All right, since it's 7.05, we'll get started. Number one, welcome everyone so much to our Member May event for the International Rehab and Global Health Committee put on by AAPMNR. We're so glad to have you here. Very glad to have members specifically of our committee here with us. We have our chair, Dr. Nina Tamayo. Thank you so much for joining. We also have Dr. Reyes joining us here tonight, and then also myself, Dr. Jenna Libby. Before I introduce our speaker, I wanted to give an update regarding what the committee has been busy doing and let people know about ways that they can get involved if interested. Hopefully you can see in the chat, I posted a Google Form link for our International Rehab and Global Health listserv with the contact information that you can put through that link there. The purpose of that link is that we can collect information of everyone that's interested in joining our community. We can send out our newsletter to you if you provide us with your email, and that helps us keep in contact with you, let you know about different opportunities that you could take advantage of by working with us. Another thing that is very helpful that I'll place in the chat in about one minute is our committee is working on creating a medical mission directory. The idea is that if you've been involved in a medical mission or work with a program organization that does International Rehab or Global Health, please fill out this form, let us know about it, and help us build this directory. This information is going to be open to those who are interested, increasing their exposure to international rehab opportunities. Let me take a moment to add that to the chat for everyone. Great. If you have time, feel free to fill that out as well. Some exciting news that the committee is going to be doing, be on the lookout for posters as well as sessions that we'll be performing at this year's ISPRM National Conference in Sydney, Australia. We're very excited to be presenting our posters there as well as our talks. And then another very exciting thing that we are doing is upcoming in this November, we have successfully received information that our session was accepted for this upcoming AAPMNR National Conference, the Humanitarian Rehabilitation and Conflict Zones, Lessons Learned, and Future Strategies. That will be Saturday, November 9th at 1045 to noon. It's going to be a very interesting talk. Obviously, you know, conflict zones and rehab are a hot topic right now, and I think it'll be very helpful for us. Next, I have Dr. Reyes giving an update on his end for our committee. Hi everyone, I'm Dr. Reyes. I am the head of the IMG subcommittee. Our goal for the subcommittee is to assist individuals with foreign medical backgrounds in gaining more exposure to physiatry in the U.S. And through this subcommittee, we plan on developing a rotation observership directory for international physicians. So what we're doing is we're compiling all the rotations and observerships available to international medical graduates and any pertinent information when seeking clinical U.S. experience. So today, we sent out a Google form to all program coordinators to fill out any relevant information regarding or any relevant policies regarding IMG rotations. We're also opening this up to private physicians. So if you are a private physician not associated with an academic institution and you're willing to accept international medical graduates for rotations or observerships, feel free to reach out for us. And then I'll post the Google form in the link in the chat as well. Great, thank you so much, Dr. Reyes. All right, at this time, I have the esteemed privilege of introducing our speaker for tonight's session. I'm very happy and so grateful to introduce all of you to Dr. Yepsen. Dr. Yepsen is currently at the University of Colorado in the Physical Medicine and Rehabilitation Department. She has an impressive global health background, which is why we've invited her to speak to you all today. She actually served in the U.S. Navy from 2014 to 2023. She has a lot of formalized training in global health, for example, military tropical medicine courses, global health ambassador to Tanzania, graduate certificate in global health and global health engagement, and currently is in the New York Presbyterian global health track. I am delighted and so excited to have everyone here tonight to learn from and hear from Dr. Yepsen. Dr. Yepsen, take it away. All right. Hello, everybody. It's nice to see a couple of friendly faces. I'm going to share my screen and give me a few moments while I set everything up for the PowerPoint. Does that look good? Looks great. Perfect. So the name of our talk today is Forging the Future for Rehab, focusing on the WHO's 2030 Rehabilitation Goals. Again, as stated, my name is Haley Yepsen here at the University of Colorado, and happy to be giving this talk to a room full of people that are like-minded and motivated to advance global rehabilitation. Most of the time, I'm explaining what it is and why it's important. So it's nice to share with some people who are excited about this field. These are my objectives for this talk. Give me just one moment. There we go. So first, give a very brief introduction into global health and specifically global rehabilitation, discuss the challenges facing developing nations and that these concepts are universal to all under-resourced regions, not just, you know, on another continent. I want you to be able to appreciate why there is such a dire need for our specialty at a global level. And finally, talk about ways in which we can utilize the WHO's framework to improve rehab access worldwide. So a few financial disclosures for today. As, you know, as part of my introduction, you guys heard, I've been in the U.S. Navy for the last decade and have had some formalized training as well. Each of those trainings have made me realize that the lack of access to rehab as one that's never covered as any of the topics, and two, it's just kind of repeatedly stated that there is a lack of access to rehab around the world. So we have nearly unlimited potential in what we can achieve in this field. And I look forward to learning more about the projects people in this room are already working on. And hopefully at the end of this, creating a dialogue amongst us to make new partnerships, new projects, things like this. This is me standing in front of a military hospital in Zanzibar when I was there as a ambassador working with other military physicians. So jumping in, in case there are people here who are at the beginning of their global health journey, I figured I'd start with a brief introduction of exactly what is a developing country. So first, there's no consensus on preferred terminology. Third world nation is out is kind of the only consensus, but typically through the literature in today's presentation, you'll likely hear me refer to this group of countries, either newly emerging economies, low and middle income countries, or developing nations. This classification comes from the World Bank and is based on the calculated gross national income and separates countries into the four different categories you see below. These are dynamic designations. And as the country gains further economic opportunity and their incomes rise, they can progress through the different categories. This is a map demonstrating those same income levels around the world in those four categories. I want to point out the heavy concentration of low income nations in Sub-Saharan Africa and lower middle income countries in Southeast Asia. The vast majority of efforts in global health to date have been focused on these two regions. Tonight, you'll see a lot of different maps. And I hope by the end of this talk, you'll be able to appreciate some stark trends, again, highlighting our need for our specialty, especially in low and middle income countries. But first, let's take a quick look at some of the challenges that affect low and middle income countries as they pertain to overall public health and therefore their rehabilitation potential. These causes are pretty self-explanatory and are what we typically think of in global health and our role in medicine. Helping countries improve the most basic tenets of health. Many global health initiatives over the last several decades have been focused on these direct contributors and we have made significant gains in addressing these needs. These are the primary needs or focus of the WHO's Millennium Development Goals and also now the Sustainable Development Goals have been focused on these. However, if we want to make a more lasting and pronounced change to health care, working to change the indirect contributors that are associated with economic development is more important, but also significantly more challenging. Physical security is essential for access to health care, regardless of the specialty. And this is both true for patients and providers and something that we often take for granted here in the U.S. If collectively we can't engage in health care due to war, gang violence, political coups, et cetera, then patients with non-life-threatening conditions will likely weigh the pros and cons of seeking treatment, which delays care and ultimately affects our outcomes. To a degree, this is true anywhere there is relative poverty and the same sorts of issues arise. So here in the U.S., we have areas of food and medical deserts. We have areas that have corruption, lack of government support for social safety nets that can address the needs of our most vulnerable. We have emigration from poor rural areas to urban areas to seek better financial opportunities. That's the topics that we discuss here tonight. I want you to apply them to our backyard, not just to foreign nations. So we just talked about how poverty impacts overall health in the health care system, but we are physiatrists, so I want to focus us on how all of this relates to disability, function, and rehabilitation. Globally, there are 1 billion people living with a disability, which equates to about 15% of the world's population. Additionally, 80% of those living with a disability live in a low and middle income country. However, in many regions of the world, PM&R still doesn't exist as a specialty, even though globally that's where our target population lives. In the whole of sub-Saharan Africa, there's not a single PM&R residency training program. Furthermore, this disparity gap is only going to grow for all the reasons that I have listed here for you, and we'll briefly kind of expand upon each of them. First, life expectancy is increasing on every continent. This is in part to many of the global health initiatives that governmental and non-governmental agencies have prioritized over the last 50 years. Health care systems are better equipped, even in the poorest regions, than they were 70 years ago. Additionally, our understanding of diseases and treatment options has increased significantly over the last 50 years. As we know, with more people living, prevalence of every disease is going to increase, so simply the volume of patients with disabilities will also increase. Furthermore, as the population ages, there's a whole host of disability related diagnoses that present predominantly in the geriatric population. Now, with the exception of Africa, there's not a single PM&R residency training program. This is in part to many of the global health initiatives that governmental and non-governmental agencies have prioritized over the last 50 years. Now, with the exception of Africa, the life expectancy is already exceeding 70 years old currently, and predicted to exceed 80 years old by 2050. Like I said, that brings a whole new wave of diagnosis and under-treated rehab diagnoses, as the countries don't yet have the rehab-related infrastructure to meet these new needs. Again, the highest concentration of the low-income nations was in Africa, and this directly contributes to that decreased life expectancy shown here for all the reasons that we just discussed. So, through medicine, people are living longer, but at the same time, they're living with more medical comorbidities like hypertension, diabetes, coronary artery disease, all of the things that we all know. These types of diseases are called NCDs, or non-communicable diseases. They are not spread from person to person. While initially, many global health programs focused on these infectious diseases, NCDs are increasingly becoming a priority. This is because this category of diseases has risen dramatically around the world due to all the contributors listed at the top of this infographic, which we are very familiar with. If you focus your attention on the bottom portion, you'll see it's happening disproportionately in lower-middle-income countries. These nations are the most vulnerable, as they are just starting to have some economic development, with their citizens having increased access to some disposable income, which is unfortunately then being used to copy westernized diets and trends, causing additional premature death and disability. Those above and below this economic divide seem relatively spared according to the study. Around the 1990s, there were several countries that fit this exact description, and they were studied. In global health and economics, they were referred to as the BRICS nations. BRICS stands for Brazil, Russia, India, China, and South Africa. These five countries have experienced significant economic development over the last 30 years, and has been studied fairly extensively to see how this development has affected the health of their citizens. As you can tell from looking at this graph, regardless of the culture or continent, rates of type 2 diabetes has dramatically risen as they gained more financial stability. The reason this is so important is that this data has been recreated across other emerging economies, contributing to the overall skyrocketing prevalence of diabetes worldwide. As we all know, diabetes is a significant risk factor for stroke. Here we have a map showing the stroke-related dailies around the world from 2013 that are directly attributed to modifiable risk factors like smoking, BMI, and physical activity, those contributors that were listed at the top of the last slide's infographic. A daily or disability-adjusted life year is a common measure used when researching the impact of disability at a population level. Dailies represent the sum of the years of life lost due to premature mortality plus the years of life lived with a disability due to the prevalent cases of a disease in a population, in this case stroke, around the world. Dailies are important because mortality alone doesn't give a complete picture of the burden of a disease since we all know how associated disability can drastically impact the quality of life for individuals. I want you to take a moment again and find those nations the BRIC countries, so Brazil, Russia, India, China, and South Africa and appreciate that they are all on the upper limits of this scale demonstrating their relatively high mortality and morbidity associated with stroke as compared to the low-income countries in the majority of Africa and the high-income countries in North America and Western Europe. While there is not any available similar study looking at disc vascular lower extremity amputations globally, I would anticipate a nearly identical map to thus if that study was done. Again, I want to remind everybody this is not just happening over there. This is the same map of poverty in America that I previously showed with the darker colors representing the poorest counties here in the U.S., which nearly perfectly aligns with the rates of diabetes, which nearly perfectly aligns with stroke-related deaths, and unfortunately is the near perfect inverse of physician density. I want you to note that there is no available data that I could find looking at the density of physiatrists anywhere in the country, but I believe that if that research was to be done, it would closely follow this map shown, because due to brain drain, physicians of all specialties from any nation favors areas with better economic opportunity. For most of us, this storyline isn't anything new, but hopefully scaling it globally helps to illustrate its importance. Additionally, I hope that this highlights the role of health care and economics. As rehab specialists, we are uniquely poised within the health care system to appreciate this dynamic and intervene. We know that people with disabilities are less likely to have employment opportunities and access equitable education leading to poverty and further social exclusion as society assumes their voices less important and their disabilities can impact their ability to advocate for themselves. This feeds further into poverty as they have disproportionately higher health care costs, decreased health care access, and increased vulnerability to worsening disability as they are lost to follow-up. And the cycle continues. Those in practice are likely thinking of several patients that this cycle has affected. When we scale this to the national level, we see the needed role of government in setting of prioritizing infrastructure and public transportation that is accessible to those with disabilities, the role of health care and specifically rehabilitation, the role of the education system, the role of national advocacy groups, and the role of the business sector all coming together in order to address disability and its associated health and economic impacts. As I hope you come to appreciate, there is a growing disability around the world that impacts individuals, families, communities, and nations and we as physiatrists have ability to change that narrative. So finally getting to that topic of the WHO 2030 Rehab Goals is all these reasons that the WHO in 2017 developed a call for action with 10 rehab-specific goals to be implemented by the year 2030. Here are the 10 aspirations set forth by the WHO. I have selected a few to discuss in greater detail for the rest of the talk. Discussing some with clear ideas for ways to better accomplish these goals and others with a litany of unanswered questions that I hope the group can discuss in the second half of this event and see what our recommendations would be to try to implement this. So here are the few that I have selected to highlight, but all 10 are equally important. So the first one, strong leadership and political support. We are here tonight able to gather and discuss this important topic because of a strong national specialty society like AAP Menard that it exists. AAP Menard's role is vital as a platform for networking, education, and to help advocate for the needs of physiatrists and our patients alike. But globally, only 42% of countries have ever had a National Rehabilitation Society and currently only 16% of nations are actively participating in ISPRM. Without advocacy, the governments of these low and middle income countries will not just spontaneously support interventions aimed to help with disability and rehabilitation. Any desired project that we would want to implement costs money, a resource that is a scarcity in these countries, a resource that has to be divided among many competing interests like education, the military, infrastructure, public safety, and healthcare. In every country, if we want a bigger piece of the monetary pie, we must convince those with the purse strings that our cause is important enough to invest in. Since individual nations have been struggling to advocate for rehab on a national scale, the WHO helped to form the World Rehabilitation Alliance to help fill this void. The World Rehabilitation Alliance is a group of rehab stakeholders that are lending their name, members, money, and status to help advocate for rehab and the WHO's initiatives in low and middle income countries. However, this group was only formed like six months ago and if anybody here has more familiarity with the organization, we would love to hear about it and the role we may play as a member community or as motivated individuals. What other ways can we make changes? Be an active member within AAPMNR and other societies or communities, which you obviously are because you decided to be here tonight or are watching online afterwards. Continue to advocate loudly here in the U.S. as we have many areas of underserved populations within our own countries. Continue to push global rehab onto the national stage. Perfect example is tomorrow's National Grand Rounds is on global rehab. So we are doing it and the goals should just continue to do it. Additionally, for those in a position of power within these organizations, considering partnering with those outside of the US when able to include their voices and to lend your support. Moving on to the second WHO goal. One of the most common ways physicians in the US have historically been involved with global health is responding after a humanitarian crisis. One of the largest NGOs within this space is the Red Cross. In 2020, they released a statement saying, despite nearly a decade of addressing disability issues and armed conflict and other situations of violence, we have been slow in implementing disability inclusive programming and activities in our humanitarian action. This is a region where our expertise and voice is desperately needed. Together, working to get a seat at the table during the planning and execution portions of these humanitarian missions is vital. Partnering with the established organizations already doing that work is very needed. If this sounds interesting as alluded to, it's going to be delved in more detail this November at AAPNNR, so hopefully we'll see you guys all there. There are some who have devoted the whole careers to this endeavor, and with the expected challenges with climate change, we can anticipate that there will be an ever-growing need for us within these circles as well. An easy way that we can address this in our own day-to-day clinics is discussing with our patients on if they have an emergency plan, what would happen if whatever region of your country has a natural disaster, do they have a plan? Can they live safely within their home or evacuate safely? I wanted to use this case study from Guyana to exemplify the next few WHO goals and create a stage for discussion after the presentation. If you're like me and have a hard time reading and listening simultaneously, briefly, this is a success story of implementing a curriculum to teach the basics of rehabilitation to a mid-level type therapy provider to improve access to rehab services. This story demonstrates many of the themes we have discussed up until this point. First, the huge unmet rehab need with only 12 physiotherapists within an entire country, and the disproportionate presence of those few professionals within an urban area, and the international effects of brain drain affecting the field. It shows the partnership between countries and tasks shifting to address this unmet need and the possibilities for further research, partnerships, and leadership. Leave this up for just a few more seconds so that people can get a good sense of it. And this comes directly from the WHO's kind of handbook on the 2030 rehab goals. So returning back to those goals, the WHO has specifically stated that developing a multidisciplinary rehabilitation workforce is a priority. But where do we start when there are very few or even no therapists within a country, such as in Guyana, prior to the initiation of this new training pipeline? What recommendations should come first? I've listed a couple of different options here, but I'm definitely curious to hear thoughts and experiences from all of you in the second half of this event to kind of further talk about where do we start if a country wants to take this journey? Furthermore, the WHO has aspirations that rehab should be integrated into the healthcare sector. While I wholeheartedly agree with this statement, if there is not yet a robust workforce, do you try to build the workforce first and then integrate? Do you try to integrate as you build? Within the WHO literature itself, it even states that there is no published data related to this topic. So we can kind of come up with that idea and see what we would recommend, which transition us to the next goal. As with many topics within rehab, there is a dearth of information. And I think one of the primary drivers that will help with all of the other 2030 rehab goals is to push and expand and strengthen the quality of rehabilitative research. I know that there are a lot of words on this infographic, but I want you to focus your attention on the strength and quality of the currently available research. This infographic was created by the WHO for low and middle income countries for their governments to implement rehab in their country. Meaning this is the best available research that can be found. And the majority of the evidence is weak. Apart from the two statements that a multidisciplinary rehab workforce should be available and that inpatient rehab units should exist within healthcare systems. Again, while I agree with these statements, we just saw that even these two components can be a challenge to implement within many of the low and middle income countries. Even more importantly, when looking at the financial allocation and insurance coverage recommendations, we have very poor quality of evidence to suggest that rehab services are vital and should be prioritized. So imagine being a young motivated advocate in a low and middle income country who's joined a national society, if they have one, and goes to their government and tries to advocate that additional funding should be spent on these services. And this is the best research that we have to offer them. We primarily are in the descriptive phase of research at this time in global rehabilitation. And then a few articles that are on this topic tend to repeat the same themes that I have presented to you here. The vast paucity of research is one of the easiest ways that we can contribute to rehab at a global scale. So I have listed a few research proposals that could benefit all patients, proposals that improve access, decrease costs and expand the reach of physiatry, joint research initiatives between hospitals in high and low income countries, foster innovation and advance medical knowledge for all. These collaborations can lead to development of solutions that are relevant to a multitude of healthcare settings. Additionally, during the discussion portion of this evening, I would love to hear what other people in this group are already doing and are working on. Which directly leads me to the final WHO rehab initiative that we will discuss, creating partnerships. Partnerships are truly beneficial to both parties and can provide opportunities to all involved. I've listed a few examples below that seemed relatively easy for anybody to engage with. Again, the strength of our community lies within creating, maintaining and parlaying partnerships to help increase access to rehabilitative services around the world. One of our projects that we mentioned at the beginning of this hour as a community is to create that living database of projects and partnerships so that as more people join this community and want to become involved, there's a place with the resources to do so. As we are coming to the conclusion of this portion of the talk, I want to show you that countries are starting this journey and we are trying to address the issues that I've brought up in this presentation, but there is still so much work to be done. And I'm excited to be joined by others who are ready to do the work as well. In summary, there are common challenges facing under-resourced communities and these issues directly impact health, disability and economic prosperity. These concepts are universal, whether applied domestically or foreign. Globally, the population is getting older and sicker and this is occurring more in lower middle income countries causing a further mismatch between disability and available rehabilitative services. And lastly, countries are working hard to try to meet this need and we can be an asset in assisting their journey as well. Thank you for your time and attention. Any questions? Awesome. Thank you so much, Dr. Yepsen, for sharing. I would just like to reiterate what you mentioned. I just want to kind of open up the floor to just have like an open discussion about this, about how we had this great conversation about like the World Health Organization's 2030 goals. If anybody wants to share about any personal experiences or talk to any of the questions that you proposed throughout our talk. Yeah, I just want to take this moment to just open up the floor. Firstly, I just want to say, Haley, that was an amazing presentation. So well thought out, just such great background research and I think really provides a great foundation for a lot of the stuff that we're trying to do as a community. So I just want to say congratulations and thank you for giving us the time to talk about your work. So congratulations again, fantastic work. Congratulations again, fantastic work. I could like talk about this all day, every day. And I think, you know, one of the things that you kind of mentioned was a collaboration and, you know, to myself, Dr. Libby and Dr. Louisande, who's not quite here. She's sort of remote and joining us. We all just came back from Namibia. And so your talk just really made me rethink about our experiences there and how, you know, you were asking about what sort of strategies do we implement, you know, if we're trying to start PM&R in a country that doesn't really have it. I think for us, one of the projects that we wanted to really take on as a community was to, you know, do these state of PM&R in different countries and hopefully find collaborators in those countries who have a vested interest in starting rehabilitation facilities or centers or programs, whether it's something as small as an outpatient clinic or, you know, maybe they're ready to tackle inpatient rehab, whatever it is, but, you know, talking about what rehab looks like in those countries. So one of our posters going to ISPRM actually talks about the state of PM&R in Namibia currently. And we were very surprised because they have a spinal cord injury program in the state and they have a private inpatient rehab. So, you know, you go to the state if you don't have any and you can go to the private if you do. But truthfully, there's really no rehab physician there. So, you know, I think one of the things that we tried to do as a team was really to understand what does rehab even look like? You know, how do they practice? How does one even get services? So we asked, we did an interview. So like our poster in ISPRM is gonna talk about that process. And I think just developing a relationship with the people of that country is so important and maintaining that relationship, not just that one time that you went, but, you know, throughout the year, continuing having conversations with them. And I think it's really important to highlight our collaboration with other organizations. So we wouldn't have been able to go without the organization C-Mana. And also, you know, our relationship with the International Rehab Forum, Dr. Andy Hague's, you know, a nonprofit. And so we were able to identify physicians who were interested in becoming potentially the first rehabilitation physicians of their country. So I think, you know, those, like sort of doing a needs assessment and also just developing those relationships with other people of that country and not sort of barging in there and saying like, this is how you should do it. You know, I think it's super important because if we don't have sort of an understanding of what their needs are, I think, you know, it could backfire, right? Like the plan to establish rehabilitation programs could backfire. And, you know, I think that other things I just wanted to mention before I forget, you mentioned climate change and disaster preparedness, two very, very important topics for me. But that we do work with a nonprofit organization called Sustain Our Abilities. It is led by Dr. Markalee Alexander. She is a spinal cord injury physician, but she is doing really some amazing work in that field. I'm gonna put a link to that. We're actually doing a pre-course at ISPRM regarding disaster preparedness for people with disabilities in the context of climate change. And one of the things that I would like to try to bring to this community is a speaker by the name of Layala Kedeli. She's a physical therapist. Australia has created a workbook that can be used for people with disabilities and also for healthcare providers. Because one of the questions I had is it's great that they have this workbook where people can literally, there's eight different sections where they fill out how to create a disaster preparedness plan. So the resources exist. It's just, we have to adapt it to our individual countries. And again, in the context of climate change, like even us here in the US, it's regional. So you would expect to see hurricanes more in like Florida, Miami, tornado. We had a tornado warning today here in the Midwest. So just sort of adapting it. But I think the other question is, how can we train the trainers with that thought in mind? So I'm hoping that we can bring her in as a speaker to kind of continue on this theme and especially doing our part in terms of educating the healthcare providers and getting them to understand what else do we need in our tool belt to be able to prepare our patients better. So I will go ahead and link sustainer abilities and hopefully, I don't know if any of you are gonna come to ISPR, but if you haven't gone yet, please consider going in the next year or two. So that's my two cents. Thanks so much, Dr. Chamayo. Just wanna make sure anyone else, if anyone else wants to come up to you, if they wanna ask a question or give a two cents, just wanna take a moment to give an opportunity for anyone who wants to say anything. And also feel free to unmute and give your comments like throughout, because the idea for this is that it will just be kind of a discussion portion for the last bit of our talk. But kind of going off of what you said, Dr. Chamayo, about the emergency preparedness, I loved what you said, Dr. Yepsen, about when you see your patients, do you ask them, do they have an emergency plan? It sounds so straightforward and simple, but I hadn't thought of that before. And I was like, wow, yeah, I mean- I didn't either until we had like a field trip essentially, like one of our didactic sessions, we went and talked with people who have a nonprofit here in Denver, that that was their focus. And he actually sits on the committee here in Denver and is the voice, is the advocate for people with disabilities. So when like our hospitals do a disaster training, he goes and goes, okay, now how would you do this with somebody with a wheelchair? How would you do this with this? How would you do that with that? And I was like, I have never once thought of this ever in my life, and I'm here in this specialty. And so I agree with you. It's something that prior to a couple of months ago wasn't even on my radar. And it's this whole field that should be talked about. Oh, a hundred percent. And actually I want to pause and say that I'm so amazed that you actually did a disaster preparedness plan or like a drill, like you were used to like fire drills, but I personally have never been introduced or participated in a disaster preparedness drill for people who may have disabilities in regards to ambulating, or maybe people who are confused or need directions or vision abnormalities. That's amazing that you are doing that. That's stellar. That's actually our ISPRM workshop is we are actually using that Australian workbook and coming up with disaster preparedness plans. But I think the other question too is within our own hospitals. So I think about this all the time when I look at the design of a hospital and accessibility and how certain rehab floors are on like the second floor or above. And if a disaster strikes, whether it is climate change, whatever it is, like I always think about how are we going to get some of our spinal cord injuries down the stairs? If let's say the electricity blows, or even our brain injury patients or stroke patients who are hemiplegic. Like I think about now, how like even the design, because you were talking about accessibility and the environment as well, and how that plays into everything. That's why all rehab should really be on the first floor. And I kind of chuckle at it, but when you really think about it, you're like, oh yeah, yeah, because that would be a problem like if they were on the eighth floor of a building. So yeah. So comical, like oftentimes here in the US, like accessibility is an afterthought that is kind of like a checklist and it's not built into the design inherently. One of our SCI units here that we rotate at, they forgot to put like electronic door openers on the unit for a spinal cord injury unit. And they did not have ways for our patients to open doors. So it really is not inherent in our processes. It tends to be an afterthought, which kind of leads me into the second portion of, at least we do have a governing body, right? We have like the ADA and we have set standards, but that requires a functioning government in order to pass laws and then be able to enforce them. So in some low and middle income countries, that government is not functioning in a way that could employ those strategies. So if there isn't that regulatory role, then there is no like check mark, whether inherent or after an afterthought. Yeah, and I think you're bringing up a really great point that I came across when we were in Namibia is that there's also a need to understand the perceptions of people about disability. And I think understanding, just because rehab doesn't exist in certain countries, they don't know what's possible. And so they hold on to these old beliefs or what they just know what to do. Oh, you can't do X, so you're just gonna stay in the house and sort of wither away and they're not seen. But we're very blessed here and also in other higher income countries that have disability acts like ours, maybe not quite the same. That's the other problem is it's not standardized across the world. So an accessible room in London can look very different from an accessible room here in the United States. But I think just kind of going back to what we were doing in Namibia, like again, understanding the perceptions of people with disabilities on both sides is also really important as a starting point. And it's just a conversation to start having with those individuals, you know? So, but really, really great points for sure. Anybody else wanna contribute? A lot of faces. Can we take a moment to like just turn on our cameras? I always do this, so. If anyone wants to. Can we see everybody? It's okay if everyone's shy, it's okay. Oh, we got one. Oh, somebody left. It's okay. Oh, there you go. Yay. Okay, all right. Yeah. I like, similarly, a lot of topics that I'm also like very passionate about could also talk for forever on, but I did wanna touch base back on your mention about like the need for research for like the World Health Organization's 2030 call. You know, I feel like a lot of people who may not be used to research are kind of shy away from it and be like, well, I don't know how to do an IRB approved, you know, randomized controlled study, but like, no, no, like, you know, we don't have anything, right? We need information out there. Literally, like one of the things that we did right was just like a state of rehab, how do you do that it's like a narrative review so you just like look at what data is out there, and then you collect it and then publish it. And a lot of our national physiatry organizations like AAPMNR, as well as others have journals that are very receptive to narrative reviews like that. And once again you may say like, Oh, narrative review that's pretty extensive you know there's a, it's a lot of papers to go through. Because there isn't many papers at all to go through to write your narrative review. And even if your conclusion is like, oh there's a paucity of information. Okay, but like we need to like start getting that information out there. It's a great opportunity to start getting involved. You know, start dabbling in the world of global health, if you want to let us as the committee know about like something you want to write and you want someone who's written a paper before to help you. We, our committee would love to help you on that, because at the end of the day, we're all meeting that same goal of promoting physiatry worldwide right and hoping reach that World Health Organization 2030 call. One of the things kind of piggybacking off of that I did another talk recently on spinal cord injury around the world. And most of the data comes from high income countries. So all of the information that we do have available. Most of it comes from high income nations, there is some middle low and middle income countries that do track that data, but it's mostly coming from 22 countries around the world. And there are a lot more than 22 countries. And there are many countries that have no published data on spinal cord injury, and just because there's no published data occurring in X country doesn't mean that they don't have spinal cord injuries right we know that that's a universal diagnosis that somewhere somewhere in that country has a spinal cord injury. Like you said, like there. When I say that there's like a paucity of information, like I'm saying like very basic narrative stuff does not exist for many countries. So the bar is really low. And I mean that in the best way possible is that it's not hard to jump into versus if you were doing. Like you have to be like so high and doing these really detailed like, you know, studies. And so like here it's like what you see just describing it can really make an impact and start changing the way that we address some of this. Right. And just to let everybody know so for example like myself, Dr. Libby and Dr. Luis on put together and Dr. Velasquez put together the state of PM&R for Namibia, as well as the state of PM&R in Colombia, and Dr. Reyes, and I, along with a collaborator from the Philippines wrote a paper on state of PM&R in the Philippines. And Dr. Yepsen, I think you're going to be doing your own narrative review. And I can't remember quite the country. Tanzania will be the hope after my visit there next year. And then we have Dr. Grace Hershey who I've invited. She is actually just starting her work in Malawi. So, and I see Karam here. So I think he's going to be my lead for Ethiopia since he's done extensive work there. So the project is ongoing. And so we're inviting all of you if you have worked in other countries or if you're interested in, you know, particular country that maybe you've worked in or you visited or you're from that country. And you want to write potentially the seminal paper on PM&R for that country because we know that these papers haven't been written in a lot of other countries as Dr. Yepsen was saying. We really want to put this as part of the agenda for this community. So, you know, and with the support of AAPM&R, I think it'd be great, you know, to show that, you know, we are not just a national organization, but we are really, you know, getting out there in an international sense as well. So that's just a another formal invitation for everybody who is interested in getting involved. If you've got med students, you know who you want to mentor and write something, this is a great way to, you know, get their feet wet and also get them involved, get them have publications. And yes, while we are here representing AAPM&R, as you have already heard, we go to other conferences as well. And they know that we're, you know, representing AAPM&R for sure. But it's really important to get as much of our work out there. Cesar, I see a question. Yes, this is Cesar Astudillo, Peds Rehab Fellow in Dallas. So I was wondering if the team has any advisors, like, do you guys have like any database that you shared, any platform of medical missions that have included rehab physicians or especially Peds Rehab physicians? My experience is only in Ecuador with Project Perfect World Foundation. It's basically just like an orthopedic surgery, neurosurgery type of medical mission. And they incorporated Peds Rehab physicians from Kansas City. In the past, as a medical student there, that's how I found out that Peds Rehab existed and I fell in love with it. And I pursued that path until now. So I was wondering if there's anything like that available from you guys, because as I grow older, in my specialty and knowledge, I would like to join medical missions that include Peds Rehab physicians. Or you could just start one. That's also a dream. Let's pick a country, you know, any country. Yeah, I think, you know, it's, again, what would make it easier too is if we have, that's why it's so important to go to ISPRM and to network, you know, and even though I think Dr. Gibson, you said it was only 16%. Was that? Yeah, that's still 16%, you know, of the world that you can, you know, start to collaborate with. And, you know, I think it's really important to find the people in those countries you're interested in to say, hey, this is my, you know, specialty, I would like to give back, how can I do that? Sometimes, all it takes is being in the right room at the right time. You know, for example, for, again, for my three ladies, my two other ladies, you know, I don't know if it's going to pan out, but I certainly know that going to Namibia opened a door to potentially, you know, work in Egypt, for example. So I think, you know, as far as the resources are concerned, we're still building that and that's why what Dr. Ray did for the IMG subcommittee, we are, you know, we've been kind of trying to tell people about this, the medical mission directory as well, but I don't think people have really been filling it out just yet. We do require a lot of information because we want to make sure it's as accurate as possible. But if I could ask everybody who's here tonight to sort of post it, tell people about it, I think the more people know, the more information we can get. And so then we can have a truly robust, you know, medical mission directory. And certainly, you know, if you know of any of those physicians who went to, you said Ecuador, please like put that on the medical mission, you know, directory. Yeah, we currently don't have like an easy like, oh, you're interested. These people are going on this day, show up this day, and you'll have an easy plan to trip, right? That just doesn't exist for rehab right now. It exists for like family medicine, like infectious disease, etc. But like, that's one thing our committee and our community is trying to build, right? Hopefully, like, that would definitely be like a five year goal, like for our team. But, you know, at this point, we're in like the building phase, collecting information phase. And like, you know, like, Dr. Tamayo mentioned, her along with Dr. Louisant and I were like, kind of trying out different locations. And, you know, with jobs, you can only go to so many countries a year. So we're kind of like trying out different places and seeing like, hey, is this a place where we can really build like a good relationship or long term that we could bring other people? Is this a place that could be recreated? But that's all I want to say. But I know someone else raised their hand too. I was gonna follow up one last thing. So here at CU, I didn't have any rehab, like opportunities for international trips. So I had to create my own. And so like, I did the same thing, a lot of cold calling, a lot of cold emailing with people that sound interesting. And then also how you said ortho and neurosurgery, we work with them a lot here. And they're the same people we'd work with there. So they often have trips. So the trip that I'm building is piggybacking off of what neurosurgery here at CU already is doing. So they're, they're doing work. And so you know, where neurosurgery goes, there's a rehab need following them that was left unmet. And so that's how I got kind of my foot in the door. So if it doesn't exist yet, because it's still so new, like just cold emailing or cold calling or following with the people that you already work with and seeing if there's opportunities that way. Awesome. Thank you very much. And it looks like you've got some more information on the chat. And Ian, Dr. Libby actually, I believe went to Zambia last year. So Yeah, I did. I'd love to hear your thoughts. But I also worked with CURE as well. So yeah, what was your thoughts on those ones? So I haven't, I haven't gone yet. But our university, Michigan State has worked with the University Teaching Hospital and Medical School in Lusaka, Zambia. And so we've gone there for a number of years, the last decade or so. We work with the neuromuscular specialist, Dr. Kvolson there. So I'm going to be piggybacking on some of her patients and trying to do feeds neuromuscular. That's awesome. Yeah. Yes, when I was there, the university there in Lusaka had a lot of people coming, working with EMGs and the neuromuscular department. One of my friends actually from Michigan State, not University of Michigan, also went there and I think worked with that same doctor as well. What was their name? Key? Yeah, I know Key. Key was my senior last year. Yes, he's one of my good friends too. Yeah, so if you're interested in neuromuscular EMGs, it's totally a thing. Another organization there, which isn't necessarily medical, it's very like physical therapy or physios, OT based is Special Hope Network, led by Holly. It's almost like a day rehab for kids with disabilities. Okay. Do you want to type that into the chat as well, Jenna? Yeah, yeah. I see Karam has his hand up. Hello everyone. Thank you again for the amazing talk, Dr. Yepsen. So yeah, as Dr. Tamayo mentioned earlier, I did recently came back, I spent a month in Addis Ababa, Ethiopia. I got to work with, they only have four physiatrists in the country, but they have no like rehab unit at all in the country. So that was like something, this organization I'm in where there's trying to build like a musculoskeletal trauma center, but on top of that, they're also trying to build the first specialized rehab unit in the country. And something I wanted to ask to follow up on that is, the lack of infrastructure is obviously a problem that's being addressed, but the cultural thing is something I kind of wanted to touch on. A lot of people in Ethiopia, like when they have like musculoskeletal like long term care, they go out and seek care from traditional healers, traditional bone healers. And that was something that we encountered a lot with where patients didn't want to stay in the hospital long term or because of the long waits or because of fear of like amputation. So I guess I wanted to kind of touch on how can we work on bridging the gap with the culture and like trying to maybe bring in people from this historic cultural influence of traditional bone healers into your future plans. That's a great question. That's a fantastic question. I don't have an answer right now. Anybody else? Definitely like a good discussion point. Yeah. I haven't personally been in that situation. But one of the courses that I completed, we talked extensively about this topic. And so the consensus from that person who did go through a similar experience was trying to educate the traditional healers and finding a like common language that could be utilized. So a lot of the sentiment may be similar, but the understanding or how they would describe it would be different. And so trying to educate them and then letting them advocate for the medicine on our behalf, because that's already who the people are going to. So kind of your point of access is them because instead of changing them trying to go to them, you kind of change the information that they're giving was the consensus that, you know, this one group had success with. Again, I don't know if that's possible in your scenario, but one person's, you know, point of view. I think the idea is, you know, if you can't, it's not about leading people away from them. It's partnering with them, you know, and saying, OK, you have an option, right? If this doesn't work, then perhaps you would consider our, you know, our methods and strategies. But that takes a lot of work because you're right. Like the cultural aspect of it is really difficult to break down. For example, in the Philippines, you know, just even taking my own family. Right. And already I'm a physiatrist and, you know, my parents are also physicians. However, you know, I look at, you know, what they choose to do and like massage is a very popular thing. Putting ointments is a very popular thing. Sometimes they put ointments on things they probably shouldn't be putting ointments on, you know. So it's a conversation, you know, but at the end of the day, I don't think it's necessarily changing. We don't want to change necessarily the culture. Right. We just want to add to it. So I think that's a really important philosophy to have. And so your language and how you present PM&R to them is really important, like really thinking about the verbiage. And I think it's and I thought I saw Dr. Ice in here earlier, but the curriculum that's being built, you know, for global health, for residents, I think a lot of that is actually addressed in the curriculum. So knowing the right things to say, you know, or appropriate things to say, culturally respectful things to say, you know, having sort of the skill of being able to convince them to that what you're doing is not the strange thing. Right. That it's something that is evidence based. I think those are all part of your tool belt that you have to build. For sure. Thank you for that insight. I did like conduct a little bit of interviews with some of the providers while I was there about this exact topic. And just basically I did notice like there's a big generational divide where the older the older physicians and providers were like they really wanted to preserve the history and culture. They wanted to help bring these bone setters on board and like help build a partnership with the younger providers. I'm guessing there's just like some resentment that was being built up and they were not they said they were afraid. They didn't want me to go meet the bone setters because they were like, if you come there as an American, you're just legitimizing them because they're going to take a picture and put on a billboard and blah, blah, blah. So this was like something that's really hard to navigate. I just want to thank you guys for your insight. Great. Feel free to just unmute. Oh, sorry, sorry. I guess one thing that I didn't touch upon that very last statement that you said about being an American and then you don't like legitimizing or whatever. That was really expressed in my military global health engagement course that I took, because if I was in a uniform and showing up somewhere, then that to other people kind of represented all of America showing up and legitimizing or saying like this is what America believes and supports in. And so but, you know, even on an individual level, making sure that you're working to partner with the people who are already providing services there because global health has, you know, not the best history of being sustainable. And oftentimes, and the military is probably the worst at this, we show up with a giant ship and then basically decimate all of the local care that's being provided and people would delay going to their providers, whether it's a traditional healer or a physician or whoever, to wait for the ship to come. And so things would get worse. So, again, at least being aware that what you do as somebody coming from an outside country can really impact that and in a lot of different ways. Right. So legitimizing people or whoever you choose to partner with can really have a big impact and something that I think we don't often think about inherently on your first trip. Cesar, I don't know if you wanted to unmute and join, but feel free to just join whenever. Everybody don't feel like you have to actually raise your hand. Just, you know, come join our conversation. I actually forgot to lower the hand. I'm not really well versed on it, but now I found it like you have to lower your hand. Now I know. But yeah, no, thank you so much for all the information, everybody. I've already downloaded it and bookmarked it and I'm working on the forms that you guys sent me to register a few things and so I really appreciate it. And I hope to see you guys in Australia. I'm going there to present a couple posters there. So we'll see you there. I'll see you there. Yes, meet Dr. Tamayo, say hello, take a photo. Yes. Join our community. Absolutely. Absolutely. Thank you very much. Yes. Oh, we have a work in Turkey. Yes, that would be fantastic. Wonderful. And also just to mention to like, you know, one of the things we also want to do is to sort of partner with the other organizations like AAP, AOC, PM&R, ISPRM, you know, I think the nature of this community is that it's supposed to be global. Right. And so I know that this is a members only event, you know, but certainly our work is hoping to bridge, you know, the gaps between the organizations as well so that we're not repeating the work, you know, we're collaborating rather than, you know, reinventing the wheel. So, yeah, I think that's just a point that I've made in a lot of our sessions and I think it's an important one too. Pro collaboration. Yes. I want to make sure we're mindful of everyone's time. We went way over, which was great. Really great. I mean, like, like Dr. Tomayo said, I could talk about this for hours and hours. It's something we're all very passionate about. And there's always another point of like, oh, what if we thought about this or this, but I just want to open up one more time. Anyone have any like last other additional questions or comments they wanted to add? All right. Well, if that's the case, just some friendly reminders. Like I mentioned, Dr. Tomayo will be representing our committee in ISPRM in Australia. We will also, the majority of our committee should also be present at AAPMNR this year as well in November. We are open to collaborating, communicating with you all. If you have any suggested projects or papers you want to work with us on, we would love to join you. Love to help kickstart anything. Please fill out our listserv so we can get your information and we can disseminate our newsletter to you if we have any opportunities. And please fill out our medical listserv that's collecting information about opportunities. Once again, we're in the growing phase. We're hoping to collect a lot of information about different opportunities. And then once we're able to kind of test out different opportunities and we can like make sure it's like, oh, this is great. This is positive and helping, not hurting. We would love to then hopefully in the next five years disseminate a great resource for everyone to get involved. I just want to make sure I didn't miss anything here in the chat. Great. Yeah. Oh, thank you so much for this information. Yeah, I should screenshot this before we actually leave. But I can screenshot that in a second. Before you could kick us out, Christina, let me screenshot our chat. But otherwise, I just want to thank you so much, Dr. Yepsen, for coming and putting on this great talk, helping us have such a stimulating conversation about something that we're all very passionate about. And please keep in touch. Let's all work together and promote rehab globally. Thank you again and thank you everyone for coming. We'll see you at our next session.

physiatry

community building

global health goals

World Health Organization

rehabilitation services

cultural perceptions

traditional healing practices

rehabilitative care

education and collaboration

evidence-based practices