1. Stephen Bickler, MD Associate Clinical Professor of Surgery and Pediatrics University of California, San Diego

2. Pediatric surgery in The Gambia Main government referral hospital  All children aged <15 years treated for surgical problems during 29 months  Inpatient (n=1726) -34,625 total inpatient days -Average census = 40 pts  Outpatient (n=6606)  Operations (n=1347)

3. Spectrum of surgical conditions Bickler et al, WHO 2000

4. Estimated Need for Surgical Care Bickler,et al, Trop Doct, 2003

5. Risk factors for surgical deaths Analysis of pediatric surgical deaths (n=88) Univariate and logistic regression Highest in-hospital mortality Children aged < 1 year (OR 2.9, p=.0005) Burn diagnosis (OR 5.2, p <.0001) Residence outside the Greater Banjul Area (OR 6.6, p =.01) Female sex was associated with an increased risk of death (P=.065). PAPSA, 2005

6. Incidence of common conditions Number of Cases in The Gambia Incidence (per 10,000 children <15 years) ExpectedObservedCaucasian living in the USA African living in the USA African living in The Gambia APPENDICTITIS50616*20100.6 # PYLORIC STENOSIS 910*3Less common - For population of 270,000 living in close proximity to RVH during a 29 month period. *Chi square P value <.001 # 1/30 th the rate for Caucasians living in USA Bickler, et al, Ped J Gastro Nutrition 2000

7. Surgery in settings of limited resources

8. Strategies for improving care The role of pediatric surgery in developing countries remains poorly defined Health care policy does not reflect the surgical needs of children Major problems with delivery of care Long distances Limited facilities, equipment, human resources Shortage of qualified pediatric surgeons … the challenges for pediatric surgery in developing countries are those of definition, policy and delivery. Bickler & Rode, Bull WHO, 2003

9. Strategies for improving care  Focusing our efforts  Demonstrate the need for pediatric surgical care  Define a cost-effective package of pediatric surgical care  Improve pediatric surgical care at the community level  Strengthen pediatric surgical education Bickler & Rode, Bull WHO, 2002

10. Career tips Travel as much as possible Always go for the best opportunity, even though it might not be the most direct route to your eventual goal Get as much overseas work experience as possible

11. Career tips Learn a foreign language Acquire formal training in tropical medicine Publish, publish, publish! Create your own foundation

12. Career tips Identify mentors Get yourself into a position where you can influence the bigger picture Don’t be discouraged by traditional thinkers Take risks in your career Have fun!