiatry as a military hospital, and prosthetics and orthotics were one of our first programs. And we have a large number of Ukrainian physicians and surgeons that are really invested in this conflict. So, right at the start, like, spring of 2022, my chief of medicine, physiatry is under medicine in my hospital, is Ukrainian, and she came to me, and she said, you need to help. There's a lot of amputations, and there's a lot of trauma going on. And so, we were linked with this rehab hospital, which is a public-funded medical, like, a territory in Lviv. It's called Unbroken, and one of their mandates is treatment, prosthesis, and rehabilitation for Ukrainians in Ukraine, and with that specific. And for us, it was like, well, this is challenging. We're not in Ukraine, and when you think of any conflict zone, it's hard to actually get the resources and the infrastructure to make change. And we look at Ukraine, you know, again, we reference to sort of mainstream media, but everybody wants to appear strong, right? Like, both sides of any conflict doesn't want to disclose how many injuries they have. It's just like sports teams. You don't know the exact upper extremity or lower extremity injury, but there's actually more patients with limb loss than both World Wars combined in the Ukraine currently. So, tens of thousands, if not nearing 100,000 of limb loss victims, and they're civilians and military. What we've really learned is the field tourniquets are important, and so they've been doing a lot of training, because if they're really high, then guess what? It's a short transhumeral, or a shoulder disarticulation, or a really short transfemoral, or a hip disarticulation. So, you know, our team and many other teams are sort of doing even just tourniquet training, because that can affect the functional outcome. That can affect whether the limb is saved or lost. Often, there's multiple limbs affected, and as Colleen is working with the spinal cord injuries, like, these are complex patients. These are polytrauma patients. They've got brain injuries and limb loss. They've got spinal cord injuries and limb loss, and they all have an element of mental health and PTSD. There's also that issue of patients going abroad, and you see that, and you see that on social media, too, right? Like, they come to the U.S., they come to Canada, they get their fancy devices, but what happens next, right? We know that a prosthesis and limb loss is not a one and done. You know, the first socket is not going to last them, and there's really, like, pre-conflict limited trained P&O clinicians in Ukraine, and so there was a gap pre-conflict, and there's definitely a huge gap now, and no digital workflows. When we talked to them, when we first talked to them in 2022, there was no digital fabrication at all, and so we are really at a loss. Like, this is a big ask, and where to start and how to help. Like, we know we're, you know, experiencing trauma, but this is a lot. This is not sort of where we're dealing with workplace accidents, car accidents, and gunshot wounds, right? Much different than this, and so what do we start with? We actually started with, you know, our first video conference and sort of needs assessments in spring 2022, so as the conflict was starting, and really, like, Zoom and email discussions and starting getting to know, like, what do you guys need? And some of the things they needed were just very basic rehab protocols. The prosthesis was very open. I've only done transfemorals and transtibules. Like, I have no idea what I'm doing with these other levels, and same, actually, OT pre-conflict did not exist in Ukraine. They didn't have occupational therapists, and so they're, like, you have bilateral upper extremities, and they're Googling, and they want to do myoelectrics right away, and trying to convince them that, you know, body powered is the way to go. You got to get these up and going and doing your, you know, your ADLs, so we sent over a lot of our rehab protocols and sort of particularly mental health resources, and they were translating them, and then they were like, well, we just don't know what to do with these levels, like partial feet, shoulder, and hip disarticulation, so we actually just sent our prosthetic prescriptions, and they, you know, they went by those, and sort of they were getting sort of components from different sort of sources, and prosthetic fabrication guidance, so the prosthetist that we were working with had him broken. He's like, I've never dealt with carbon fiber. Like, these people are coming back from the US or Europe, and they've all got carbon fiber sockets. Well, guess what? Everybody wants them now in the hospital, and so actually working with the team to see how they could, you know, fabricate carbon fiber on site, and again, component selection, so that sort of restarted, but there was challenges, and I think when we think about sort of providing care in a conflict zone, and Colleen is sort of evidence to this just being on the ground, you know, there's, especially at the beginning, there was a lot of blackouts and just the inability to communicate, and then the time zone difference, so, you know, we tend to meet with them at like 7 or 8 in the morning because that's like in, you know, 3 to 4 p.m. in the afternoon, and then language, so I'm the only one who's not Ukrainian, but even like our Canadian Ukrainians, your Ukrainian is not 100%, so there's always that delay in understanding and loss in translation, and it was really integral that we did have Ukrainian-speaking members on our Canadian team, and then we had to figure out what they use for tech, right? Like, so I'm used to using Zoom all the time. They hated Zoom, so again, and then like I couldn't figure it out, like, why aren't they responding, so I have about like 10 WhatsApp group chats now, and they love WhatsApp. If you ask them a question on WhatsApp, they answer it right away, but if you send them an email, and again, they probably don't have access to their email consistently. You know, sometimes we didn't get responses, and then another thing I think we need to recognize about conflicts is just the stress and the workload on the conflict teams, so there's missed meetings, you know, like routinely, and they have multiple teams assisting them, so sometimes it's like you're part of another group, or there's other teams sort of helping them out, and really sort of recognizing, like, you being the non-conflict zone team, you need to be flexible, and you need to be able to pivot, because their needs and their resources change dramatically. Like, when we first met them in 2022, they had nothing, and now they have like a very beautiful rehab hospital they've built, and many sort of teams visiting and sort of working with them, which is great to see. And so our first on-site visit was in December 2022. I like Nazar as sort of the prosthetist, and his t-shirt says, we're not perfect, but the safest hands are still our own, so I like that sort of mantra for somebody in a conflict zone, and it just reflects sort of also their trust sort of of teams coming in. You have to sort of recognize the conflicts of people that are working in conflict, and so we did an updated needs assessment. When we first met with them, they were working out of a portable, the prosthetist, and they were building a new facility, and for us, we really needed to see if we were going digital, which we were going to sort of talk about, you know, what's the space like, what's the team skill set, and then also the team provided some on-site education just with rehab protocols and mental health. And so then we came back. Like, we can't solve all their problems. We are really going into digital fabrication at our hospital, so we had a lot of sort of skills in this, and we thought really we could help increase their prosthetic lab capacity by decreasing their fabrication time and their manual labor. They just didn't have the hands to make the sockets, and what are we going to do? We're going to do an in-Ukraine for Ukrainian solution for digital prosthetic fabrication and fitting, so all on-site, nothing that's sort of centrally fabricated. We did think about that, but just the, you know, the difficulties of border crossing and actually making sure that sockets got to them on-site was a challenge, and so how is this enabled? Again, so like, how did we get here? How did this actually work? We got some university funding. So the Temerdy family, it's the Temerdy School of Medicine at U of T. They're Ukrainian, and so they gave us a grant. It wasn't a big grant, $150,000 Canadian, but it really allowed us to do this, right? Like, it allowed us to send people over. It allowed me to buy some components and ship them over, allowed me to buy printers and make it happen, so grateful to the Temerdy Foundation. And so we chose, this is a non-for-profit system that was developed in Toronto, and we'd done some pilot work with them, but basically it's all on-site, so scan, you know, rectify the socket and print, all in that sort of site at Unbroken and fully digital, and they've been doing trans-tubule sockets and AFOs and working into some trans-radial sockets as well, and so why digital and conflict? So it is quicker. Like, you don't have to, it doesn't take as long to take the shape capture, but it can be done anywhere, right? So, you know, it can be done at a soldier that's been injured miles away, and, you know, the prosthetist can rectify sort of in the prosthetic lab. It requires a lot less materials, and it really creates a digital shareable file that can move anywhere, right? Because sometimes it's hard to move patients and people in areas of conflict. But it's not easy, and so, you know, some of the challenges in this was the people on the ground were saying, like, when are you coming? When's this happening? And a lot of stress to get this together, and really sourcing equipment in a conflict zone is challenging. You have the availability, the cost, like sometimes the quotes we were getting, like there was a lot of variability, and we were really unsure if they were reliable, because of course there's corruption, you know, in areas of peace, and there's corruptions in areas of conflict as well, and there was border shutdown. So, when we first talked to the, we thought maybe we could get the components from the prosthetic manufacturer in Ukraine or Europe, and they basically shut us down. So, we actually had to ship our components from Canada to make it happen. We often use Poland as a drop zone, and actually our teams, when they're flying in, they go to Poland, and they do land travel over to the Ukraine, and the prosthetic components and supplies, like I said, they were donated, and the new were all shipped from Canada. We couldn't make it possible. There was just so much red tape and sort of fear that they wouldn't get there, so we did all direct shipments from Canada. All the little things, like the scanners, the laptops, and even like some of the, you know, the hands and stuff, our team just brought on the flights, and we have like sort of a Ukrainian Canadian courier. They've been essential as a company, but beyond helpful to make this work, and we actually had to think about like tech, right? So, you have to think about like what tech, we know what tech's going to work with us, like we have steady Wi-Fi, you know, we can order things on Amazon, it happens, it comes the same day, but we really went with entry-level, less experienced FDM, so those printers that go around, because they were available, and we also could sort of repair them in that area of conflict. We set them up with two for redundancy, and we used sort of a filament they could use, and it was durable, and they could dispense, and we did solid wall printing, if anybody's like a 3D, I am a 3D printing, I'm going to say nerd, but we did solid wall printing for strength, and really sort of allow the process, they could still sort of modify the sockets, they weren't just one and done, but they could work with the sockets, and so they were there in December, and then came back August 2023. We really felt we needed to do on-site training and education, and setting them up with their printers and sort of technology, and that's just sort of a sample of the printer and the socket, we do a really long print time, so that it's, you know, a very small sort of filament, and we can sort of do padding to protect the skin inside, and this was like the best check-in, and I don't know, can you play that video if you click? So this is from the prosthetist, and this is the most important thing, today we tried on a prosthesis on the patient, and everything is just great, he just went home with it, and this was a long wait, so this is, you know, we started in spring 2022, this was October 2023, and they sent us videos, again, all on WhatsApp, the guys are like running on them, like they are just using them, and they're working, and so it just made us so happy, it made the work, you know, really gratifying, and then what else was gratifying is the team came to us, and so they were actually at Sunnybrook from October 21st to November 2nd, multi-disciplinary team, so there was two physiatrists, PT, OT, a prosthetist, and their leadership team, but what we found, we thought they just wanted to learn about prosthetics and orthotics, but you know, they needed to learn about our burns rehab, they needed to learn about trauma, spinal cord, and they also came with the new thing, like conflict is ongoing, but so is the burden of chronic disease, and so they have also complex medical rehab patients, right, like they have cancer patients, they have renal cancer, and so the thing with conflict is all the resources has been shifted to trauma, and now all these chronic diseases, those frail, elderly, medically complex, they're getting sicker and weaker, and so how do they, you know, rebuild and sort of include all, and this is sort of our picture, we have a helicopter pad, so they wanted to see sort of, because they have acute care and rehab, they wanted to see sort of how we were doing our trauma protocols in Canada. Their parting wish, and I won't forget this, and this was their CEO that was sort of going, is one day we are, like your hospital, built in response to a war that becomes a hospital providing care to all in a non-conflict zone. And so just a quick summary about how this has been working, we started in May 2022, we did those deliveries and those visits, and actually currently I have two team members in Venicea, so we're now setting up with a new rehab hospital and prosthetic team in Venicea, they're there currently doing sort of that on-site education and training, and you know, ongoing work, we still are doing virtual education, case discussions, and resource translation, we also have a Canadian team that's in Poland, we set up a unit there, and so they are sending me a patient who's got a drop foot and a shoulder disarticulation, and then, you know, a thumb amputation, and some of our medical teams, like they've all been funded, like you said, to respond to that and do the surgeries, but what next, like what's a thumb prosthesis, so it's the physiatrist that can really sort of guide, and like how do you access them, and what rehabs do they need, and we actually work as an advisory council, myself particularly, because the Canadian Ukraine Foundation gets a lot of requests for rehab funding, not all of them are evidence-based, and they are coming from a zone that has had little rehab infrastructure, and so just providing some expert guidance, and you know, what would be the best funding initiatives from our Canadian Foundation. The keys to success, I have to say, is our funding, like I don't think this project would not have happened, and also the support from our hospital, the Ukrainians on the Canadian team, and ongoing communication, but learning that it had to be by WhatsApp, because if I relied on emails, probably this would have not been done, and sort of supplementing the virtual work with in-person. And really, I think, in any conflict, and keeping this at heart, to know what the teams are going through, and Colleen's there, you know, in person now, but flexibility and persistence to know that you're, you know, you're going to make a difference, but sometimes it takes longer than you anticipate. So, I just want to acknowledge my teams. Toronto, it's sort of Sunnybrook and West Park APT Care. Neotech is the non-for-profit. And then the Ukrainian team in Lviv. But I'll pass it on to the next speaker. Good morning, AAP Menar. It's my pleasure to be here with you today, and to speak about a topic that is of one of my great passions when it comes to being a rehabilitation physician, and that is rehabilitation in the humanitarian space. Specifically, I'm going to speak about some of my experiences, and those of my colleagues in trying to provide care and capacity building for spinal cord injury rehabilitation during situations of conflict. At the beginning of this decade, the United Nations declared that we've entered into a new era of conflict and violence. Conflicts pose challenges to individuals due to the implications on security, the results of mass displacement, the targeting of health structures, and as well interfering with the access to aid and health services, not to mention that conflicts themselves directly increase the number of persons who will sustain disabling types of injuries. In 2022, a report was released that did a global overview of the trends in conflicts over the past almost 70 years. And we are seeing, without question, an increase in the number of conflicts almost on a yearly basis. And this includes countries where you have state-based conflicts, non-state conflicts, as well as one-sided conflicts and violence that occurs in many countries throughout the world. There are very few areas of the world that are unaffected at some level by conflicts. In typical conflicts, those who survive injuries typically far outnumber the number of deaths. And with the increasing complexity of conflicts over the years, particularly currently, we are seeing a much greater increase in the number of persons who are going to be in need of rehabilitation services. The United Nations Convention on the Rights of Persons with Disabilities indicates that in situations of risk, which include conflicts, that all necessary measures need to be undertaken to ensure the protection and the safety of persons with disabilities. In a typical emergency, including conflict, these create huge surge in rehabilitation needs, both for new injured, as well as persons with existing injuries and new complications. This can overwhelm even the most strong of health systems. At the same time, essential services are being disrupted, and so trying to maintain those services is hugely important, all in the backdrop of a population that is usually displaced. In that context, then, my objectives for this session is that you will recognize that conflicts create immense risk to persons living with spinal cord injury and those who are trying to deliver spinal cord injury health services and training. At the same time, I would like you to appreciate the essential role that rehabilitation plays in conflict emergencies and why we need to focus on building rehabilitation capacity. I want to introduce to you the story of a peer mentor with spinal cord injury and his experience trying to deliver care in the wake of an earthquake in 2021 on the background of severe gang violence that has disrupted the country's health system. That earthquake resulted in almost 10,000 persons injured and over 5,000 people, predominantly women and elderly with disability, being affected by loss of home and structures and displacements. These are the words of Sui Basilis. Sui is a young man who sustained a spinal cord injury, thoracic level, in the earthquake in Haiti in 2010. He now works as a peer mentor in Haiti, and so he was trying to work as a responding individual to the events of the August 2021 earthquake. And these are his words because he's not able to be here with us to tell us his story. He said this circumstance was extremely tough to deal with a tropical storm, a country already grappling with the coronavirus pandemic, a wave of gang violence was sending the country into political chaos. The project that Sui was tasked with was to act as a liaison and coordinator to transport manual wheelchairs from the northern part of Haiti down to the south to be accessible to beneficiaries who required these new mobility aids, and to arrange for the training of individuals in the communities in order how to put these together and how to fit persons requiring them persons requiring them appropriately. In Sui's words, the gang activity in the seaside district of Mardisant, just west of the Haitian capital, also was complicating relief efforts. Double-digit inflation was deepened, the transport of equipment, damaged access roads, were the main challenges for me to reach the vulnerable beneficiaries with the wheelchairs and other equipments. And where they were trying to go from was the northern Cap-Haitien down to Lake Hai. This is a distance of 245 miles, so keep that in mind. So recalling that the access roads and gang violence made it difficult to transport, Sui did use horseback to get to some communities. He said, I had a real determination in advocating to help people with disabilities in this particular terrible situation, as I could have simply returned to life by the power of God in the Haiti's earthquake of 2010. I was like, I will give back what I have received. So he's very good at getting himself involved, and he tells us that he had the chance of participating in the meetings with the humanitarian actors. I did plea for people with disabilities, and I rejoined the local office for their social services in Lake Hai. Volunteers and other organizations to get the job done with my perseverance and leadership as an actor in the sector for persons with disabilities. And so he did manage to complete the project. You'll notice the date here is March of 2022. So to get these chairs 245 miles, it took from August 2021 to March of 2022. These chairs were distributed through eight communities, and nearly 50 chairs were distributed from children through to geriatrics. And his challenges included the political unrest, the civil disturbances, which then ended up causing shortages for fuel. There were barricades through the road, phone and communication, internet connections were lost many of the time, and the gang violence made things very difficult. I'd now like to take you to another conflict that I think everyone is quite familiar with, and that is in Ukraine, and talk about the international collaboration through organizations that have worked on the effort to improve the care and capacity of delivering spinal cord rehabilitation in the situation of war. It's hard to get exact numbers, but it's anticipated that there are at least 600 or more new cases of persons with spinal cord injury sustained as a result of conflict-related events, including bombs, explosions, mines, and gunshots. This equates to about one new person every day sustaining a spinal cord injury. It is important to recognize that before the escalation of the conflict, for the previous decade, there have been very intentional efforts on behalf of the international community and the national rehabilitation networks within Ukraine to build rehabilitation capacity within the country, and that this isn't something that just happened because of the current conflict, but has certainly negatively impacted the ability to move forward, while at the same time has really escalated the urgent need to have appropriate rehabilitation services and capacity in terms of the workforce in place. Through the International Spinal Cord Society Emergency Subcommittee, we have a memorandum of agreement with the World Health Organization, as well as Momentum Wheels for Humanity, and it was through these collaborations that we worked through our main areas of focus, which are on coordination, communication, and capacity building at the onset in early 2022 when the war escalated in Ukraine. We've been able to provide some ongoing coordination and communication support around the building and support of new spinal cord injury rehabilitation centers, and have advocated for the need for capacity building and mentoring and training, drawing on our membership and connection to be able to provide some in-service, as well as virtual supports in a number of these areas. Our approach to capacity building in the situations of conflict and other emergencies is to abide by the World Health Organization's recommendations that rehabilitation needs to be incorporated at all levels of the emergency response, and that includes preparedness, readiness, the response, as well as building the resilience. And a big role that we had is trying to make sure that we have the capacity building the resilience. And a big role that we had is trying to work in providing mentoring and training, both through virtually by volunteers working with organizations on the ground, including Momentum Wheels for Humanity and the World Health Organization, in providing on-site training, and then providing visiting opportunities for health professionals in Ukraine to participate in our international meetings, and on-site training at a variety of spinal cord centers around the world. I myself was very fortunate to be able to work in-field in the summer of 2023, where we worked very closely with Momentum Wheels for Humanity, and under their guidance, in delivering training opportunities for strengthening spinal cord injury in situations of emergencies. I'm actually back in Lviv right now, as we work with an international team led by the Ukrainians in delivering one of their first national conferences. Some of the factors that are important when working in Ukraine is being aware of the risks that are always present, not just to the civilians, but to health professionals as well. And so we monitor with an application on our cell phones, whenever there are air raid alerts, and then we do proceed down to shelters, which are typically basements, basements or below-ground level areas. Even with one of the air alerts and one of the first hits that happened in Lviv when I was there last summer, the very next day, this is everybody still showed up for the last day of our training, and the country is still vibrant and living their day, in between. I don't want to give the impression that everything, that life is halted. Ukrainians are incredibly strong and resilient, and Lviv is an absolutely beautiful country that celebrates their culture at all times. Some of the key tools that have been developed now through these collaborations include the translation of the INSCE, the standard neurologic classification, the standard neurologic classification of spinal cord injury, into Ukrainian. That was done by Asia. The ISCOS, working with Momentum, has translated their eLearn SCI all into Ukrainian for at least the first overview for the interdisciplinary teams. Momentum, as well, working with the Praxis Spinal Cord Institute and the University of Toronto, translated the Canadian spinal cord injury practice guidelines entirely into Ukraine, and this is fully available at all times online. As I mentioned as well, Ukraine is about set to host their very first national conference on spinal cord injury that is occurring next week, and already has over, I think, 600 registrants for this. This, again, was an international, interdisciplinary team that worked to bring this to fruition, all being led by the Ukrainian teams. Finally, I just want to leave you with a few key resources that all of you can use and access for your advocacy efforts. Last year, the World Health Assembly endorsed an overall strengthening of rehabilitation and health systems, and this included calling on member states for timely integration of rehabilitation into emergency preparedness and response. The World Health Organization has developed a policy brief on strengthening rehabilitation in health emergency preparedness, readiness, response, and resilience, and this is very useful with practical tips on the reasons why and how rehabilitation should be incorporated in these situations. This is the recommended integration of rehabilitation into the health emergencies preparedness, readiness, response, and recovery and resilience framework that we should be incorporating into all of our efforts as rehabilitation health professionals. And probably one of the most important resources available to rehabilitation and emergency teams responders is the initiative of the World Health Organization for the classification and minimal technical standards for emergency medical teams. And this sets the stage and the standards and the vetting and validation that should happen for any emergency team that is responding to situations of emergency, including conflicts. And it incorporates the principle that just having good intentions is not really good enough. And this allows for an actual standard by which an emergency medical team should be preparing and responding in disasters. The World Rehabilitation that launched last year has an emergencies work stream, which is intended to push the advocacy message about the importance of rehabilitation in emergency with the key messages that rehabilitation is an essential health services in emergency and should be integrated at all stages of the response continuum. And I'm just going to leave you now with a few key resources that all of you can use in both in your advocacy efforts and as well to help guide you in your own planning around responses in emergencies and in response to emergencies. And including conflicts. This is a policy, a fact sheet on the policy brief of rehabilitation in emergencies available in multiple language. And you can scan this QR code and it will take you to the site. These are various publications that have been developed by both World Health Organization, Handicap International now called Humanity and Inclusion, and a number of other international organizations. And they include guidelines on early rehabilitation and conflict and disasters, the minimum technical standards for and recommendations for rehabilitation. As well as a do's and don't guide for responding to internationally to disasters for persons with for rehabilitation professionals. And very soon company will be the specific minimum technical standards for spinal cord injury. Finally, I want to thank you all for your attention and remember that health services and professionals are protected under international humanitarian law and are not a target and access to rehabilitation is a human right. Thank you for your attention. Hi, everyone. My name is Armine Babikyan and I will be presenting about my experiences in Armenia and Artsakh. I will just preface, I am an occupational therapist, not a physician, so my perspective might be a bit different. But we address multidisciplinary needs of rehab, and that's what I'll be presenting on. Just to start with a land acknowledgement, I wish to acknowledge the land on which the AAPMR annual assembly is operating. For thousands of years, it has been the territory of the Kumeyaay people. Today, this meeting place is still home to many indigenous people, and I'm grateful to have the opportunity to visit and be on this land. In light of the upcoming Thanksgiving holiday, I invite you all to reflect on the history of this country prior to 1492, and the impact that colonialism still has on communities today. Colonialism is still taking place globally, and has a strong connection to conflict zones that we are discussing today. So I'll just briefly introduce myself, the geopolitical context of Armenia, and then I'll go into explaining how rehab has developed in Armenia, and the conflicts that have been going on for the past four years, and our humanitarian efforts. And I'll close with some lessons learned, and strategies to take from this. So the lens that I bring to my work is a little different from my various personal and professional experiences, privilege, oppression, social roles, and interactions. I bring a different positionality to this presentation. I am not neutral. One way to describe my positionality is insider outsider. As an Armenian rehab provider, a disability ally, and a developer, I have insider knowledge on the topic, and I'm part of the community that I'm examining and supporting. But as someone born and raised in the US, educated in Western institutions, having the role of a researcher, I'm also an outsider to the setting, and the people that I'm researching and collaborating with. To situate all of us, this is Armenia, a small country in the South Caucasus bordering Iran, Turkey, Georgia, and Azerbaijan. We have about three million people in country, and about seven million Armenians diaspora worldwide. And so the location of Armenia creates a very tense geopolitical environment. We are a landlocked country with closed borders on the East and West, so following genocide and conflict with Azerbaijan and Turkey. We're also a post-Soviet republic. There was a heavy reliance on Russia for resources and regional security. And the region on the right in red, internationally known as Nagorno-Karabakh, is an indigenous Armenian region which we call Artsakh. Artsakh was an autonomous state which always had a majority ethnic Armenian population. And when the Soviet Union collapsed, it was supposed to be joined with Armenia, but Stalin intervened and gave the land to Azerbaijan instead, and there has been conflict ever since. So just to show these conflicts play a pivotal role in the development of rehab in Armenia, and continues to be a spark for further development in the country as well. So rehab was introduced in 1988 following humanitarian efforts after an earthquake, and this led to the founding of the first rehab center and the first physiatrists. You can see also allied health developed after the first Artsakh War, and then a veteran rehab center after the following war. But the third war in 2020 was when monumental development really happened for rehab because this introduced WHO's involvement in the rehab system specifically. And it also put health systems and rehab strengthening on the national health agenda. And with WHO's support, we now have national data on the gaps and strengths and the needs of the field, and so we are responding accordingly. But you might see the WHO got involved after the conflict and so there were needs right away. And so that's where we had a bit of a unique situation in Armenia, where as I said, we have a very large diaspora community. And so with local leadership in crisis response mode and international experts not readily available or lacking awareness of the local context and culture, the diaspora led many of the humanitarian efforts in Armenia. And so we helped create a bridge between the international experts and the local leadership with our deep understanding of the culture and context, familiarity with the government structures and also community partners on the ground, and also access to global experts in the field. And so, like I said, what makes our situation perhaps a bit different than Ukraine is many people didn't even know this conflict was happening. It was during the peak of COVID. I remember reaching out to people for support and saying, will you help us with this war in Armenia? And they're like, what war? And so a big part of our effort was also education and advocacy. And so then you'll see also how that plays into the way we responded. The WHO made this nice diagram through their rehab trauma assessment. So they basically identified the main priorities, which included service delivery, training, and equipment. And within the rehab sector, we had a couple organizations involved in rehab support, but my organization, Therapists for Armenia, was the only one that exclusively focuses on rehab. And so we were leading the training needs from the very start. And so, as I mentioned, because of the war took place during COVID, Azerbaijan got away with several war crimes, including the use of white phosphorus and cluster munitions, civilian and religious targets. So over a 44-day period, over 4,000 Armenians were killed, and thousands of soldiers and civilians were injured. So this conflict highlighted a lot of gaps in the rehab system, especially adult rehab and emergency response. Most of the injuries were amputations, burns, traumatic brain injury, spinal cord injury, orthopedic and peripheral nerve injuries. So this helped us to focus our training. And the burns, it was an interesting approach as well, because I was also reaching out to burn specialists in US, but many had never dealt with white phosphorus burns. So that even reaching out to global experts was still a gap and a bit of a mystery of the best way to support. In 2022, Azerbaijan initiated a blockade of the only road that connects Artsakh with Armenia. This blockade lasted 10 months, isolating Artsakh and cutting off fuel, electricity, food, and essential supplies. In regards to healthcare, there was no gas to go to healthcare facilities, no ambulances that could operate, no electricity for the hospital machinery, shortage of lifesaving medication, starvation, and malnutrition. So this resulted in deteriorating chronic health needs and many secondary medical complications. Eventually, the blockade led to a military attack and forced displacement of 120,000 Armenians from their indigenous homeland. During this mass exodus out of Artsakh, an explosion took place at a gas station where everyone was lining up to fill their cars to make the drive to Armenia. And this resulted in over 300 injured and 170 dead. So to summarize, in a four-year period, we were dealing with very complex and evolving rehab needs with multiple armed conflicts, multiple waves of displacement, starvation, severe burns, physical and mental trauma. So how did we respond? My organization is based in the US. A lot of our efforts were mostly remote with some mix of in-person initiatives as well. And we implemented with local partners. And so with our focus on capacity building for adult rehab and complex health conditions, as my colleagues mentioned, many of the local clinicians were asking for protocols and guidance on these complex injuries that they had never dealt with before. But most of the resources and articles are in English. So we were translating resources and created the first ever Armenian Rehab Resource Library on our website. And we hosted bilingual educational webinars and a virtual conference on rehab interventions for traumatic brain injury, spinal cord injury, wound care, amputations, PTSD, and community reintegration. All of the male therapists were serving in the military. And so we had a shortage of providers as well. And we sent traveling volunteers to support the needs. And we sent various medical and rehab supplies that were not available in Armenia, such as compression garments and scar gels for burn recovery. And we also created educational resources for patients and caregivers in easy read formats to support activities of daily living and quality of life. And as a therapist, I also think about psychosocial needs. So we created Armenian social stories about COVID and the war, which help children and people with disabilities or cognitive differences understand complex topics. And we created Armenian activity books for the displaced children and worked with local organizations to distribute to border regions. And my colleagues and I, we knew that 2020 wouldn't be the last conflict. And we had to think about future needs and preparation. And so we partnered with local leaders in the field and government officials to develop the Interdisciplinary Rehabilitation Fellowship, which was under the National Institute of Health in Armenia. This was a 10-month hybrid post-professional program focusing on post-conflict rehab. Participants were educators, clinic directors, clinicians, presidents of professional associations. We really tried to get the leaders in the field involved. And the topics had clinical modules related to the injuries that I mentioned, but also we wanted them to be change makers in the field. So we also had modules on leadership, advocacy, teaching, research, and health policy. It was a really successful program. We had 28 fellows, but unfortunately we couldn't find funding to continue the program and had to suspend the program. So now WHO is much more heavily involved in Armenia and engaging in capacity building for burn rehab and healthy aging. So my organization, we're focusing our efforts on supporting the displaced Armenians and capacity strengthening in the regions outside of the capital city. And this past summer, we had our first service and learning trip as an organization where I hosted five therapists and we led knowledge exchange workshops and case discussions and consultations with providers in Armenia. I'm a big supporter of working with the local providers rather than being the ones to provide the service yourself because you will create a vacuum if you do that once you leave, who will continue your work. So we work really closely with the service providers in Armenia. And then we're also in the process of becoming an ECHO partner to lead virtual educational case discussions. This is a evidence-based model for virtual education in healthcare. And we're also launching a 3D printed assistive technology program made in Armenia for adaptive equipment, as well as a support cafe for older adults who have been displaced with a focus on social and psychological support. So Armenia is just one example. Of course, approaches will vary based on the context and the needs, but I thought these might be some helpful lessons learned for others interested in this work. First and foremost, have a good understanding of the context before helping in any situation. Do a needs assessment, ask questions, identify priorities with local partners, and know who are the key stakeholders and the key players in the field, as well as community leaders. And establish relationships in different sectors. In a conflict situation, you'll be dealing with Ministry of Health, Ministry of Defense, social affairs, community organizations on the ground, international humanitarian organizations. And remember that the diaspora is a really valuable resource as well. As I said, they provide the cultural familiarity, but also might be helpful to explain things in a way that is more familiar to people from other countries. Include service user perspectives. This is often left out of initiatives and development efforts, but ultimately all of these efforts impact them, and it's important to center their needs and their priorities rather than your perceived notions of their needs or priorities. Identify the priorities and co-create solutions, as I said, with the local leaders and partners in the field in order to make sure it's really meeting the needs. And think about top-down and bottom-up approaches. Health system and policy change takes a very long time. And so sometimes bottom-up grassroots community efforts might have a quicker impact, but ideally you wanna approach from both ends. Have a good understanding of trauma-informed approaches, not only for the patients and service users, but the people you're collaborating with, the government officials, the healthcare providers, they're all going through this trauma as well, and it's important to be mindful of that and be empathetic and understanding. And keep in mind you can support from afar as well as in person. So what we did were just a few different examples, and I'm sure there are many other creative ways to support as well. We didn't get a chance to do this because we were constantly in crisis response mode, but collect data and publish if you can. It's important to document impact, but also it's a form of advocacy. And so if you get the opportunity to do that, please do. And as I said, always think about sustainability. When you are gone, who will continue this work and how will it impact the country going forward? So that is all, Shnoragalem, thank you. Feel free to reach out if you have questions or if you would like to partner. We're a small group of volunteers, but we really could use support and knowledge from anyone else who's willing to share. Thank you. Thank you. Thank you for all of your wonderful presentations. That was very insightful and really excited to have all of you here. If I could have the two of you come up. And we're gonna just start the Q&A session now. And we'll have, they're working, yeah. Maybe we'll see good on that side. We'll put her up here. There any specific questions from the audience? Even just comments or concerns? We'll start over here. Hello. Thank you for your talk. Coming into this, I wasn't sure what was Rehab's role, and I think putting all the multiple stories together, it sounds like a lot of support remotely, especially in the instance of equipment delivery, as well as training. And I was wondering for the training piece, because it sounds like you do go sometimes, but most of the time it's actually remote, for the training piece, are there certain issues that are coming up frequently that kind of maybe transcend region to region, which is you find that you have to commonly address, whether it's an issue with using equipment or a patient problem that providers there are just not that familiar with dealing with? Yeah, I would say in our context, we actually, because we shipped the printers ahead of time and we did a bit of virtual training, and I didn't mention this, but they actually ruined one of them, and so I think a lot of times when it's a hands-on skill or a very complex new technology use, it's often good to do in person. So yeah, we were a bit delayed, because they did ruin one printer just trying to figure it out on their own. Yeah, that's a good point, because actually in Armenia, that happened a lot, where people from other countries or from the diaspora just wanted to help in some way and would send these big fancy machines thinking, oh, I'm going to help advance the field, but teaching how to use the machines, teaching how to fix the machines is also really important, because otherwise it just sits there and collects dust. That's happened in the past, where people thought they were helping, and ultimately the equipment is not used, because they don't know how to use it. And then also, I think in Armenia, the biggest question was with the polytrauma, like these very complex injuries was often very challenging to understand what's the priority, what's the best way to address it, what are immediate needs and other considerations. So yeah, that was for Armenia. Colleen, do you have anything to add? We can put the mic. Yeah, sure. A lot of what we've been doing is a lot of remote by videoconferencing support around not just training, but in terms of directions around the equipment. So specifically around spinal cord units, for instance, here in Ukraine, we started over two years ago with just the support around how many nurses per bed, how many beds per population, how many beds can you fit in a room, how much space do you need around the beds. So very practical guidance that you don't necessarily need to be there for. But when it comes to some of the hands-on technical skills, for instance, there's a big work right now being done in multiple sites for training in urodynamics. So that is complemented and being managed by on-site training as well as people from Ukraine going to other sites to learn different processes and then bringing that information back. So a bit of a train-the-trainer concept. And some other skills are along that way as well with a local hands-on training. You made a really good point about the equipment that sits there. And there is so much equipment in some of these hospitals that is not ever going to be used. Super high-end, highly technical equipment that most of us in our rehab centers would never be using, but it looks good, it has a sticker on it from whoever. And some of the very basic things are not being supported. For instance, here in Ukraine nurses are paid not much more than what a secretary or a cleaner would make. And so it's very hard to get rehabilitation nurses engaged, but no one wants to fund salaries for nurses. So you have to work more on the advocacy side for that. And like was just said, a lot of this fancy equipment, it's not even needed and it sits in a corner somewhere. Yeah, I think it really highlights the importance of doing a needs assessment and making sure you have local partners to understand what's actually happening on the ground. And not just giving equipment or giving services that-because oftentimes I think when we think about global health, we want to do good, right? And we have our own concept of good. But the good that really needs to happen is based off of what's happening on the ground. And you can't do that without a needs assessment or a local partner. So yes, more questions? Hey, wonderful talk. My question actually goes along with the needs assessment. So I'm currently working on a project in Tanzania, and I'm struggling with balancing the needs assessment and respecting the locals' insight with them automatically deferring to everything I am trying to say. And I'm trying to continue to move the project along at some pace, whether that's glacial or not, but also wanting to empower them to lead and tell me what they want. And they're like, well, anything you can offer is fine. And I'm like, well, I'm trying to avoid bringing equipment that you don't need. So tell me, what is it that you actually need? And I don't know if they've never encountered somebody asking them for that or what, but if you guys have had similar experiences in how you've dealt with trying to empower them to actually advocate for themselves and tell us what is needed and helpful. Yeah, I think for our project, and we began to recognize that there's a lot of asks and they want everything, but we did partner, I didn't mention, but with the WHO and ISPO, like the International Society of Prosthetics and Orthotics, and some of those local team members just to see sort of what they were building and trying to make sure that we were in line sort of with coordinated efforts and also not creating, like Armene mentioned, the vacuum, like it's not just our expertise, but we're guiding them to sort of develop their own sort of education and training and therapy programs. Yeah, and I think sometimes it's helpful to provide that guidance of how to understand what you have. So maybe it's even explaining, like take inventory of what you have and providing alternatives because you don't know what you don't know. So perhaps some places have X, Y, and Z. Do you have these? That might be a helpful approach as well. So you're still providing your input, but you're not guiding it and it can get co-created in that way. Colleen? Yeah, I would just add that it really depends on the location and the legislation that's in place in the various places that you might be working. So for example, here in Ukraine, any equipment or things that are brought here have to be approved by the government. There has to be a ministerial order that approves a particular piece of equipment right down to the PO number. And they are trying to have a process where any pieces of equipment are going to be nationally recognized and will become like the national thing. So for instance, when we're talking about the Eurodynamics training and programs at multiple sites around the country, it is really important. It took two years to get everybody on board to agree that this is the piece of equipment that is going to be used and that's what people will be trained on. And it makes sense, right? So everybody is going to have sort of the same types of equipment to train on, especially when resources and capacities are really quite low at this stage. So my advice would be just really trying to make sure that you understand what the national governments, legislations, health systems have already as their priorities and not just showing up in bags of equipment that somebody you talked to said, this is what we want. Because you just really got to work with the national leads on the programs. Yeah, and just to add to that. So Dr. Libby, myself, and Dr. Louisant, I actually went to Namibia, not a conflict zone, but I had a very different assignment from the two of them. They actually had clinical work. My job was to actually understand how physiatry, if at all, was even present. It was, but they didn't have a physiatrist. So really understanding what services are available and what their goals are. Because my job was to find a physician who could go into Dr. Hague's program, which is the IRF. And he's training physicians to become physiatrists, especially in Africa. So they go through a certification program. But for me to understand, that's one thing, right? You can pick somebody, but then understanding if the system is even ready for a rehab program really took a lot of conversations with the people who are actually providing rehab services. So I talked to the therapist. I talked to the physicians who are running the spinal cord injury unit. I went to a private hospital, right? So getting a lay of the land also helps. Again, that's in a non-conflict zone, but it's part of your needs assessment, right? And asking those specific questions about, yes, nursing to patient ratio. What types of pathologies do you actually see? Like getting numbers and seeing, do they see mostly strokes or spinal cord injuries or traumatic brain injuries? Where are their patients coming from? And if there are facilities in the community that can continue the work that maybe you guys start in a central hospital. So those are sort of the questions I was asking, and it gave me a better idea of whether or not it was even possible to start a rehab, a true rehab program there. And then just to add on as well, it was mentioned by my colleagues, but sometimes some of these things are available in other clinics or other centers. So making sure that there is that higher level approach of not just one facility, but perhaps redistribution of resources might be what's needed rather than bringing in new resources as well. Yeah. And the Ministry of Health piece is super important. We actually got to meet the Ministry of Health and sort of understand the politics behind it, because that's the other piece. Any other questions? Oh, Cram. Thank you. Thank you guys all for the amazing talk. I wanted to ask, I know we kind of already touched on prioritization, needs assessment, stuff like that. When you find, like even here in the United States, I feel like a lot of us are used to having to market our field and rehabilitation and what it really is and what it can offer. And a lot of times when you go to these areas, like in some of the places I've been at, maybe they have funding coming from another organization or they're already building something. And as you can clearly see, there might be a very big need for rehabilitation, a lot of amputees, for example. But when you're trying to showcase that need and maybe physiatry and rehabilitation is unknown to them, they're like, how can you, I guess, discuss and show how it can help them when maybe in their head, they're like, oh, we don't have time for this new thing. We have a lot of other things to focus on right now. And I guess try to show that it's not this versus that, where it can all be together. Yeah, I think for us, we've been working with the Ministry of Health, but also the universities and trying to recognize really like physiatry as a medical specialty, because it is new to the country. And it was nice because they brought over their hospital leadership when they came for their visit. And part of their mission was actually looking at the training programs and presenting them was actually looking at the training programs and particularly the prosthetics and orthotics training program, because there's been a lot of sort of like mini trainings, but not like valid certifications. And so they actually visited the Prosthetic College and that was one of their sort of needs assessments just to see how we were structuring certifying prosthetists and orthotists in Canada. Yeah, and I think also some of the WHO resources that were shared are really helpful. Even if some of those guidelines won't answer every question, but WHO is a powerful name. And so saying that this organization recommends this, it definitely helps your argument. But also, bottom line, money talks. And that's a really important factor as well to show how rehab saves the health system. Money, time will make things more efficient, will reduce hospital stays. So those points are very important, especially when talking to policymakers and people at that level. That might be something that pushes the initiative further. I would just chime in. I started working in Haiti over 20 years ago. And we're way, way, way behind from talking to policymakers and even health systems. Because, and I think a bit of what you've alluded to in the question, there wasn't even, for the most part, a recognition that a person with a disability was a person or even had any value in society. There's absolutely zero rehabilitative consideration. Because people, there was a lack of even acknowledgement that someone who was disabled actually could be a contributor to society. And so it was a very long road in terms of working towards building up even the concept of recognizing these people as full persons who have value and contribution. And where we actually started was always partnering with local organizations and local leaders and bringing in persons with disability as part of that advocacy and change. And, you know, giving talks in grade schools to say that, you know, these kids are kids and trying to get positions for kids to be able to be in schools, being able to be in universities. Like it was really starting at a low, at that sort of basic level. And I think here in Ukraine, one of the most powerful thing is actually the persons with lived experience, the peer mentors have a very strong, over three decades of experience here in Ukraine, who have been some of the main drivers for pushing forward rehabilitation services here. So, and just to add to that, so this is something that happened in Namibia as well. Again, non-conflict zone. However, you know, we, there was already a group that had been going every year providing pain management services. And Lauren, he was part of the team that went in 2022, 23, 23. And we all went with her in 2024. But when we were having talks this time last year, you know, the framework we were using was that they understood pain management as rehab. And it was a component of rehab. So we were really focusing on their need. And then I was added to the team because I added the neuro rehab perspective. And I didn't actually know that there was a spinal cord injury center there. I found that we did our literature review beforehand and talked to some of the physicians. But I didn't, when I showed up, I had no idea that there was a spinal cord injury unit already existing. So it's also, it was also a surprise. But the main thing was there was some foundation, you know, about rehab. But the most of the people really looked at us as pain management docs first. And then when I came, I said, oh, well, we also do stroke, TBI, spinal cord, you know, and I'm spinal cord injury trained. So I was able to, you know, participate in like rounds and like family meetings. And the team that I was working with already knew how to take care of spinal cord injury. And they had protocols from Sweden. But, you know, they were interested in the other neuro diagnoses. So that was an additional, that was when it started to grow in terms of, oh, we can actually do this. We have some capacity to do it. We just need that physiatrist. So it really goes back to like, what is their understanding and what are their needs? And we kind of attached our assignment with that concept of pain management and rehab first and then grow from there. Yeah. Yeah, yeah, I think we're time. So thank you all so much. If I could just get like a quick video of everybody clapping and saying, that'd be great. Thank you.

Humanitarian Rehabilitation

Conflict Zones

Dr. Ninia Tamayo

UN Convention

Digital Fabrication

Prosthetics

Global Collaboration

Spinal Cord Injury

Capacity Building

Diaspora Networks

Interdisciplinary Training

Local Involvement