Good afternoon. My name is Jennifer Squibbs. I am a member of the Professional Development Committee. Before we begin, I have a few reminders. By now, you should have the AANA meetings app. As a reminder, this is how you will submit CE credit through the application. You have until Monday, September 9, noon Pacific time to enter your evaluations for credit. Don't forget to mark your calendars for the 2025 Annual Congress in Nashville. We will open up the call for abstracts on August 14th. If you are interested in submitting an abstract, please see our webpage for information and instructions on how to do so, the criteria for the abstract submission, and formatting for writing that abstract. Now, it is my pleasure to introduce to you Dr. Edwin Aroque and Dr. Christian Tecway. Dr. Aroque is an Associate Professor, Director of the Ph.D. Program, and Director of the Dual DNP Ph.D. Program at the University of Alabama at Birmingham School of Nursing. Dr. Tecway is a CRNA and the President of the Association of the Cameroonian Nurse Anesthetists in America, and the founder and owner of the medical apparel brand Mozzie. Did I say that correctly? Please join me in welcoming our speakers. All right, thank you for the kind introduction, again, just to give you a little bit of context to our presentation for today. Let me see if this is going to advance. All right, looks like the slides are up, good. So again, I'm Edwin Aroque. I am one of the co-founders of the Association of Cameroonian Nurse Anesthetists, served as our Vice President for the first few years, then President. Then I'm joined here by Dr. Tecway, who is our current President. And some of the work that we are going to share with you today really speaks to the work that we are doing in Cameroon, focusing on improving anesthesia care in Cameroon. We are going to share a little bit of some of the challenges and some statistics in terms of global health. But again, I really want us to think of this from a solutions mindset. I am a big proponent of, we already know what the problems are, so why spend so much time on the problems? Let's really start thinking about what can we do to solve these problems. And we're also going to really spend a little bit of time talking to you today about some of the challenges and some of the lessons we have learned, specifically really thinking about mission trips and what can we do to make sure that they are sustainable and long-term and achieve some long-term outcomes. We have no conflicts of interest to disclose. We have no financial relationships with any of the content that will be presented here. But like I mentioned, it's going to be important for me to really acknowledge some of the support that we have received, because as you know, doing global work and doing work in low and middle income countries requires a lot of resources. So we have been supported by the Diversity in Nurse Anesthesia Program and Dr. Lina Goum. We've received some help from Dr. Jackie Rose and her foundation, Our Heart, Your Hands. The UAB School of Nursing has supported some of my efforts as we've engaged in this work We've partnered with Webster University and they've also supported us. Apex Anesthesia Review has really been instrumental in supporting some of the students, as we will share with you, in Cameroon. And of course, most importantly, we want to acknowledge all our ACNA members, ACNA being the Association of Cameroonian Nurses and Anesthetists in America. It's their dues, it's their commitment, it's their time of work that has really made all of this work possible. So we really owe a lot of gratitude to them. So as we think about our speakers for today, or our lecture for today, these are some of the outcomes that I hope we will really achieve at the end of the day. I want us to understand the challenges and the implications of doing short-term work. So we're really saying, what are the challenges that you face if you're just going to go in and do one mission trip and leave? How can we think about long-term sustainability? So that we really start recognizing some principles through which we can do to make sure that we achieve the outcomes that we intend to achieve. So recognizing how we can use the brochure declaration to really make sure that our interventions are ethical and, again, sustainable. Then we will share with you, for the bulk of the presentation, some of the things that we are doing in Cameroon, so that, again, we hope that this will be a blueprint that others can do. Because as you think about anesthesia in low- and middle-income countries, one of the good things that we have now is most low- and middle-income countries have nurse anesthetists here in the United States who were born in those countries. And as such, we hope that this could serve as an inspiration, as an awareness to them to say, you can go back and help improve anesthesia outcomes in your own countries. These are things that we are currently doing to help improve anesthesia outcomes in Cameroon, where both of us were born, and now this is our own way of giving back to our own home country. But first things first, this 2018 systematic review really put to light what the challenges are when you're thinking about low- and middle-income countries. And in this, they were looking at data in terms of mobility and mortality. And they found that about 15.6 million excess deaths occur in low- and middle-income countries. And of these 16.6 million deaths, about 8.6 were related to amenable health care. So basically, they were saying, you can attribute about 8.6 million deaths in terms of how the health care was delivered. But of real interest to us is the fact that when you look at these 8.6 million deaths, 5 million deaths occurred for people who actually received care, while 3 million were for people who did not access care. And what this is showing us is that there are times when, especially in low- and middle-income countries, having poor care or accessing care that is of poor quality may be even worse than having no care at all. Because we are seeing that those who access care but receive poor care tend to do even worse of that, even if they did not receive care. And so I come today to really submit to you that, as we start thinking about low- and middle-income countries, it's important to think about access. Yes, for a long time, global health was really focused on universal access to care, right? We want everybody to have access to care. We want everybody to have health insurance. But maybe we should really rethink that problem and say, it's not just access to care that is important, but also access to high-quality care. It's the quality of the care that you are receiving that may be even more important. So let our focus not just be on access, but how can we improve high-quality anesthesia care in low- and middle-income countries? And again, thinking about global health from a global perspective, this is really where we see the problem, right? The problem of morbidity and mortality, and also think about the challenges that low- and middle-income countries face. And that is where we'll focus most of the rest of our presentation on, is how can we help improve quality in low- and middle-income countries? And what you see here – sorry, these slides were not updated. We updated them, but these are old slides. But what you see in the map here is a distribution of where you have people, and the proportion of the population that has access to safe care. And you see in red there, including my beloved country of Cameroon, right down in the middle, it's really showing you very dense red areas where people have very limited or no access. Approximately 100 percent of the population doesn't have access to safe surgical and anesthesia care when they readily need it. Then you come to the west to the areas where you have more care. So this is really what we are trying to address. How can we make it so that most people have access to care? How can we ensure that everybody has access to high-quality care? And again, our goal here really being not just universal access, but universal access to high-quality care. So when we think about anesthesia outcomes specifically, there are three main things that I really want us to focus on. There are the problems of high mobility and mortality. We already know this, right? I'm preaching to the choir when I bring this up to your attention. There's a problem of limited access to surgical care. But now there is this additional problem of always comparing to the high-income countries. But I submit to you to say, well, maybe we should not just be thinking about this, but just say, what can I do? What can you do to improve this outcome? What can we do to change the narrative so that it's not just always, oh, they have low outcomes. Because again, what we continuously preach and what we continuously feed is what continues to grow. So if we switch from just focusing on the problems and start thinking about the solutions, then we are more likely to identify more solutions. And that is really what the Lancet report here, or the Lancet Commission on Global Health really did. And I'm going to share with you the six key messages from this report. And they came down to this. One, we already know this. There are global disparities in outcomes when you look at surgical care and anesthesia outcomes. So despite all what we have done, the disparities persist. So what can we do? Maybe we should start working on really bridging that gap. Two, historically, when you look at global health, a lot of interventions have really been focused on communicable diseases. A lot of efforts have been placed on really preventable, communicable infectious diseases. But little less effort has been placed on surgical and anesthesia care. And what we are now saying is, well, surgical and anesthesia care is an integral part of health care. And we cannot achieve universal health care without addressing this very, very critical component. For us, nurse anesthetists, what's not so good for patients is that the need for surgical and anesthesia care is only projected to increase. It is expected that, again, more and more people, especially in low and middle income countries, are going to be requiring surgical and anesthesia care in the next few years. Maybe because of cancer, accidents, injuries, cardiovascular disease. So again, for us, nurse anesthetists, it means there is job security. But for the patients that are really dear to us, our family, me and you, that is not so good. Because again, I will share with you that if there is one thing that anybody in a low or middle income country terrifies or is afraid of, it's facing surgery. If we think people here are anxious, preoperatively, wait until you receive a call from a loved one in a poor country like Cameroon who tells you, I'm going to go in for surgery. Then you are terrified because the statistics do not look good. The other key messages from the commission's report was really, again, access and affordability. And basically, they advocate for the fact that, yes, we have to do something to increase access, but also make it affordable. Because at the moment, it is very, very expensive to access high quality care. We have to use a multidisciplinary approach. And this is really where, for us in our association, we realize that as anesthesia providers, we are highly specialized, and we cannot go on mission trips without our physician colleagues in terms of surgery. So we needed surgeons to go with us. But what can we do independent of surgeons? So that is really some of the roots from the perspective from which we decided that, yes, we can do some things. We can educate nurses and anesthetists in Cameroon. We can empower them to provide high quality care. So that at the end of each mission trip, when we come back, we leave high quality providers who are going to continue the care after we've left. All of this would not be possible without changes in policy and action. So I'm going to put in a big plug on an app, so anybody who has done patient work to say, yes, they do make a difference. But let's really start thinking about what kind of difference does it make. So like I said, mission trips are good. But I just want to caution us that they can have unintended consequences as well. And again, not just to dwell too much on the problem, but to say, beware of this. Short-term impacts are good. It's easier to go in and take care of patients on a mission trip and then leave. But how do we ensure sustainability in the long run? And I submit to you that as you think about going on a mission trip and think about what you want to do, look for nonprofit organizations that are focused on long-term sustainability, whose goal is to focus on long-term outcomes or have long-term outcomes. I'm not saying you alone as an individual, you are going to change or achieve long-term outcomes. I'm saying the group should have long-term strategies. Creating this circle of dependence, there is this notion of toxic charity, where basically it says, if I help you the first time, you're going to appreciate it. If I do it a second time, you start creating anticipation. Then the third, by the fourth, fifth time, I'm going to create dependence in you. I'm going to create a belief in you that I'm going to always come to help you, especially if I am doing things that you can do for yourself. So again, as we go on these trips, I want to caution that we always have that at the back of our mind to say, let's come in and help, empower them, empower the local community, but not necessarily do things that they can do for themselves. Participation or participants may unknowingly perpetrate the colonial mindset. I think that speaks for itself. Again, we are not coming in as saviors, so I always say, let's check ourselves and our own biases to say, why am I doing what I'm doing, and make sure that we remain culturally, we maintain cultural humility, and maintain cultural sensitivity. I will share with you that even for us who were born in Cameroon, culture changes over time. When we go back to Cameroon now for mission trips or for any work that we do, we are innovating constantly, continuously, and we've done many mistakes where we will project ideas that we have been educated with and have lived in the United States from the last 20 years, which are not applicable in the local area. So again, I bring this to just say, as you think about doing a mission trip, there are some things to bear in mind. You have to take care of your own self. Going back and forth over and over and over again can cause a lot of distress, both emotionally and psychologically. And we want to make sure that our expectations align with reality. It's very easy to think that we're going to go and change the world, but when again, let's make sure that we create the excitation, the clear expectations. Again, I'm not saying mission trips are bad, let's be very clear on that. I am a big proponent of it, I support it, but it has to be done right. We have to think through. So mission trips definitely can make a difference if we're thought out. So at this point, I'm going to transition and let Dr. Tegwell share with you a little bit about some of the work that we are doing in Cameroon. About what we do in Cameroon, I know that most of you here must have heard the word Cameroon. Interestingly, recently when I was talking to some colleagues at work where I came from, and one of them say, is that where the guy from 90 Day Fiancé, I don't know, 90 Day Fiancé, is that what you call the show? And 90 Day Fiancé, interestingly. But we are known for many other very good things. Soccer is one of them, as well as the fact that we are very diverse people. Cameroon is called most often Africa in miniature. We are located at the armpit of the continent, but we do not stink. So just keep that in mind. Very diverse. We have both the tropical rainforest, a third of the tropical rainforest, as well as the savanna and up to the semi-arid or desert regions of Africa in one country. You have white and black sandy beaches in the same country about three to four hours drive away. We speak two languages, English and French officially, and about 250 different languages. So it's very interesting. The size of the state of California with all this diversity. As beautiful as we are as a country, we have our challenges in other things, including anesthesia. It's like 27 million. I think there are about 39 or 40 million people in California. We are 27 million, not as big as California in terms of population. As of our recent statistics, there are just about 500 or less nurse anesthetists in Cameroon, trained in very different settings, and under 100 physician anesthesiologists, serving 27 million people. So you can imagine how much challenge that is for the providers. Believe it or not, these are actual pictures from our mission trips. Those used ambu bags that are patched and reused and used, those endotracheal tubes and intubating blades that we donated and went back and saw them again being reused again and again. So there's a lot of shortage of equipment and supply in Cameroon when it comes to providing safe and effective anesthesia care. So that's where we came in. As people from Cameroon, nurse anesthetists originally from Cameroon, we wanted to do something. And as Edwin said, we're thinking about how sustainable our actions could be, not just providing medical missions with physicians. There's a role and there's a place for that. But we wanted to be able to make it more sustainable and create a foundational change that will help change the entire system of care in Cameroon when it comes to anesthesia. But we realized at the same time that we needed to create a strong foundation among our membership, building a strong community, fostering education and support among us, providing continuous educational training. We also have our own national meetings that we hold. We have a fall leadership conference coming up in October. And then we have our annual conference in April. These conferences are opportunities for us to strengthen our membership, providing educational opportunities as well for the members. And then we also do have a pipeline where we kind of curate our members from the ICU. We call it a future CRNA program. But we mentor them, prepare them for interviews, applications into schools, interviews for the schools that they go to, and also support them through mentorship through the CRNA route. And when they come out as well, we provide them with some kind of coaching, pre-employment coaching. And thanks to our members as well, we can provide them scholarships. While they're in school, they have to apply for those scholarships to support them during their educational journey. And within our association, in our approach to Cameroon, we operate on three key pillars. Professional development, we're looking into long term. We want to be able to provide the foundation for training and education for the members in Cameroon. So we started in 2021 to organize and plan with them the Cameroon, what we call the Cameroon Conference of Nurse Anesthetists, where providers come from all over the country, gather in one area for about three to four days to provide workshop with hands-on experience and practice for them. But we also thought it's important to begin to empower them, give them the opportunity to take ownership of their own training and education. So we help them create a national association that is now being legalized and being recognized in the country, actually being consulted now for issues relevant to anesthesia care and practice. And then we also thought of, why not create a change at the foundational stage? Yes, we can support the providers, but why not go where they are being trained? So we partnered with the University of Boya, which is an alma mater of Edwin and I, to form a master's level program in anesthesia and critical care where we have a cohort, just the first cohort of students now entering to their second year. So those are images and pictures, as you can see, for our first conference, which held in December of 2021. On the left there, you can see material that was donated by Dr. Rawls Foundation, mannequins. And to the right, once we train and educate them, we award them certificates. And then also to the left, I know you may not be able to see it quite far, but those are members from the team from the USA, as well as also members from the local leadership team that has been helping us. One of the things that we actually emphasized, beginning from the first conference, is basic foundational training in airway management and ACLS and BLS certification from the American Heart Association. We're very lucky and fortunate to have one of our members who is certified to provide that training. And that has been part of our training every time we go to Cameroon. Again, for the second conference, as you can see, our emphasis this time was regional anesthesia. And then we worked with students from Webster University as well. And then this time, we had some of our members demonstrating there how to use ultrasound to place both central lines and epidural in a patient. That was continuously the second conference. Again, as you can see in the picture in the middle, in the background, that's Mount Cameroon. It is the second highest mountain, if you are interested in climbing high heights, second highest mountain in Africa. That's not the summit you can see in the background. But the three conferences we've held have held at the foot of the mountain at the University of Boya. And in the top right-hand picture, they have this tradition. Every time we go, they have a conference. They like to dress us in our regalia. It's exciting, even for us who have not been there for a while. We're originally from there, but it's always that traditional. And this is the last conference we held in April of this year. There were about 60 participants. But interestingly, this time, we had over 50 students coming from different training programs within the country. For the very first time, we didn't really anticipate that. The students were very excited. And we didn't tailor most of our training to them. But the nurse anesthetists were also present. And we focused this time on obstetric anesthesia, because taking feedback from them, that was an area that they needed more training and support from. Again, we still focused on BLS and ACLS certification. And as you can see there on the left-hand corner left, that's Alan, who is always helping us with that. He's a guy who is certified to, he's an SRNA, by the way. He's always going on mission trips. We're really grateful for his support. And he's demonstrating with the intubation of a pediatric mannequin. And then on the right-hand side, that's Dr. Agbo, who is sitting right here. He's helping with ultrasonography. In the hospital, one of the things that we do is not only provide a training in a university setting and do hands-on demonstration, but we actually go into the hospital to work with the providers who are there. That's also the anesthesiologist, who is Dr. Bereni in the background there as well, who helps us. She's, I think, one of the few anesthesiologists in that hospital. But she also teaches in our program. So we're very grateful for her help. We partner with the University of Bowie, as I mentioned before, with the creation of the master's in anesthesia and critical care medicine. The students of the first cohort are standing behind there with the donated books, which, thanks to Dr. Aroke, he did an online campaign. And some of you might have donated books. So we are very grateful for your support. Those books are now into their hands and can supplement the material that they have from their training and education. We also provide lectures and help with designing the curriculum for these students and do provide mentorship to the students as they go through their programs. So it's very important that we continue to support them. This program, yes, it is a university program. But our association, thanks to the support of our members and our donors, can support them because it's a very expensive venture, both for the students and the university. APICS anesthesia review also granted us access. We're very grateful for that. So our students can now have access to high-quality training material. Just like Edwin said, it is not just about access, but quality that we are trying to emphasize in Cameroon. And as part of our mission to increase their capacity, their foundational capacity of practice, we thought it was important to also link them with international partners and practitioners from other countries. And so this year, in the inaugural of the PANA, which is a Pan-African Association of Nurse Anesthetists, which is a branch of an arm of IFNA, the International Federation of Nurse Anesthetists, we sponsored some of our members in Cameroon to participate in this conference and a student leader from our class from the university program to attend this inaugural conference. You can see those are the members. Dr. Aroke is here in Cam, the picture on the top left-hand corner, as well as some of the members from Cameroon and the USA. And then on the right-hand corner, that's the president, the national president dressed in Cameroon regalia, the national president of the Association of Cameroon Nurse Anesthetists. So what are the lessons we've learned? What comes out of our experience? We are a young association, but there definitely are some key points I would like to share with you. The first thing, as Dr. Aroke pointed out earlier, is to realize that charity could actually be toxic. There is actually a fine line, very subtle but significant, between appreciation, which is what they express the first time you try to offer a hand to help, and dependency through anticipation, expectation, and belief. So we are aware of this. Our goal at ACNA, the Association of Cameroonian Nurse Anesthetists in America, is to thrive to break this chain. It is not easy. The intention is always good, but sometimes in the application, we may tend to ignore some of these subtle changes that may happen because we get caught emotionally, and our desire is always wanting to do good. So the first thing is never do for the community what they can do for themselves. It is very important to recognize that, yes, we have more knowledge, but they operate in a different environment. We cannot carry our experience and training and impose, superimpose upon their daily practices. When we leave, they have nothing else. So the goal is to always empower them through active participation. We involve them in the many things that we do so that they take ownership and they can contextualize the training that we provide. Know your why. It's very important to recognize why we went there in the first place. When we go there, we know, we plan, but once we start working with them, we say, oh, poor people. They don't have this. Oh, well, let's provide this. We just carry all of our love and pour into them and then stop the growth and the learning that can come from them if we just let them own part of the training and educational process. But also, it's very important to recognize that medical missions do have inherent in themselves some challenges, especially short-term medical missions. There's a limitation to how much medical equipment you can carry. So I think we attended Dr. Henker's lecture this morning. He also does quite a lot of these medical missions focusing on education. And he actually emphasized that there's no need to think of bringing so much material because you carry it there. They're not used to this lot of material. They're experts in working with scarcity, as Dr. Aroki always says. We are experts in working with surplus, too much. But bringing so much material there, it's also not feasible. You can't take everything. We couldn't transpose the OR from here to Cameroon. So keep that in mind. There's also a culture and language barrier. Yes, we are from Cameroon, but also we have not been there for about 20 years right now. So when we go back, we have to recognize that things have changed. The educational environment, as well as the practice culture, is very different. We do recognize, and it's very important to realize that sustainability is not necessarily guaranteed. When we do short-term medical missions, there's no telling that whatever changes or education that we provide will be sustainable in the long term or will stay with them once we leave. So there's a chance that we, by doing that very often in short-term medical missions, there is an expectation they were waiting for us to come and replicate whatever we did the previous time. And then it's also important to recognize, like I mentioned before, we went with SRNAs from Webster University. It's important to recognize that they did not have the full scope of practice. So when we go with them, we have to monitor and watch over them so they don't step over their competencies and potentially cause harm. Logistics is an issue. We actually shipped ahead of time material that we wanted to use for our training and education to Cameroon in both the last two medical missions, and they did not arrive in time. And so it's very important to keep that in mind while you're planning to go to a medical mission in a low- and middle-income country. Accommodation could be an issue, as well as coordination with health care authorities. And that actually links me to cultural experiences. Dr. Agbor here remembers when we went to Cameroon this last time. On the night of the conference, starting with all the guest speakers and the dean of the Faculty of Science, Brady, we did not even have the banner. 12 midnight, there's no banner. But we have already been promised, oh, everything is fine. Don't worry. Everything is OK. And then even at that night, midnight, so that's fine. We'll bring it in the morning. So they have a culture, a way of just being comfortable, even with uncertainty, that we couldn't manage. And I wanted to go that same night to bring it on. And we had to intervene to make some changes in order to get it to happen, because it was still not going to happen. But for them, it's OK. So some of these, we really have to be humble, but also know how to communicate with our local partners. We also have to recognize that there is a challenge of impacting the resources once you get on the ground. They make a lot of changes in the OR on their schedule. People travel, cancel their vacation time to accommodate us on our medical mission. So these are people who are already resource depleted. And so when we go there, we have to be very cognizant and be respectful of that. And also, there is a lack of standardized measures or processes of evaluation once we go there to really find out whether what we're doing does help in the changes that we seek to provide. So in the background of all this, I think the Broadchart Declaration, as mentioned earlier by Dr. Aroki, seems to really be a good foundation or a guide that can help in the provision of short-term medical missions or make it even much more sustainable in the long term. The first part is to recognize or approach it as a mutual beneficial relationship with the local providers, especially if you are going there for foundational training and education. It's a bi-directional process. It's not an I know and I'm going to tell you what to do. It's a learning process on both ends. We seek to empower the host community. It's very important to let them do what they can do. And then we might support or strengthen them to do what they can be able to do better in their own environment. And also, it's important to, this declaration talks about making sure that the programs or whatever help we're giving is sustainable in the long term and builds capacity. And we have to also comply with the local laws and regulations. The way we practice here is not the same as they do in low and middle income countries. And we have to be very humble. Yes, there's a tendency to think that because we come from a stronger culture, America is very good at selling itself. But when we go there, we need to be humble in order to create a long-term impact. And also recognize that we have to be accountable to our actions. These people, yes, they may know and have little. But we also have to be, as professionals, recognize the importance of being accountable for everything we do there. We are from Cameroon. But as I mentioned before, it's been a long time. I go there often. But I don't think that we do manage the nuance of the changes that occur. I didn't practice anesthesia in Cameroon. I studied languages, English and French. I came to the United States and did anesthesia. So I don't know the environment quite well. So it's good to also have this posture of self-reflection, being open and receptive to potential changes that may be suggested by the local providers. When we design our programs and our missions, we listen to them. We incorporate them and find out what's important and relevant to them. And we actually include them into the programs and the presentations slowly. Because we are trying to increase their capacity. We bring them into both the training, the planning, as well as the management of our programs in Cameroon. What is unique for our program at the Association of Cameroonian Nurses and Anesthetists in America is that we are originally from Cameroon. So we really do have historical ties. And as Edwin was suggesting earlier, it does provide an advantage for people who come from low and middle income countries to be able to go back home. It's easy to connect. It's easy to understand the language of the authorities you may be wanting to deal with and understand even how to get them to help themselves. I remember even on our last trip when we went back this time in April, in even laying out who has to speak before the other person, you have to be very careful. Because if you step on toes, your whole training program might be in jeopardy. And even how to address somebody, doctor, how to place the titles. And the titles are not necessarily the way we do that here. So even how to relate to them, talk to them, it's very important. And you can even, in ignorance, call somebody by their first name, and you're in deep trouble. But we are aware of that. That's an advantage that we have, even though it doesn't give us a blanket protection. But that's something that we have. And it gives us the opportunity to say, how can this experience and our background provide some form of a blueprint that you might be able to replicate for improving anesthesia care and outcomes in low and middle income countries? So the first suggestions we will have is to organize yourself into a reliable, professional, not-for-profit organization that has that focus, of course. It has to have that focus. And we are also very, very specific in terms of our mission. Yes, we can partner with other people. Yes, we can liaise and provide adjunctive service. One of our members, very active, is currently in Cameroon again, and Cam, whom I mentioned in the photo, is a founding member, but also very active. He's working with a medical mission. But when a uniquely AGNA initiative is operational in Cameroon, it is only anesthesia. It's important to identify local partners. As I mentioned before, not only did we work with the University of Boya, with whom we have a master's in anesthesia and critical care program right now, but we also helped to create, found a session of Cameroonian anesthesia by the Cameroonians. So they are leading it. They have a structure, a leadership. We just had a brief overview of their meeting that they had this afternoon with their executive. So they are doing it. And it's important to strengthen their capacity so they can take over the reins and claim ownership of what they do. And as I mentioned before, empowering them through these conferences. We sponsored them to Kenya in June of this year, June 18 to 20, I think. And then also in our partnership, helping them have capacity-building workshops, and also focusing on leadership in the long term. Because these are not just what we're doing. We're looking at it as something that is going to be sustainable in the long term, both for us in the United States as well as for them in Cameroon. In the United States, I have to say that I took over from Edwin as a president. And I'm actually the last of the dinosaurs of the founding members. And a new leadership breed is coming within our association, coming from our pipeline of mentors, SRNAs. So we want to take that same culture and tradition back to Cameroon to see how they can continuously build and sustain the initiatives that we do in Cameroon. So capacity-building, super important. Foundational training with a master's program. Liaising with the International Federation of Nurse Anesthetists and sponsoring them for other exposures that will help increase their capacities and practice in Cameroon. And it's also important to have ethical standards and work with the local laws and regulations that have to do with regulating that practice. So it's important to when that's why we're forming that association. The Association of Cameroonian Nurse Anesthetists is created by Cameroonians, reflecting the local laws, has to be approved by the government, so that when we go there, we work within that umbrella so that we don't go there and impose what we know from the United States, which may not work with the local environment. How do we assess our impact? After each conference, we work with the local association as well as our organizational committee to get feedback through surveys and also communications with them post-conference. We have meetings by ourselves. We also meet with them, what did work, what did not work well, in order to recognize what we can make and adjust for the next conference. Future plans for us at AGNA. We currently are still, of course, working with the University of Boya to support them in strengthening the foundations of their program, supporting the students. We are seeking a memoranda of understanding with different institutions that provide health care in Cameroon. Beyond the University of Boya, and also seeking to see if we can support the nurse anesthetists in Cameroon for the very first time. Again, in this philosophy of not just providing fish to them, but teaching them to fish, we've organized three first conferences. Now they have to organize for the very first time their own national conference, Cameroon Conference of Nurse Anesthetists in 2025. And our goal is to make sure that they can take the reins and we will continue to support them, but they need to stand on their own feet as we provide a foundation for sustainable initiatives in Cameroon. So I'm just going to quickly summarize some of the key points and then open it up for discussion and questions. So in terms of thinking about the how and why and what we've done, again, we have used this global sustainable approach to what we've done. But when you really come down to it, I think there are key lessons that we've learned. One is, yes, all of these challenges are there. But I think for a moment, if you are thinking about embarking on a project like this, do not take anything for granted because it takes a lot of logistical planning. One, when we said we're going to go on the first mission trip, for instance, we had thought about doing, again, an educational conference. But what kind of content are you going to deliver? Are you going to start on pathophysiology and pharmacology and physiology? Are you going to do airway management? And we said, okay, maybe let's start on the very basics. What is it that is essential for every nurse anesthetist to know? And then we thought, okay, these are already practicing providers. Would they think mannequins are too lame? Should we use mannequins? Should we not use mannequins? Then again, we began in consultation with them and realized, well, even though they are already providers, just like us here, continuous education is something we all can continuously benefit from. So we made a decision that it would be important for us to acquire some mannequins, some models where they can actually practice and go back and start from the basics. So these are some of the key things that we did during the first mission trip and the first conference. And I will tell you that by consulting with them and involving them in that decision-making process, it turns out to be the most important thing because there are multiple, multiple steps along the way that you have to think through. And the only way you can make sure that you do not step on so many toes is by involving your local partners. Empowering them has been something that has been very tricky for us over the last few years I've worked with them. Because as you can imagine, you have a group that, for instance, for us serving as a president here in the United States, then creating another entity in a different country and then kind of partnering with them but also mentoring them at the same time. So it's like you take two steps ahead and they say, okay, now it's your turn to take a step. So for instance, when we created the association, we said, okay, let's register the association so that it becomes part of the IFNA. That was something which was very, very important to the anesthetists in Cameroon to make sure that the country is represented at the international level. But we also realized that it's an easier way for us if we're going to affect education long-term. The only way is to make sure that we can give them a mechanism to hold each other accountable and educational programs accountable to say, are you meeting the international standards? So by facilitating that process of creating the association and facilitating the process of registering with the IFNA, now they have an external mechanism by which they can hold each other accountable. Now they can all say, well, the IFNA standards are this. This is what a nurse anesthetist should be doing. This is what the educational training for nurse anesthetists look like. And it has become a very easy mechanism for us to go back and say, can you guys work on these outcomes? When things happen now, oh, for instance, when we're creating the program at the University of Boyle, we could easily say, okay, you want a master's program? This is a sample curriculum from the IFNA for what a master's program should look like. So it should include X, Y, and Z. And it has really helped to empower them in that sense. Also, when you're thinking about local empowerment, making sure that we are very efficient with our resources was very important. Because, again, initially the mindset from a lot of mission trips was you bring in equipment, you use it, you donate, and then you return. Then the next time you come in again, bring in a whole set of equipments, you use it, you donate, and you return. But we realized that that was not gonna be very efficient. So we started looking for a mechanism to say, can we have core equipments in Cameroon that we can use from year to year? So there are some equipments that we give away, but there are some that we retain there so that when we go back year in and year out, plus now some of the local institutions can come to us and borrow equipments from us. So long term, we are now looking at the possibility of creating a center for anesthesia excellence in Cameroon where we have resources for training and also equipment that other institutions can come and borrow from us to use. In terms of building and partnering with other countries, when the Pan-African Conference of Nurse and Anesthetists came, as Dr. Peque mentioned, we thought it was very important that Cameroon be represented in the setting in Africa. So we sponsored about eight of them to travel from Cameroon to Kenya to attend the conference. And one of the key outcomes from that conference has been now the creation of an African Nurse and Anesthetist Association. And so now we had about 18 countries represented at that conference. And I just had a conference call with them a few days ago talking about developing the bylaws and the constitution for this new association, which is going to incorporate all of Africa. And this is very important because, again, they are the ones who can police each other. They are the ones who can set the standard. And the challenges are the same or very similar across Africa. So why not bring all of the resources together, develop curriculum, which is going to take into consideration the challenges that they have and what their strengths and weaknesses are? So again, these are some of the key strategies that from ACNA we have been looking at in terms of, how can we make sure that this is sustainable in the long run? Of course, we do all of this, as Dr. Christian mentioned, within the backdrop of making sure that it's ethical. So ensure that we are building mutual partnerships. So it's not just us coming in to help and save them. We are not coming in as saviors, but we are coming in to say, how can we work together to solve this problem? What is the best way? From our perspective, this is the best evidence. What are you guys saying? Do you see what I am saying? Local empowerment, sustainability, maintaining that cultural humility. I cannot emphasize that long enough because it is very critical. Ethical standards are very different. Ethics is something which is very challenging in terms of even us here in the US. But let alone now transpose it to somewhere with very limited resources. And maintaining accountability, we also have to be accountable to ourselves and to our local partners. So I just want to share with you this link. If you are thinking of going on a mission trip, it has a very good frequently asked questions sheet, which I would encourage you to check on it. It answers a lot of resources, gives you a lot of information that you should be thinking about if you want to embark on any mission trip to a low and middle income country. But finally, I will not end without really giving you a call to action. I'll say again, disparities in anesthesia outcomes between different countries are well documented. We already know that these problems exist. We don't have to come here to preach to you, to tell you that there's a problem. We are aware. But what can we do? We can all support and participate in an ethical way. That is the key word here today, is to make sure that we are doing this ethically, that we are doing this with the mindset of creating sustainability, with the mindset of creating long term outcomes, and making sure that we have sustainable impact in these underserved communities. And these are some references. And we'll have about 10 minutes for questions and comments. And I will invite Dr. Ekwe to join me. No, not yet. It's good now? Yes. Thanks so much for your presentation. My name is Gary Hu from Virginia Commonwealth University. So I used to be actually a nurse anesthetist in China. So I personally, I benefit from the international collaboration. So 15 years ago, VCU reached out to us and to create a collaboration to develop the international recognized nurse education program in China. And we developed the first one. And we extended it to many others in China. So now I'm a faculty member at VCU and I serve as a director of the research and the global outreach at VCU. So I feel international collaboration is great. It's always challenging, influenced by many other factors. So now we have some collaborations with the associations and also institutions in China, Germany, and Liberia. So we are trying to really engage our students in the process. Because students are very interested in it, they would like to engage in the international collaborations. But because they are very busy, you know, they already have many things on the plates. So I wonder whether you have any strategies or any recommendations for us, how we can bring the students or engage them in the process. Thank you. Sure. So I would take that. I think one of the key strategies in engaging students is, for you as a faculty already in the program, that is a big plus, right? So you have to really work with the faculty to make sure that what is going to count when that student takes that time and go out to a different country. So for instance, is this going to be vacation time or is this going to be clinical time? It comes down to making sure that they are supervised. Because for it to count as clinical time, the student has to be supervised at all times. So those are some of the considerations. Another big barrier we have seen, which we were lucky when we were partnering with Webster University, has been the funding. A lot of crowdsourcing to support funding these days. So if your students are already funded, another strategy could be to make sure they are well funded. If the funding is already covered, then you have to make sure, is it the right student? You cannot take a student who is struggling. So I would really say strategies will be right student, right time. So right student means they have done their DNP project, they are doing well in the program, they are clinically strong. Right timing means, OK, generally speaking for us, it's a senior who is almost about to finish. And secondly, do they need this to count as clinical time or not? And where for the most part, we say it should not necessary. It shouldn't be necessary. Yes, it can count if they are supported. And if, again, the program director and the clinical coordinators are going to allow it. And of course, there is a slew of other COA requirements behind that. But that is what always has been our strategy. We don't have, there are plenty of students who are interested, I will tell you that. But you just have to make sure it's the right student. Because it is very demanding. When they come back, it doesn't end. They cannot just come back and go back to clinical and life continues. They will need that time to transition before they leave and upon return. If I may, just one more thing. Quite true what Dr. Arreka said. One of the things which we do, which we enjoy in our structure is the relationship between the, we have a mentorship relationship. Most of our students are paired with a mentor who is part of our leadership or in a committee. And so when a student might raise an interest, like one of our students who constantly goes to Cameroon to help us with our medical mission, we talk to the mentor to assess. It gives us a bird's eye view. So the student might be excited and interested. Sometimes they may caution us, like, oh, hold on. He's not really strong yet. He doesn't have this, you know, beyond what he just said. That is also an extra layer of caution. Because the interest of the student is also very important, not just his desire, his or her desire to go on medical mission. Thank you. Thanks so much for sharing these great suggestions and strategies. I think I really appreciate your great efforts to promote the international nurse anesthesia workforce. That's great. Thank you. Thank you, too. Dr. Tegui and Dr. Iroki, thank you so much for your presentation. Very insightful. One question I had for you in terms of you talked a lot about working with local groups and support, which I think is, I agree with you, very important. I was wondering, what types of interactions have you had with Ministry of Health? You did allude a little bit to scope of practice. Is there anything in terms of policies that you've worked with Ministry of Health on in terms of nurse anesthetists in Cameroon? And have you had any barriers or successes in terms of working with the Ministry of Health? OK. I'll let you go. OK. All right, let me start. I'll take that first. That's one of the reasons why, thank you for the question, Dr. Henke, and I followed your presentation earlier, quite informative and educational. One of the reasons why we created a local association is also they operate within the National Board of Nursing, which has codes of ethics, practice standards. So the association is within that scope of practice. And the way the practice is defined by the Minister of Education. As to Minister of Health, Public Health, and one other thing is that Cameroon is very complex. I'm sure you've worked with middle-income countries. You do recognize that politics is not direct. It's not very clear. There are several ministries that regulate the practice of anesthesia in Cameroon. It's not very clear which one you have to talk to, like different heads of the same snake. But what we benefit from is the fact that that association has a council, which is the Council of Nursing. But we haven't had any direct conversation. We've attempted before with the Minister of Health. But it has not been, unfortunately, very successful. We've not gone that far. But we are grateful that they provided us an avenue, as we are operating right now, where we be on the side and implement what we can. And then working also with the University of Boya, which is, we are very grateful. The dean of the Faculty of Health Sciences is very supportive. And so in our partnership with them on the educational ground and then with the association in Cameroon, we tend to navigate so far our ability to influence the practice in Cameroon. Dr. Aruke, I don't know if you have something. Yeah, so a few policy things that we've really tried to influence was, so about two years or three years ago, Cameroon decided that they're going to look at the scope of practice in nursing. By then, that is when we're trying to form the Association of Nurse and Nurse Studies. So we did definitely reach out to the leaders of the Nursing Council. And the relationship between nursing and anesthesia is very similar to what we have here, where I say anesthesia is kind of like stepchildren. So we try to encourage the nurse anesthetists in Cameroon to be involved. We reached out to the minister directly in Cameroon. It didn't work. Even when he came to Canada, we sent somebody to go meet him in person to try to discuss some of these challenges. The best we have gotten out of them was, one of the biggest challenges we had as a group was, we could not even have some of our members have visas to travel to Cameroon to do mission trips. So what we finally have heard from the minister was, well, if you are going to Cameroon for a mission trip and you are as a health care provider, then it has helped us to facilitate that process. In terms of scope of practice, that is something that we are still trying to wrap our heads around. But again, it's something that we'll probably be reaching out to you for other strategies on how to go about it. But it is one of the most difficult challenges that we have at this time. Thank you so much for the work that you do. And it's great that you're working on advocating for nurse anesthetists in Cameroon. So thank you again. Thank you. Hi. So actually, this was something I had kind of looked into. I'm originally from Ethiopia, in case you didn't guess. And I guess my question was, when I brought it up with, I guess they were nurses and administering anesthesia because they were pulled from nursing programs to be trained as a certificate, maybe, at the time when I asked. I didn't really ask too much of it. But I guess my question is, in Ethiopia, it sounded like close to 98% of the anesthesia is provided by nurses. So if that's what's going on, then how do you even define scope of practice? Because you don't have a physician anesthesiologist administering. So is that the same, kind of? I would say Ethiopia, coincidentally, is one of the unique countries in Africa in terms of practice of anesthesia. From my understanding, from talking to people in Ethiopia, they have up to about six levels of providers of anesthesia in Ethiopia. You have nurses who are administering anesthesia, but you also have non-nurses, right, anesthetists. They call themselves anesthetists, who are technicians or certificate trained directly to administer anesthesia. So the challenge is, which has, they have already brought this up as we have discussions about the African Association of Nurse Anesthetists, which is, are you going to include us who are not nurses? Or are you going to only require that it has to be somebody who went through nursing to become an anesthetist? I would say my approach or my view of that is, I look at the way the IFNA looks at it, which is, again, non-physician anesthesia providers. However, what we have done in Cameroon, too, is when we were writing the bylaws for Cameroon, I used the long-term view. I said, OK, we're going to be all-inclusive of everybody. But at that time, that was like 2021, 2022. We said, but from 2032, so again, for about a 10-year period, if you are going to be a member of the association, you would have had to go through training from X, Y, and Z. And that is the catch where we said, you have to have gone through re-training. We are going to grandfather everybody who is already providing. But from 2032, we will no longer admit members who did not go through formal training. When we are working with the University of Boya to start the anesthesia program there, we also made it very clear that, OK, we are not going to admit anybody who doesn't have a bachelor's in nursing. Because initially, the suggestion was to admit both students who have a bachelor's in biomedical science, because they are strong in science, and nurses. And we said, no. In two years in a master's program, you do not have enough time to train somebody with the basic nursing and anesthesia. And that was one of the big, strong red lines for me, which we had to say, no, it has to be somebody who has a bachelor's in nursing. So those are some of the strategies that we are using, where if you change it today and say you require everybody, it will not work. But by saying, OK, we will be inclusive of everybody over the next 10 years, then requiring maybe 2035 to belong in this association, you should have gone through this kind of training. Maybe more amenable. At least, it was acceptable to the people in Cameroon at that time. Thank you. Thank you. Mary Mugabe. Hello. Oh, Mary. My name is Mary. I'm from Kenya. I'm not practicing in the US. So whatever is being discussed here is what is happening in our environment. But that's a great presentation. And for me, it's just to comment on a few issues. This is exactly our environment. We are from diverse candors. And that is who we are, because our people have to get safe anesthesia. So my take is we start slowly, even as we develop our people. That is our practitioners. Though we are coming from diverse groupings, I think, and I believe with the time, we can correct this. So we start with the very, very basic information. That is trainings. And then from there, we get the young people that can be able to go through school, be taken through very, very strong programs. And eventually, though it may take time, we'll have the correct cadre. Look at the whole of Africa. Sometimes you go to different countries, and you are like wondering, now, whom do we call this group? But that is the young people. Those are the people who are providing anesthesia in those environments. So do we dismiss them? No. We can't dismiss them. So where do we start? Down there, slowly, basic, basic skills and information. But at the same time, with the correct focus. Where do we want to take these people? Are 10 years to come. Do we want to have the same cadres? No. We want to have a different grouping that will be well, well-educated. And that is where now we develop them. And as we start of this now, because I'm looking at the time we come together as African countries and have our standards. But it's not going to happen tomorrow. Definitely it will, but not tomorrow. So it's for us not to give up. It's for us to push very hard with the people of the right mind and the right interest, and we will find ourselves there. Now for you people coming from this kind of environment, as our colleagues have said here, when you come to our environment, even if you tell us this is how it is done, we only do it while you are there. But once you exit, we go back to our old practice. So it's for us to come together, to join together with you, and you make understand as to why do you have to do this. And then even after you exit, you do the follow-up. And then with that kind of follow-up, definitely we'll have a change of our mindset as we understand why not to do it, but the reason behind why we are doing it. And then after that, then we like take a few people, work with them, them that are very interested and are seeing the future of their own countries, you develop them in one way or the other. And I like your ideas. We should not live on charity, because a day will come and you'll not be there for us. So it's for you to support us. I'm a big believer in being supported to do what I can. Not you do it for me, but you support me and you teach me how to do it. And then once you leave, I'll continue doing it. So for us, it's about education. It's about education. If you come to where I am, don't talk to me about anything else. Education, education, education. And once you leave, education will continue. 10 years down the line, education continues. In Kenya, nurse anaesthesia started back in 2006, and we borrowed it from US because we had an anaesthesiologist who had come from US. And this person, what he did, when he came and looked around what was happening, he showed to us the idea of nurse anaesthesia. And it didn't just happen the following day. It took us 10 years to convince the Ministry of Health, the Nursing Council that it is doable. And finally, when everybody now got the idea and the curriculum was done, this person never left there to see that 20 years or 10 years down the line. But what did he do? He took the first class, the second class, and I could tell even with the second class, he is looking at a strong person who could take over. He has now exited the country. Nurse anaesthesia training is going on. So that is the whole idea, yeah? You develop people of the light mind. You strengthen them. And then education will continue. We are not where we are, but definitely we are somewhere, and we are moving somewhere. We can see the light. We will move somewhere. We don't have masters, but even at the level that we are training, we have a strong curriculum, and we are still fighting hard to find ourselves even do a nurse anaesthesia master's curriculum. We have a scope of practice. And also, we didn't just wake up one day and got a scope of practice, but how did we approach it? We involved, again, stakeholders. They are anaesthesiologists. Definitely they didn't want us to have it. They were really out to water it down, but we are the people who don't give up. So we involved them and many other stakeholders, and we have just done a review of our scope of practice. And the other nursing practitioners, they never had a standalone scope of practice. It was only like one scope of practice for all the nurses in Kenya. So we were the first group to go out and have a standalone scope of practice. And so many people are trying to follow what we do. We got our scope of practice. We have been doing our conferences. I think we have done 12, and the other group were just there. So we try to challenge ourselves. That's why I'm here, to see how you are doing it. And then definitely I will take home something and sell it to our people. Because as we keep on saying, we are a third world. Yes, we are a third world, but we can't keep on crying that we are a third world. We have to change something and we have to move on. Thank you so much. Thank you. Thank you. All right. Thank you so much for attending the session, all the great discussion.

AANA app

CE credits

2025 Annual Congress

Nashville

abstract submissions

anesthesia care

Cameroon

global health challenges

Association of Cameroonian Nurse Anesthetists in America

educational conferences

sustainable healthcare