Claire Lyon is a midwife at Liverpool Women's Hospital. She's now working in a clinical research role. Claire has previously worked on a project exploring the lifestyle attitudes and behaviors of pregnant and postnatal women. She completed a Masters of Research at the University of Portsmouth in 20... Looking at the health outcomes of the whole of her midwife, she proved the use of an RCTP of an intervention to prevent post-traumatic stress disorder symptoms in women following a traumatic birth experience. Her professional interests include women's birth experiences and perinatal mental health. I'm going to turn the presentation over to Claire now. Thank you so much for joining us this morning, Claire. Thank you, Cecilia, and a big hello and thank you to everybody else who's joined the presentation today. And just a big warm thank you for joining us to celebrate this fantastic day of celebration for midwives around the world. I think it's true fantastic. And without further ado, I've had a fantastic introduction there from Cecilia. So thank you for that. And I will just crack on now with the presentation. It should take around 25 minutes, maybe, and then there'll be plenty of opportunity for discussion and questions at the end, okay? So today's presentation relates to a project that I was involved with about 18 months ago now. And the project was a European-funded project looking at the lifestyle, behaviors, and attitudes of pregnant women in new months, so up to 12 months postnatal. And the postnatal Pilates project was delivered as part of a campaign of activities to help improve the lifestyle of pregnant and postnatal women. Other activities that we also developed and we delivered included free swimming sessions and a walking group, but by far the most popular activity for the postnatal Pilates sessions. And in fact, it was so popular that the instructor that we worked with has now gone on to continue the course in a slightly different part of the city. But yeah, it just shows that these things can take off and there's some really positive consequences as a result of the project. So in the presentation, I want to cover some literature around Pilates in pregnancy and the postnatal period. It's not designed to be an exhaustive review of the literature, but just some highlights to get you started and steer you towards further reading should you wish to delve into this area much more in the future. I'll talk about the details of the program, so how we designed it and how we delivered it before presenting the feedback from the study. I'll then talk in slightly more general terms about things that you may wish to consider if you choose to run a course of this type or any other course aimed at postnatal women, for that matter. I then want to give a brief overview of the current guidelines that we have here in the UK about exercising in pregnancy and beyond and that will lead us on to time for discussion and question. And it will be great if we can hear your experiences or your thoughts on Pilates either in pregnancy or postnatal or any other exercise or lifestyle advice that you routinely give. As Cecilia said, we'll try and keep the discussion towards the end, but please do raise your hand if you've got something that you want to say so you don't forget when it comes to the end. All right, so before we continue looking at Pilates because it was best to just describe what Pilates is and try and explain it for those who perhaps are unfamiliar with it, Pilates is a low to no impact mind body exercise system. It encourages participants to focus on their breathing, concentration and their core strength, making it nearly an ideal exercise choice for pregnant and postnatal women. In women's health, it encourages the pelvic floor muscles to work with the deep tummy muscles to build up stability and strength in a trunk. And we know that a well supported trunk will help to protect the back and it may help to lessen any lower back pain women are experiencing. So you can see why we chose Pilates, a fantastic activity for women in the postnatal period. So as I said, I'll just start by introducing you to some of the literature that's been and some of the research that's been done in this area, but there is only a small amount of literature about the effects of Pilates and postnatal recovery and in particular there's a shortage of good quality randomized control trials. There's a number of articles explained about postnatal exercises and how Pilates can help with recovery in the postnatal period and pelvic floor exercises. But the studies that I pulled out to just run through with you today focus on a whole range of postnatal related symptoms so they look at how Pilates can impact on postnatal depression, on pelvic floor tone, on core muscle strength and on sleep quality. Okay, so there's about five studies that I were able to pull out for you coming from all over the world, which is really appropriate considering today's International Day the midway. And as I said, they looked at various different things. So we've got studies coming from India looking at core muscle strength. So in that study they were looking at the effects of a MAP-based Pilates exercise against conventional exercises on core muscle strength in postnatal women. So there were 50 women randomized to receive either Pilates training or conventional exercises and the women in these groups completed 30 minutes of exercise six times a week for three weeks. And what the study showed was that there was a statistical significant difference in both groups of women. So both groups of women benefited. However, Pilates groups show a statistically significant greater core strength as compared to the control group. So those three conventional exercises. When we move on to the pelvic floor muscle randomized control, there's two of those. And I think that probably makes a lot of sense considering the area of the body that Pilates is focusing on. So there's a couple of studies there. One where they talk 62 women again randomly allocating them to receive either traditional physiotherapy or Pilates therapy. And both groups showed improvement in pelvic floor muscle strength. So there was no difference really between those groups, nothing statistically significant. Another study was looking at Pilates exercises again on pelvic floor muscles following childbirth. And there were 120 women suddenly twice as many women involved in this study. Half again were allocated to receive Pilates and half were in the control so they took measures of vaginal resting pressure, systolic pressure, and duration of traction. And in the Pilates group, those pressures were greater. Not statistically significant, but still there was some difference there. So again it shows Pilates when used can make a difference. Another one looked not only at the pelvic floor tone, but also postnatal depression, which I found was really interesting. Very, very small though. There were only 17 participants in this study. And participants exercised three times a week, between 40 and 60 minutes for seven weeks. And what they found were that vaginal contraction improved in the exercise group versus the control group. And also the postnatal depression symptoms improved in the exercise group. Obviously only a small number of people involved so difficult to generalise those findings, but I think really interesting findings nevertheless. And finally, one more study that I found was looking at sleep quality and the effect of Pilates exercise on sleep quality in postpartum women. And we know that women postnatally, if they can improve their sleep quality, I'm sure they would set the hand off if you had something for them. So this study, another randomised control trial, 80 postnatal women allocated to either a home-based Pilates programme or control, which was nothing to do, nothing other than their usual activity. In the exercise group, they started to exercise from 72 hours postnatal, so quite quickly afterwards. And there were exercises exercising five times a week, for eight weeks. They measured sweet sleep quality. At week four and week eight, in the intervention group, the Pilates-based group showed a significant improvement in their subjective sleep quality and their sleep latency. But there was no difference in sleep duration or their sleep efficiency or their sleep disturbance, which I don't think is very surprising there. So that's a quick run-through of some of the literature that's out there. And if any of you have got any comments to make on that, you know, please keep this to the end and we can discuss them. It would be great to hear your thoughts on some of that. So what I want to do now is move on to the actual programme that we were running. The programme was delivered as part of an EC-funded programme, so we received money along with five other cities around Europe. And each city did something a little bit different. First of all, we consulted with women, so we consulted with pregnant and postnatal women about the types of activities that would be beneficial to them in different periods. And from there, as I say, we developed a programme of postnatal Pilates. So the sessions were physiotherapist led. So we found a physiotherapist who wasn't working in maternity at the time. But she was a Pilates instructor and she had undertaken additional training in working with pregnant and postnatal women. And we found her by doing a Google search of Pilates instructors in the local area and looking for reviews on something called Mumsnet. So that's a discussion board where new months, expected months, can come together to discuss pretty much anything. And I thought that would be a good place to kind of get the low down on good therapists. And instructors, and that's what we did. So I contacted several therapists, instructors, and Nikki, who we got was by far best. We devised four week courses. These were an hour long. And we were advised to deliver four weeks because women would begin to feel the results of their work after four weeks. And what it also enabled us to do was to run more courses than if we'd only run six week courses. So the sessions were an hour long. It was split between a practical element, which it was predominantly, and an education element. So we would spend the first five to ten minutes of the class looking at the muscles that we'd be working in that class, and also ironing out any problems that maybe women had experienced in the previous week. So they were really informative. It would be an opportunity to learn and practice different exercises to the next sort of coordinates. And during the sessions, there'd be different levels. So women who were familiar with it would be able to do a slightly more advanced exercise. And they would all receive one-to-one attention. And what was great about these sessions were mums were able to bring their babies with them. So the mums were already members of gyms, or had already done exercise programs before. So they were familiar with exercise. They'd now become a mom. It was difficult to fit it in because they weren't able to take their baby with them. So we knew that that would be a barrier, accessing the program. So from the outset, it made sense that mums could bring their babies. So if the baby was sleeping when they arrived, they would pretty much stay in their pram or their push chair while mum got on and did the class. If baby was awake, though, we would have have some mats laid down in the centre of the room so mum could still see their baby. And while the instructor was running through the class, I would be available to go comfort the baby if needed it, do the on nappy change, anything that allowed mum to carry on. And if baby needed feeding, mum would just take a break and feed baby. So there were really good sessions from that point of view. The classes were community-based. So we held them in what we call children's centres, so a bit like a community centre. We did that because we knew that the centres were accessible. The centre was where we had consulted with women in the first place with the types of activities that they wanted. We're familiar because often women had received their midwifery care in these centres. They were easily accessible, so they were on bus routes. And also there was car parking facilities for those travelling by car, but they should have been walkable nearly from most women's homes. Now, as I say, we offered five courses in total and the first two courses we were able to offer a praise facility. Because the children's centres had nurseries attached to them, we were able to access play workers. So again, to remove another barrier, for those mums who had older children, they were able to bring those along. And we had play workers who could work with those children while mum had no of themselves. Now, we only ran that for the first two courses. And that's because after that, we were mainly seeing first-time mums, so we didn't have that concern. But the course just happened to fall when their old children were already in a nursery setting and so mum was available. So the gracious ability really wasn't needed after those first two sessions, the courses that we ran. But what I'm saying is, we know that that is often a barrier for women. And so we did attempt to overcome that barrier. So moving on to feedback that we received. So we weren't attempting a randomised control trial as I talked about at the start. We wanted to just evaluate the value of these courses to women. So I'll just run through now some of that feedback that we received. So we had 40 women in total attending the various courses that we offered. And 11 women provided feedback. I think that's often because we asked them to complete the forms at the end of the final session. And those mums who had other children to collect had to go ahead and do that. So they rushed out to the room. They might have had to feed the baby at the end of the session. So quite a low response rate considering how many women were involved. And the response rate you can see there, 27.5% response rates. We've been looking at the graph on the other side. We were asking about the correct colors of the course. So was the venue suitable? And all women responded yes. It was a suitable survey for them. So we know that women want accessible community-based exercises. We asked there was anything about the venue that they would change. And nine out of the 11 women said no. So the venue was really suitable. Somebody else asked for a larger car park. They found that the car park was too small. Before, yeah, it was a little bit small to get to their early to get to the parking space. Somebody else would have preferred a soft-clay area for the baby. You can see on the right-hand side of the slide now was the class at convenient time for them. And the class that we ran was a bright afternoon between 1.30 and 2.30 in the afternoon. 10 out of the 11 women agreed that that was a good time. And one person thought that it was a little bit late to pick up their older child from school. I think really important feedback that that was a good time. A deliberately train of trying to avoid anything wrong in the morning when you're working with postnatal women, because having been there myself, morning cannot exist for most new moms. The moms involved in these classes were typically moms around six weeks postnatal and some very new bomb babies. So a little bit more feedback from the sessions. We asked, did you find the educational part of the course useful? And 100% found it useful or very useful. So that's really warming. And we also asked, was the practical pilates easy to follow? And again, all of the women, all 11 women said yes, they did find the pilates. The practical side of the class easy to follow. We limited the class size to eight women. And that was so that the instructor had enough time and enough capacity to focus on the women, to correct any postures or to talk through any more advanced exercises that the women may be able to do. And speaking of which, we asked, do you think you received enough feedback from one to one attention? And again, all 11 women completed the feedback that they had received enough feedback and attention. So again, that's really positive. So we asked women for their comments about how they did they feel any difference in their body during the last four weeks. And you can see their range of comments. So women reported feeling more strength in their abdominals, becoming more aware of their muscles and their pelvic floor tone, that they're aware of muscles switching on, and that they regain some flexibility. I like the comment there that the women felt much more relaxed as well as flexible and somebody else reporting that they felt more toned. A few more comments. Women reported that they felt that their back was stronger. Again, more tone in their abdominals. Women feeling better posture, the more aware of how they're standing and how they're getting up. More awareness of some of their deep muscles and less backache. It also made them realize that they needed to do exercises more regularly. So again, really positive stuff which aligns with some of the literature that we heard about at the start of the presentation. We asked whether there was anything that the women who were taken could suggest for future courses. And apart from the location, be it north of the city or along a course, women generally thought that there were no changes needed. Somebody did ask for some notes to take away so that they could continue the exercise at home. And we did in fact provide a booklet to women with exercises. It's a booklet that is produced by Physio Group who work specifically in obstetrics and gynecology with very detailed diagrams and explanations for various exercises. And they were the same exercises that we did in the class. So they did in fact have something to take away and refer back to when they were at home. So that was the feedback. All generally positive similar findings to the studies that I described at the beginning of the presentation. So now what I want to do is just talk more generally about the considerations that you would have to bear in mind when you deliver in any type of class or activity for this group of women. So I've already talked quite a bit about the venue. So what we found worked for us was a community-based venue, something that was familiar. A tower venue, there were already things going on. So there was already breastfeeding groups there for the postnatal women and women had had antenatal care in these centres. So it was very familiar. Not intimidating like a gym for those women who are perhaps not familiar with exercising or haven't done any for a while. And that's relaxed venue where we did have access to other professions that should be needed. So for example, play workers, if you were able to offer that type of creation facility for women with older children. So venue really important. It was central to community, so really accessible. The time, we offered hours, our activity in the afternoon. And as I said, I think it's really difficult to leave the house before lunchtime. And so afternoon I think is really valuable time to offer something like this. No cost is down there to consideration. I don't know what it's like in other places. And but by the time women would come into our exercise classes, most of them would have been on what we call statutory maternity pay. So it's a huge cut in salary for those women. So that's something that you have to bear in mind. And we were fortunate that we were able to offer courses free of charge because it was part of a larger programme. But what we wouldn't have wanted to have done anyway is to make cost a barrier. I know that this is a consideration for our Pilates instructor who has continued offering the classes. And I think I'm right in saying that her post-80s classes are slightly cheaper than her main stream classes because she's aware that this may be a barrier to some women. It needs to be baby friendly. So as I said, I was on hand in July to make sure that babies were taking care of some of the focus on the exercises and the mum was happy to bring her baby along. And again, we removed that barrier of them having to find care for their newborn while they went and did something for themselves. I know that the instructor who has continued the classes has got lots of things to keep baby entertained for those same reasons. Take away information. So what we know is that four weeks is enough time to start making a difference on women reported that they felt more toned, more awareness of their muscles and their posture. But we also wanted to offer them something that they could take away and continue practicing and keep making improvements to their posture and their tone. So that's really important so that they're able to take some information away from them to continue building on what they've learned in the course. And another consideration is the format of the course. And so as we saw from the feedback, women really valued the emphasis on the educational side of the course as well as the practical side. And in keeping the numbers small, you could see as well that women really valued the one-to-one attention that the instructor was able to give them. I doubt that the instructor would have been able to do that, had she had a much larger course than what we had. So really important. And again, if you've got any comments on that, feel really helpful and useful to see those when we come to the end of the session. Just want to comment briefly, because I know I've been talking for a little while now, about current UK guidelines, so it would be really great to see an international perspective on this. And the only guidelines I could really find for those aimed at pregnant women are very little, hosatal-wise. So the illustration that we have there comes from the Chief Medical Officer for the UK on physical exercise, physical activity for pregnant women. So at the top it starts with some benefits of physical activity. And then in the center, ideas for what you might consider. And I think the top right person on about somebody doing something like a Pilates pose, maybe a yoga pose, and telling you to aim for about 150 minutes of activity per week. It recommends muscle strengthening activities twice a week, which is perfect for Pilates, because that is essential what Pilates is. But unfortunately, no advice on what postnatal women should do. I think if the OCOG recommends exercising for about six weeks postnatal, if you've had a cesarean section, but nothing otherwise. So that pretty much brings me to the end of what I wanted to talk about. It would be really good if we could open up a discussion now to see what other people are doing. Any comments on the course that we offered? Any questions about the course that we offered? It would be fantastic. But really I think it would be great if we could hand it over now and see what your experiences are. Any comments, as I say, about what you were doing? If you would like to make a comment, either the text box or through your microphone, that would be fantastic. Over to you. We do have a first question, Claire. Okay. In terms of this program, what is your explanation of the link mechanism to reduced postnatal depression? So that was somebody else's study and what I think helped our women. Our women reported feeling better. They were coming into a social setting. It was an activity that was purely about their baby. So it wasn't like a breast-feeding group where all the focus tends to be on the baby and the baby's nutrition. It was something that the women were able to do for themselves without any guilt because they could take their babies with them. So they were coming each week. It was almost in their diary. I'm taking this out for myself on Friday afternoon. And that was planned in. They knew they were doing it for the next four weeks. They knew they would be meeting the same group of women that they'd met in the previous week and what they would see the following week. And I think making time for themselves in a social setting was really beneficial to these women. There was no guilt attack because the baby was with them, but they were able to pay themselves a little bit of attention. So I think that could be the mechanism for reducing postnatal depression, maybe. I know certainly the women got a lot out of the class for those reasons. Certainly there's the social aspect of support and feeling better to help prevent postpartum depression. But we know from other exercise that when there's large muscle movement, women are producing their own endorphins that are helping them feel better. Claire, you know the literature on Pilates. There's probably not a study that looks directly at endorphins or a reduction in cytokines. But I think I would do this with hesitation, but we can extrapolate from looking at other sorts of physical activity preventing or ameliorating postpartum depression that that's also a mechanism. Absolutely. I think what you said was spot on. There's lots of, or there's more evidence around other issues in women's health. So women recover from things like breast cancer where Pilates has been used as a mechanism for enhancing women's outlook on life, if you like. And I think, yeah, the same mechanisms would be in play across the two groups of women. It's absolutely what you say about exercise promoting endorphins and all those good hormones and having some part to play in it. Yeah. Thanks, Claire. You talked a little bit about cost to the women. And I was a little curious about clothing for Pilates. This is going to show my kind of ignorance about Pilates. I have this general mental image, but are women able to wear some of their very casual pregnancy clothing to do the Pilates exercises? Yes, they can. Yeah. So it doesn't really need to be any cost outlay for these women. They can wear pretty much anything that we've got in the wardrobe. So there was obviously women there who, perhaps before pregnancy, had enjoyed going to the gym and liked their gym wear and came out very well dressed in specific clothing. And on the other hand, there were women who pulled on their jogging bottoms and away they went. So there's no need for any extensive outlay on clothing. And in fact, I know one of the sessions, one of our moms who were signed up didn't actually attend the class. But there was another woman who'd come into the centre for another reason, another class which had been cancelled and she'd not been told off. So she was just in her everyday clothes. And we said, come in. We've got space. Come and join us. Don't let your journey have been wasted. Get in here.  And she did such a show. She can come in in the clothes that you would be wearing ordinarily and join in. So absolutely no barrier there to join in. Nice. Nice. But Claire, you also talked about being there as part of the research study. And my guess is Pilates is available in most large urban areas, at least across English speaking countries that I've traveled in. If a midwife were in a smaller area where Pilates wasn't available or maybe there wasn't somebody available to do the Pilates classes, how reasonable is it for a midwife to learn Pilates and then lead that group herself instead of the physiotherapist? Entirely plausible. I have no experience of undertaking any training in Pilates myself, which is why for an independent instructor, if you like, who just happened to be a physiotherapist with an interest in this area, I'm sure there must be courses available. And I'm sure also there is no end of YouTube videos that women guess at home for themselves. But then that would remove that social aspect we've talked about, which I think is really important, postnatal women. The area that we were working in, it was an area. We were in Manchester at this time and it was an inner city area with quite high levels of economic and social deprivation. Quite a lot of non-English speaking women in the area. So when we did the consultation, we offered lots of different activities and we were asking women to tell which activities they would prefer to see. Actually Pilates wasn't the most popular choice. So after we'd offered the most popular choices to women, which were the swimming and the buggy groups and walking groups, we thought, what else can we do? And we looked at Pilates and I knew a little bit about it, having done some courses myself but never trained in it. And we thought, come on, we'll give this a go. Is it a case of women aren't selecting it because they're unfamiliar with it? Is it because they don't know what's involved and so on? And I have to say that that was the case because the interest in it and the feedback that we got has been fantastic. So yeah, there will be areas where it may not be an automatic fit with the population there because that's what we found through the consultation. But I think once women get involved, they can really see the benefits and that's certainly true of our experience anyway. So it started off, we were going to do a taste, there were a couple of courses, take it from there and then we went on to run five courses. And as I've said before, the instructor has now gone on to offer courses in the community anyway. So yeah, it's quite interesting how we got to where we got to. All right. Thank you so much, Claire.


Let me move on to another young surgeon. This is my pleasure to introduce Dr. Bader Schachter. Bader is a resident here. He's currently administrative chief resident in surgery here. He's a graduate of the Eastern Virginia Medical School. Bader completed two years of basic science research, in which he did work on anastomotic leaks with Dr. John Alberti. During that time, he wrote a number of great papers and won almost every single teaching award you can get, both here at the university as well as nationally. And Bader's going to be going off to do a pediatric surgery fellowship at Washington University next year. Good morning. I have no disclosures to report. So it's clear from the faces I usually observe after showing pictures such as these that scars carry more than just their physiologic consequences. And in her book, I feel bad about my neck. Nora Ephron writes this, because even if you're being operated on for something serious or potentially serious, even if you honestly believe that your health is more important than vanity, even if you wake up in the hospital room thrilled beyond imagining that it wasn't cancer, even if you feel elated, grateful to be alive, full of blinding insight about what's important and what's not, even if you vow to be eternally joyful about being on the planet Earth and promise to never complain about anything ever again, I promise you that one day soon, sooner than you can imagine, you will look in the mirror and think, I hate this scar. And so we should start by defining what a scar is, in the medical sense at least. A scar forms as the body's attempt to heal a wound. It's the natural endpoint of inflammation and fibrosis. And it results from trauma, infection, certain disease process, and our atrogenically, often from many of the providers in this crowd. We should also talk about the adjective normal, because as one might imagine, the adjective normal is very prominent in the literature regarding scars, because what is normal is important to our patients. The sense of what is normal may differ between provider and patient. For instance, in the case of scar revision, surgeon may seek to improve the aesthetic of a scar, maybe the color matching or the contour where the patient looks to return to a pre-injury state. And this differing viewpoint can lead to significant consequences. What is normal can also vary geographically. In parts of Nigeria, pediatric umbilical hernias or bellybutton hernias are nearly ubiquitous or at least more common than they are in this country. There are published reports of mothers actually bringing their children to the hospital to say, why doesn't my kid have a bellybutton hernia like all the other kids? And certain tribal cultures, such as the Gamus in Eastern Africa embrace the tendency to scar with hypertrophic scars and keloids for purposeful injury for decorative purposes. In Southeast Asia, the neck incision that's associated with thyroid surgery and other neck surgery holds a social stigma. And as a result, surgeons have developed innovative ways to avoid the neck incision, including trans-axillary approaches or through the armpit, as well as hiding incisions in the nipple. The risk from this surgery, as you can imagine, is significantly different than the standard neck incision and maybe even greater than just a standard neck incision. In the end, what is normal or perhaps better said, what is acceptable is often determined by the perception of the patient. And this stands in concert with our understanding of autonomy. Thus we must set reasonable expectations during consultation. And consultation is a dialogue of shared decision making in which the physician provides judgment, technical guidance and expertise and the patients express their values and preferences. Another frequent question posed in this field is our scar revisions elective. Elective being defined as potentially unnecessary, at least not immediately necessary. Most of us would agree that a penetrating knife wound to the colon is not elective, that would be an emergency. Most of us would agree that cosmetic breast augmentation is elective in the purest sense. But what about a colon cancer? I know that if I were diagnosed, I would want my surgery as soon as possible, but certainly there's no need to remove that on the day of diagnosis. This distinction is seen within the field of scar management as well. Revision of an unsightly hysterectomy scar can be viewed as elective or certainly more elective than a scar that's limiting closure of the eyelid and exposing the patient to exposure keratopathy or keeping the eye open so much so that it gets dry. Perhaps an easier distinction to draw is that between reconstructive procedures and cosmetic procedures. And this distinction really comes from two giants in the field of plastic surgery, Sir Harold Gillies and D Ralph Millard, who defined the goal of a reconstructive procedure as that which improves the abnormal, whereas the goal of a cosmetic procedure, that which improves the normal or the status quo. What we're really asking on the past few slides is this, is a scar just a cosmetic problem like a larger than average nose or does it qualify as a pathology in its own right? We use the field of scar management as a prism to discuss the more fundamental issue, what constitutes a healthcare problem. The prevailing contemporary governing model of healthcare is the biopsychosocial model which expands on the traditional biomedical model that is physiologic problems to include patient-centered aspects of illness like social, psychological and behavioral facets. There are those such as well-known ethicist Leon Cass who would advocate a conservative view of healthcare. He said, medicine as well as the community which supports it appears to be perplexed regarding its purpose. It is ironic but not accidental that medicine's greatest technical power should arrive in tandem with great confusion about the standards and goals for guiding its use. For without a clear view of its end, medicine is at risk of becoming merely a set of powerful means and the doctor at risk of becoming merely a technician and engineer of the body, a scalpel for hire selling his services upon demand. Cass espouses his belief that patient happiness and other quality of life measures constitute false goals in healthcare. He implies that the paternalistic view may be more superior, that physicians should guide the delivery and the limits of healthcare. Others, including our own Dr. Siegler have advocated a more liberal definition. The more liberal view states that an issue becomes a health matter when the doctor and patient agree that it is one. In this view, one of the central goals of medicine is to improve the patient's quality of life and determination of what improved quality rests largely, albeit not exclusively, on the patient. Changes in the relationship of the doctor and the patient during the past 50 years from a paternalistic model to one of autonomy and now to one of shared decision-making suggests that the more liberal view is now the dominant ethical paradigm. Further, Cass' proposal that medicine address only narrowly construed medical or physiologic abnormalities seems to have been rejected in favor of ever expanding realm for medical interventions. This change in ethical attitude is reflected clearly in the field of scar management. The question of access is quickly raised. If scar interventions are deemed an important part of clinical care, should they be distributed equally? Almost every procedure creates an iatrogenic scar. Should a plastic surgeon be available to close every incision at every hospital? How about in the middle of the night for emergency procedures? And clearly there needs to be a balance here between optimal medical treatment and available resources. Think as a final note, we should really pay attention to disfiguring scars. These patients are not often seen because many live lives of seclusion and isolation. One of the most controversial cases in the ethical issues of scar management was that of Miss Isabel D'Norre. Prior to this case, ethical issues abounded regarding face transplant, including is it ethically permissible to give a patient immunosuppression, which could be lethal for a non-physiology, non-physiological threat? Do these procedures change the identity of the recipient? And if the transplant fails, will you leave the patient more disfigured than they were before? So in 2005, Miss D'Norre underwent the first successful partial facial transplant. This means including the nose and the mouth. Since then, approximately 30 patients have been transplanted with a mortality of 11%. Miss D'Norre passed away 11 years after her original transplant, just recently actually, she passed away in April and news of her death wasn't published until September. And it's reported that she passed away due to immunosuppression related cancers. So in conclusion, the patient perspective directs the management of scars. Expectations of the patient and surgeon should be concordant before any intervention is undertaken. And decision-making is really a shared decision-making approach in which the physician provides the technical guidance and the patient expresses their values and preferences. Thank you for the opportunity to speak with you this morning. I wanna acknowledge that this project actually arose out of an invitation to write a book chapter by Dr. Korkowski and Dr. Shoemaker. I wanna thank the co-authors, Dr. Singh, Gottlieb, Angelos and Siegler and I wanna thank the McLean Center as well.


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Hello and welcome to this event from the Lowy Institutes Australia Papua Beginning Network. My name's Anne-Marie O'Keefe and I'm a non-resident fellow here at the Institute, except of course today we're not at the Institute because of the social distancing requirements of COVID. But I'd like to begin by acknowledging you and people who are the traditional custodians of the land on which I am speaking today, which is not Sydney, it's the far south coast of New South Wales. And I'd like to pay my respects to the UN elders past and present of this beautiful part of Australia. I'd also like to thank the sponsors of the Australia P&G Network Events Programme for 2020. That's the Bank of South Pacific or BSP as most of us know it by and Coca-Cola Amital. The Institute also appreciates very much the support of the Department of Foreign Affairs and Trade for the Australia P&G Network Project. Very happy that you could join us today and we're going to be talking about the strange times in which both our countries find ourselves along with the rest of the world. P&G and Australia, like the rest of the world, are facing an extraordinary time as we tackle COVID-19. Here in Australia, we are now behind a closed border with few exemptions. P&G has implemented strict requirements for anyone wanting to enter. And while only a handful of kilometres separate our two countries, we don't know when we might be able to resume the sort of economic, diplomatic, family, tourism, all the sorts of interactions we had and just took for granted only six months ago. Fortunately, both Australia and P&G have suffered significantly less than almost anywhere else in the world. But it's not over. And here in Australia, we are dealing with flare-ups, while in P&G, it's steady as she goes, but for now. How has this shared crisis affected our bilateral relationship? We're going to look ahead today and see what lessons might have come out of COVID for our shared future. What should our bilateral priorities be? To talk about this, I'm very pleased to welcome two very experienced hands in the P&G-Australia relationship. First, I'd like to introduce Sir Charles Lopani, who served as P&G's High Commissioner to Australia from 2005 to 2017. He's also one of the original gang of four who helped establish the administration of the newly independent P&G nation. Also with us is Ian Chemich, former High Commissioner to Port Moresby and former ambassador to Germany, as well as international advisor to the Prime Minister. Ian is now an advisor with Newcrest Mining and the Bauer Group Asia, and also, like me, a non-resident fellow at the Lowey Institute. Before we start just a bit of housekeeping, I'll lead the discussion, actually I'll be putting some tricky questions to Ian and John, until about half past 11, and then we'll be opening the floor to questions from our audience. We'll be using the Zoom Q&A function to do this, so press the button on your screen and type the question you'd like us to answer. So to get our discussion started, I'd like to sort of take a broad view of how things are going with the bilateral relationship between our two countries. And it's coincidental but probably fortunate that both governments are in the process of negotiating a new bilateral agreement, namely a comprehensive strategic and economic partnership, and that's to boost engagement across a range of issues, including security, cooperation, trade, investment, regional development, etc. So to open up, I'd like to find or like to ask Charles first, if you don't mind, what do you see as the priorities that such a strategic partnership should be looking at? What can we draw from the COVID experience that should influence the way in which we move forward? I think the important area of focus could be realigning Australia's aid to supporting trade and investment and economic focus for both countries. While aid has played historically a very important part of Papua New Guinea's development and our partnership, I think to realign Australia's aid to supporting initiatives towards, for instance, a trilateral arrangement of an economic zone between Indonesia, Australia and Papua New Guinea to start off with. At the moment, there's a focus for sub-regional arrangement in Pesa Plus. I think Papua New Guinea has not been fully on board with that for a while. I'm not sure whether they have come around, but it is, we have come around, but it is a contentious area for Papua New Guinea. So my suggestion is we focus on a sub-region of APEC regional organization, which is Indonesia, Papua New Guinea and Australia, and of course New Zealand could be in there. Market size would be viable. Australia has established the North Australia Development Programme project with a funding of around 500 million. That needs to be progressed because that would provide a good linkage for Papua New Guinea and Indonesia to enter activities in the marketplace for whatever development that might arise from that. So I think, essentially, while the Development Assistance Programme on aid has been the backbone of our bilateral relations, I think to start refocusing because with the pandemic, there are views that globalization may falter going forward. So sub-regional arrangements may be the first step to reconstruct and align our economic activities and arrangements and partnerships here. Thank you. Thanks very much, Sir Charles. Ian, what views do you have on this? Look, the first thing I would say is that I believe that the cooperation between Australia and Papua New Guinea through the pandemic so far has actually been very positive, very practical. It hasn't just been about support for the PNG system. There's been a genuine exchange of information between the two governments. And our experience together has been, in the circumstances, it's been okay. PNG benefits from the fact that Australia has, notwithstanding the issues in Victoria have been relatively successful itself in managing the pandemic so far. But I must say, I think PNG's management of the situation has been commendable. As we move forward, going to the core of your questions, we move forward and think about the relationship through this and post the crisis. Yes, we should be thinking in an immediate way about what this teaches us about the importance of cooperation in the health sector. But beyond that, we're going to need a joint regional plan with genuine regional ownership when it comes to economic recovery for the Pacific. And I think Australia and Papua New Guinea will need to work very closely in that sense. As Sir Charles has said, there are existing arrangements, APEC, there's scope there with PACE or PLUS to provide a vehicle for that recovery plan. But look, when it comes to the economic and strategic relationship, I very much trust that it will be genuinely strategic. You mentioned in introducing me that I'd also been ambassador in Germany. And you reminded me of a point. When I sat in Berlin representing one developed economy to another very major developed economy, when we thought about the bilateral relationship, it wasn't just about the point-to-point relationship, it was what we could do together elsewhere. In the German case, it was what Australian Germany could do in places like Afghanistan or joined up work in the region. That's a genuinely strategic relationship. And it's that kind of mindset that I think needs to be brought to the relationship between Australia and PNG. There is scope, there is scope in the region for us to work together on common interests that aren't necessarily about that point-to-point relationship. PNG has exercised some influence in the region in the past. You think about the Ramsey contribution in Solomon Islands. When I was high commissioner, PNG had a couple of people with UN deployments in Sudan. And there is something in that. And I think it should start in the region. And to me, it's logical that it should start with an economic recovery plan for the region. Good. Staying with you, Ian, I wanted to move on to geostrategic competition in the region and particularly how it affects the bilateral relationship. As we know, the Pacific step-up is one of Australia's highest foreign policy priorities. And while the Australian government insists that the step-up responds to broad-ranging challenges of our region, and there's no doubt that that's true. Challenges such as climate change, disaster resilience, economic growth, as you've just mentioned, perhaps the need to have a joint regional plan for economic recovery. But it's also been seen by quite a range of commentators and observers, including here at the Lowy Institute, that it's seen as Australia's response to what it sees as a growing geostrategic competition in the region, particularly from China. Within the P&G context, this has played out in a number of ways. We saw that in what I called the bidding competition in the lead-up to APEC between Australia and China, supporting P&G and its ability to host APEC. And we've seen it more recently with Australia's investment in coal-sea cable. How healthy, Ian, is this competition for Australia's relationship with P&G? Look, as somebody who, like Charles, has been a very strong believer in the bilateral relationship and a very strong believer in the importance of Canberra, really focusing on the union. I strongly welcome the step-up engagement. I think it's real. I think it's genuine. I think it's taken practical form. The motivations, people can speculate about that, but I prefer to think of it very much as reflecting an assessment of the importance of the region. If there's some motivation associated with other players, then fine by me. But I think let's take it on its merits. I also think P&G is entirely entitled to diversify its own external links. I think that it's inevitable that a growing China will look at investing more strategically and economically in places like P&G, given its wealth of resources. Interesting thing is not much is actually eventuated in the China-P&G relationship since all the hoopla of APEC 2018, in my view. There hasn't been that much to it. The China relationship has been held up on many occasions in the past as the next big thing. We all remember the Look North policies of previous administrations. To me, it's not a zero-sum game. Australia needs to work positively with China and P&G. Australia has its own bilateral imperatives in Beijing. There's some precedent for trilateral cooperation. There's been a solid program in anti-malaria work in the past. I think if Australians are true friends of Papua Guinea and we are, we'll find a positive way to engage China there. I think in P&G, Charles should say, but I think while there's an opportunity to play one off against the other, there's really very little interest in P&G in my estimation in getting rolled up in a major geostrategic competition there. As for China, why would it want to work with us in P&G? Well, I do think it will, at some point, need to reevaluate its own aggressive diplomacy at a global level. It's experiencing tensions right across the world right now. Its own experience with investment in P&G has not always been an entirely happy one. So I think there's plenty of reasons for all of us to work together in a trilateral way. So Charles? Yes, I do endorse Ian's comments that Papua Guinea is of course sovereign nation. It decides who it will partnership, partner with in terms of development, but it does, it does bring to focus the potential for strategic security concerns that may flow on to Papua Guinea. We have maintained a very neutral position on this question to China and Australia because we are French to both of you. So there is no, there is the offer of a project that's really to be substantially moved forward and that is the energy project that was to be funded by, jointly by Australia, P&G, US, and Japan. That's still to be implemented that was offered to your neighbor and that was seen as a counter message to China, these activities in the region. So in the end, as Ian said, both of you, Australia and China are friends and to us there is no value in that signing with either one of you in terms of our strategic interests and our economic interests going forward. So I do endorse, you should, both should work together as far as the region is concerned. APEC provides that venue for that collaboration, economic collaboration and cooperation after COVID and we look forward to continuing that relationship. Thank you. I'd like to now move to something that both of you have raised and in particular you Sir Charles, the importance of trade and investment in P&G coming from Australia. And I guess what's happened in the past few months has created a climate that perhaps is not as welcoming as perhaps it was before. So for example, as you know earlier this year, Prime Minister Mo Ape announced that the extension to former mine would not be granted and Barrick Gold or Barrick and Guinea, the joint venture mine operator that's owned jointly by Canada's Barrick Gold Group and China's Xi Jinping mining group that had suspended production, they suspended production in April and placed the mine in care and maintenance status. And last month they denounced that it would lay off permanently more than 2,500 local mine workers as of the end of this month. Big stuff. On Monday, quite separately, the Australian listed energy producer OilSearch announced that it would wipe as much as 570 million dollars, Australian dollars off the value of its assets in P&G and could abandon some drilling projects. And this is in light of expectations that the coronavirus affected oil price collapse may not be temporary. This is all bad news for P&G's economy and in particular it creates a climate that will make investors from Australia perhaps more reluctant. What is your view, Sir Charles, on this? What do you see as this presenting for Australian investors? Well, it's a difficult position for P&G to find itself in. The Prime Minister in his statement, one of his views for underpinning this approach, this policy, is that it's a short-term pain for P&G for a long-term gain. I have grave doubts about that because investors can move around the world internationally and it will not wait for P&G in a long term. It's short-term policies seen as anti-investment in P&G. So I am very concerned also that this trend in government policy is set in a very dangerous prison for P&G's investment destination climate for foreign investment, not only for Australia but globally. Because these global companies with major investments around the world and they have a lot of say both in financing, capital flows into developing countries and international so I do share a lot of concern in the country as well by a lot of P&G's about this approach by this present government. I'm sorry to say this but I never thought P&G would get to that stage but it has happened and the consequences may be regrettable going forward. Is there anything that Australia can do to support P&G during this particular difficult time? Well Australia has done a lot to support property in these circumstances for instance the LNG project. One of the I remember a delegation of ministers coming down to seek an Exim Bank support fund that has a letter of comfort for investors and financiers to get into the LNG project. Australia under Labor government and committed 500 million of that fund. We never accessed it in the end but it was always in the background supporting this but I am not sure with this approach that Australia would be contributing to making that letter of comfort for this policy. That's my honest assessment. I'm not sure what Australia would do but I predict that two governments might have to have a bit of a chat in the end to make sure that the support to this kind of policy may that it rewards P&G as a whole. Thank you. Ian, you've got a private sector experience now post your diplomatic career. What's your take on what's happening at the moment? Thanks, I probably should disclose that in addition to the thing you mentioned I'm also vice president of the Australia P&G business council but I look I'll just give you a personal perspective. Paul Gord looks terribly messy and if you view it through the eyes of investors in major companies that are themselves engaged in P&G it just looks bad. The timing was poor. I sort of feel that advice received by government might have underestimated some of the challenges associated with transition to government ownership. I know we've got both the judicial process in P&G and the prospect of international arbitration has to be said that Barrick's most recent experience in similar arbitration was very positive for Barrick and very bad for the other country involved which was Pakistan but who knows how that will go, circumstances are different. It is about the signal it sends to the broader investment community and particularly now when companies are constrained in terms of their capital budgets they have to make even harder decisions or even more ruthless decisions but put it that way about where they put their investments. They're pulling back and where it's complicated and difficult you know it's unlikely to attract a significant investment. So I think a lot more work is needed on the messaging. Ironically it's companies that are not engaged in this particular issue at Pogra. Other companies that proportionally are more exposed to P&G than Barrick is who may be facing more difficulty in convincing their own investors in turn that their strategy of engaging with P&G is the right one and a positive one because from an investor point of view if you're a big corporate investor I don't know in New York or Europe somewhere you put together the sort of key things you without entirely understanding what's going on you put together this sort of language about take back P&G however it's made and I'm not trying to say one thing or another but that's what's preferred. You also hear about this decision and claims of lack of consultation in the process in relation to Pogra and then you you sort of see the struggles that for whatever reason people have been going through in trying to bring off new projects whether it's in oil and gas or in mine and people left with an impression. So it just puts an imperative back on P&G. Maybe Australia could help in some way but I think it is for P&G as a sovereign country to be very clear in its own messaging and in terms of consistency between external message and practice at home. Can I just add one point Anne-Marie and that is it's all up to the government as far as managing its sovereign risk very critical in terms of investment if you're looking for investment they will look at your sovereign risk and I think that those two incidents are that incident does not send out the message that P&G sovereign risk is good a good bet. And just very very quickly Anne-Marie I mean just to Charles's earlier point about that time back then in 2009 when Australia was working to support P&G as the P&G-LNG project was coming on. I don't know if we're going to have time to talk about the aid relationship but to the extent that the aid relationship is relevant and important for the future we should be taking our inspiration from that time where the development relationship was focused on a part of the P&G economy which was in itself wealth generating and which in itself laid out a future of economic independence for P&G focusing what support Australia gives in such sectors will be vital going forward. Well since you've raised the aid program let's have a look at that before we move to questions from our audience. So Australia's aid program to P&G has taken a front seat in the relationship for a very long time rightly or wrongly and the program itself this year is worth something like 512 Australian million Australian dollars and it represents the biggest aid program that Australia has anywhere. It focuses on governance economic growth and human development and right now of course it's it's had to focus very heavily on COVID response and supporting P&G in its COVID response. Looking to the future I guess my first question is given your points earlier Sir Charles about the need to focus more on trade than aid or perhaps just focus entirely on trade rather than aid should Australia continue to have an aid program to P&G and if so what should the focus be? So Charles do you want to take off with that one? Yeah well it's not going to happen dramatically that's the point it will happen over time to reduce Australia's aid and refocus on economic and investment and trade issues. So that's the first point the next point is the increasingly I think Australia is starting to target its aid so it gets the best value for its dollar and I think that's a good good good good start for going forward I think you've done a substantial amount of dissipating the value of your aid by trying to do everything in all the sectors. I think it's a good time to re-evaluate and focus on health sector is one area that Australia's aid has been very effective and very strong in all aspects infrastructure and technical assistance programs etc so I think that's that's a good start a new partnership by putting in Australia partnership for health transition to health is the initial recent initiative is a good one that's one area of expertise and it's worth about 200 million I think that you could continue in but the other component of that 520 million you raised is most most of it is on technical assistance actually I think 300 million of that 520 million is on technical assistance program which in the past has not been that effective and I think I think there is concern and realignment by Australia in that area and I think they're starting to you're starting to re-review that and realign some some of that fund towards infrastructure infrastructure is another big area that in terms of the response so to speak to China's infrastructure moves in Papua New Guinea and the Pacific I think that that also may bring some value to the to the to the dollar eight dollar that you're spending so I live it at that there is some serious consideration for realignment and that should be included I hope in the discussions between the two countries Ian as a former high commissioner what do you think about the future of Australia's aid program the reality is that the Australian aid program yes it's the biggest that Australia has it's significant in as a signal of support but if you relate the figure to the overall size of the png economy these days if you relate that figure to the size of the the size of Australian investment commercial investment in png so at 17 billion it's actually a relatively small contribution to the png economy and we Australians tend to overemphasize it in terms of its its importance in png in my view it's an important signal I would not propose giving it up at all but I do think as I mentioned earlier that it should be focused on those elements of the png economy which are wealth-generating and that it should be targeted towards png becoming genuinely economically independent so stimulating and strengthening those components of the economy that will make create wealth for png and png thanks we've reached the time where we'd like to invite the audience to put their questions forward to us all you have to do is use the q&a button on zoom and you can submit it there we have a few questions that have already lined up so I'm going to ask ask both of you to answer this question I think you're both in a position to to have have good views on it it's a question from Tim Murphy and he'd like to know how does Australia and png normalize trade and travel between the two countries now this is clearly post-covid because right now it's impossible but at least on the travel side but as we know in the past there's been issues the visa issues between Australia and png so how do we normalize going into the future trade and travel so Charles do you want to start with that one yes I think for the visa issues APAC provided excellent experience we had a magnificent effort from our immigration agency that a lot of the incoming delegates from other economies were very complimentary of the way smooth way that they can apply for their visa on the internet and get into the country but with the COVID restrictions the example that's been currently experienced is the movement of our essential your essential services staff Australians coming into power point again they still have to go through 14-day quarantine service and the power point again is returning there's been a big mobilization of effort between our foreign affairs protocol division and the immigration immigration from internationally and from Australia Papua New Guinea it's returning so the recent suggestion of a bubble for Australia and Pacific and Papua New Guinea that needs to be discussed and how to manage that within a COVID pandemic environment so I think rush in things as we can see is not a good idea while COVID is rampant internationally and within our region so it has to be carefully managed but yes there should be some consideration to movement of essential people business people technical people in the two countries so yeah the framework is here already that we can manage this thing so I think that that is important Ian do you have any views on this one look I think that the the trading relationship and the business travel relationship there's probably been a less impacted than than than many people think by COVID it is possible for Australian business people to travel in and out of PNG the company that I'm associated with and the broader council has actually found the PNG authorities very accessible very practical and in terms of its engagement with the business community take an example the new crests chief operating officer for Papua New Guinea is currently here having travelled up to PNG a couple of weeks ago yes he spent 14 days at Airways Hotel in quarantine but he's he's engaging it is we have found both governments to be honest quite the solicitude of the of ongoing business including ensuring the continuation of that key operation of the year mine and there's a lot of equipment personnel that has to come back and forward has to be subject to proper protocol both governments have helped as for normalising travel beyond this look I think Australia has to Australia has to take as a first step dealing with its own internal state boundaries we we've got to get through all that first I think a Pacific bubble is still someway away I can imagine it reasonably readily with New Zealand over time I think a reality that Papua New Guinea and other Pacific island countries will face as we move into that phase is that governments like Australia will want some kind of good solid evidentiary data about the extent to which COVID-19 remains an issue in those in those in those countries and I think I have to be said that we're probably not at that stage yet with PNG we don't have a good enough picture of what's going on clearly the country the country is not beset by coronavirus but hard data on on where it is what the status is that's going to be needed before we we move into some relaxation of travel I suspect right thank you so our next question comes from our old friend Sean Dornie and he's asking about the redevelopment of the manas naval base now I'm not sure how much either of you know about this in terms of the latest the latest developments but just to recap for the sake of sake of the audience it's being one of the big Australia PNG agreements in recent years has been the joint US Australia PNG deal to upgrade the lumbering naval base and there seems to be some pushback though particularly from the manas governor Charlie Benjamin and he seems to have the support of PNG's foreign minister for a review what what does this mean for for the bilateral relationship and as as Sean asked what do we know of what what stage the redevelopment is up to so Charles I'm going to ask you first because of of both of you you might have more of an inside view on this well I must admit I don't Henry and Sean good to hear from you it's a difficult question because it again this was couched in the framework of security and regional influence of China I think rather than anything of substantive manas based development for manas people yeah it is emerging to be a controversial arrangement so to speak to say the least so I'm not surprised that the governor of manas and at the political level it's starting to gain some attention and probably traction to to review this but it's not I am not very much in the loop on this so that's the only comment I can make it is it is contentious in terms of what its intention so thank you Ian do you want to add anything oh look I I I give a shout out to Sean it's nice to hear from you I'll reach out to your local Sean but the I would say that just express of you that to be talking about the redevelopment of that naval base is actually a more positive thing to be talking about than the predecessor arrangement the asylum seeker processing management which I think you know proved to be a difficult issue overall in the in the relationship and the cause of redeveloping an important military base to me is an important one I think that can be done in the spirit of the the bilateral strategic relationship um uh uh you know in a very positive way in the same way that other other activities in the events cooperation program run to take and like the patrol boat program okay thanks very much for that um we have now another question quite a different one from peter aid see and he'd like view from both of you are on the potential risk of movements of people as economic refugees from png if the economic downturn within the region is prolonged do you want to start with this one uh so we're hearing from all our friends today good to hear from peter uh I think um I think this does require careful monitoring I must say that the cooperation between both the immigration and customs agencies for between Australia and Papua New Guinea has been outstanding over the years and that um uh the regular exchange of information is is very positive so I think we're in we're well placed to work together in managing any pressures that arise there um I I'm hesitant to think of this as something that is you know alluming very serious problem there's been a lot of talk over the years about the potential for economic refugees to come through the ng to Australia it's proved um to be much less than many many have expected um it's not really a regular channel for uh for um refugees seeking access to Australia um and apart from some interesting historic associations by certain Papuan communities in in Australia I don't see a great flood of Papua New Guineans wanting to come to Australia either um I think the uh I also think that the arrangements we have in normal times around the border between Australia and Papua New Guinea are world class and world leading um so I think we're in reasonable shape uh the overall overall um demand for asylums that could place us in them in Australia um has declined considerably as a result of Australian policies so I don't see this as a very big deal just now something to watch right um so Charles there's a question for you from um Jan Zomedic he would like to know or she I'm sorry I can't tell from the name uh gender um do you see a need for financial aid in the PNG health sector um Jan mentions that uh they've been working for over six years in volunteer capacity in health in the Highlands and have experienced firsthand that many women and children do not have access to primary health care so with that as background do you see a need for financial aid in this well definitely um Jan thanks for that question because COVID has highlighted the necessity for just dealing with primary health care space um and and and the sanitation issues and we also thank the effort and brought by the NGOs the very important cogs in a will to Papua New Guinea's development as well as its health in the health sector so thank you for for your health efforts and and uh support in this area for Papua New Guinea yes funding by both governments it's a necessity to continue to maintain that or improve particularly primary health care uh statistics have not all good well for Papua New Guinea maternal health child health areas uh the issues of tuberculosis and malaria and continuing threats so with the pandemic uh looming um it's incumbent on both governments to continue focusing resource in the health sector in and in developing uh and enhancing relationships with those who are out on on the on the field like NGOs and rural health workers of Papua New Guinea deserve a lot more attention a lot more assistance and support so um yes I fully endorse your your question and highlighting this uh this funding and resource enough primary health care particularly good um there's a few questions on the aid program as I said before it always seems to end up in the front seat whether or not it should um so I have a question from Goody Coleman who's asking if PNG uh has focus initiative areas where Australian aid can progress and to what extent does PNG drive this so Charles do you want to start again and then then Ian if you could come in that would be great well of course Papua New Guinea should uh drive be the driver in development and setting its priorities and funding its priorities that's very critical historically um with your budget support and increase and then at times Australia's aid was funding 80 percent of Papua New Guinea's priorities and 20 percent of the 80-20 dilemma and how to adjust that to balance in 50-50 Papua New Guinea and Australia and even increasing it to Papua New Guinea 80 percent bear bearing its cost of its development and its priorities is very critical so yes um historical area of trends in Papua New Guinea's efforts to fund its own priorities have been lacking but now with the revenues from the major resource projects there should be effort uh to make sure that these uh benefits and wealth that we're getting from our resources should be focused on taking over the responsibility of our own priorities right and depending on Australia's aid to take on the burden of developing uh through our priorities policy priorities and then we uh use use our own funding for um for whatever it is that we are using so I am very very uh hopeful that government successive governments of Papua New Guinea will take continue to talk sovereignty of the nation and walk sovereignty by funding our sovereign national interest and national development. Thanks sir Charles Ian do you have anything to add? Yeah look I would just say that of course uh external assistance needs to support and reflect the key priorities identified by the sovereign government concerned and I believe the Australian aid program does and you know the the the PNG government's development plans have a very strong focus on health and education and a range of other areas. There is also a an imperative on the Australian government as the provider of funds to um uh you know see the disbursement of those funds in a way that uh it feels it can feel confident that its own that its own constituency it's its own population it's own voters uh will support so there can sometimes be at least the dialogue if not tension around around those issues um where it tends to come together in my experience and probably Charles's too was that the at the annual um bilateral ministerial forum where these issues are are talked through. I always felt the sort of looking back that was almost as we needed sort of something else something else that engaged our leaders a little bit more regularly um uh on the design and shape and management of the aid program there was a bit of a tendency for politicians to come together briefly for a half a day once a year and then back into their own political um context uh it'll be nice to see some kind of uh instrumented merge perhaps from this um negotiation over the strategic and economic partnership which actually brings us together in a more deliberate way at the leadership level over the design of the aid program. Okay um we actually have uh another question on aid but I'm going to skip that just for a moment I'll come back to it if we have time but there's a question on Bougainville and as we know the referendum last year showed a vast vast majority of Bougainvillians on independence and of course there are the local elections in Bougainville coming up uh I think in August uh Ian Prentice asked the question how do you both see the challenges and potential outcomes as that election plays out particularly given the referendum result? Um I should like I first Charles the uh um look uh this is a really interesting issue I mean there are there are very different perspectives here you know Papua New Guinea um uh uh is right to um you know very very much think about this as a as a national issue um uh Australia and its role is a matter of um some debate and discussion in in in BNG. I um uh when I look at the terms of the Bougainville peace agreement and Ian Prentice of all people knows knows all about that uh in the end um it allowed for a referendum which has taken place and as we know we've seen Bougainvillians vote um uh with a significant majority for independence but it also requires um endorsement and ratification by the national parliament of Papua New Guinea. As Australians when we listen to that and think about that that situation we often will take a slightly black letter sort of legal mindset to the situation um and assume that you know here's a serious problem it's all going to explode at some point. I don't know Papua New Guineans have a way of um finding their way through these issues and um I was you know heavily involved with Bougainville during my own time as high commissioner and I must say I I uh I did observe um significant support for independence when people were asked but I also observed a deep reluctance on the part of most to go back to the situation of the 1990s and and the conflict there um so I'm very hopeful there's a real there's there's a spirit which will see cooperation and a new way forward beyond the BPA um and that that will merge emerge in dialogue over the next year or two. So Charles? Ian um how are you all right um you should know this issue is more than any of us you you spend a lot of time in Bougainville but um there are certain basics that I think as far as national government I can't speak for them but from my observation need Bougainvillians to do and that is set up a function in public service if they want to be independent uh the funding arrangements that have been in dispute needs to be sorted out by both levels of government and um uh there are some terms of the uh peace agreement that needs to be adhered to and that is the um arms uh surrender of firearms that is in Bougainville and uh also to um ensure that um the infrastructure for for being an independent Bougainville needs to be in place so this these are issues that are not not small if you want to be independent of your currency deal with your current own currency and you're setting up your foreign relations area so the national government I think while it may at this stage express some reluctance about Bougainvillians going to be independent it's a part of what Bougainvillians have voted on it so with to our respect uh in the end I suppose the Bougainvillians desire we don't want to as as Ian mentioned revert back to the 1990s days so it is uh it is basically a challenge for both governments Bougainville people and Papua New Guinea people the rest of Papua New Guinea uh to move forward to serious discussions and how to resolve this issue because that referendum outcome will be voted on in parliament I don't know what the situation is there at the moment but yes all these uh areas critical areas for for to settle amicably this issue well I think that's uh that's a really important question to end on unfortunately we won't have time for any more I thank you all though for putting in your questions and fortunately we've been able to uh to answer most of them but I'm afraid some of them we can't um but it's been an incredibly interesting discussion and I want to thank both of you for making it that interesting Sir Charles who's been with us um from Port Moresby and Ian Chemish who's been joining us from Brisbane thank you both very very much thanks again to our event sponsors BSP and Coca-Cola Amital to let you all know we'll have a recording of this event to share on our website very soon and you can follow the Australia PNG network on Twitter and Facebook for alerts about our upcoming events I'm Annemarie O'Keefe thanks for joining us today and have a great day


So, Tracey's an assistant professor up for associate professor in medicine in the endocrinology division. She's former chair and co-founder of the Stanford Hospital Diabetes Task Force. She has an active clinical research program in the areas of obesity, weight loss and the role of the adipocyte in modulating insulin resistance. I cite many of her studies and some of the various presentations I give and I am always inspired by her insights and contributions. Tracey, you get to close the session. Thanks. Okay, can you hear me? So, yeah, I would like to thank Christopher for inviting me to this illuminating conference, which was great last year and is already inspiring me this year. Is the volume okay? Okay, all right, so what I wanted to talk about today in 10 minutes is just a little snippet of what we're interested in related to the biological properties of adipose tissue that underlie insulin resistance. Okay, all right, so first of all, there is clearly an association between insulin resistance and body mass index or obesity. I think that's well established, but here's a nice graph from about 500 patients done mostly from Dr. Reven's work when I was working with him. So this is our, I'm not going to explain it in detail, but our measure of insulin resistance called the steady state plasma glucose, the higher the number, which is the glucose at the end of the steady state, the more insulin resistant the individual. And on this axis, you can see body mass index. These are all healthy non-diabetics. And as you can see, there's a linear association between increasing body mass index and increasing insulin resistance. However, you can see a tremendous amount of variability at any given BMI. For example, at a BMI of 30, you have some very insulin sensitive people down here and some very insulin resistant individuals up here. So what we're interested in is what explains the variability in these individuals who are similarly obese. This graph shows the distribution of SSPG or insulin resistance according to BMI subgroups in 500 normal glucose tolerant adults.  And you can see that a very small percentage, about 11% are insulin resistant in the normal body mass index range. And as your BMI goes up, by the time your BMI is over 35, about 75 or I think this is 85% are insulin resistant and none are insulin sensitive, represented by the orange bar. But in this group, between 25 and 35, there's a lot of variability. So people who are 30 to 35 BMI, about 60% are insulin resistant. And about 13% are insulin sensitive and some are in the middle. And in this group, only 40% are insulin resistant. So we're very interested in why some people are insulin resistant and others are not. And we've capitalized on this observation by studying individuals who are similarly obese but very resistant or very sensitive in comparing their adipose tissue. More evidence suggesting that the adipose tissue itself is related to insulin resistance in addition to these kind of correlative associations is the fact that weight loss, so decrease in body fat and mass can improve insulin sensitivity dramatically. So this is most dramatic in the setting of bariatric surgery. These are patients of Dr. Morton's and we've looked at these guys before and a year after surgery and you can see here just the decrease in body mass index from around 54 to an average of around 30. And here's their insulin resistance improving dramatically prior to surgery from an average of around 230 down to about 130 after losing 80 kilos or 80 pounds, sorry. So clearly they got more insulin sensitive. In fact, this isn't published yet, but they are more insulin sensitive than you would expect for their post-surgical BMI, the reason for which that happens is not clear. They also, people also improve their insulin resistance with just dietary weight loss of much more modest degree. These are individuals who did diet studies with us. They lost about four and a half kilos. Here's their weight before and their weight after. So they lost a little bit of weight and here's their insulin resistance response. These guys are likely the ones who didn't lose much on this side. But in general, there's also a reduction in insulin resistance of about 23% with dietary weight loss. Interestingly, if you remove body mass, body fat mass with liposuction, there is no change in insulin resistance. Here the term IMGU refers to insulin resistance. It means insulin mediated glucose uptake. This is a study by Sam Klein that was published a couple of years ago. He took eight obese normal glucose tolerant women with a BMI of 35. He performed a different test than the one that we do. He performed a euclycemic hyperinsulinic clamp to measure insulin resistance, or IMGU, before and 12 weeks after liposuction.  And that's more than what I just showed you with dietary weight loss, which had improved insulin sensitivity. And we know from our data that our studies, if somebody loses nine kilos, they almost always improve their insulin sensitivity. And what he found was no significant differences in insulin mediated glucose uptake before and after liposuction, as evidenced by this bar graph here. In this setting, the RD refers to the insulin mediated glucose uptake. It's a different measure, so it's different units. But you can see there's essentially no change at all, with nine kilos of fat removed by liposuction. So what does this all mean? If you look back at some interesting experiments by Jerry Schulman a few years back, we can learn something from these mice. These are azip-fatless mice, so they have no subcutaneous fat. And if you look at this mouse, you can see that his abdomen is extremely distended.  This mouse has hypertriglyceridemia, insulin resistance, glucose intolerance, a fatty liver, and fat in the skeletal muscle.  Fat came out of the liver, came out of the skeletal muscle, and all the metabolic disturbances improved. So what we're seeing here is that the total absence of fat, subcutaneous fat, was causing essentially what we see associated with obesity, metabolic syndrome and ectopic fat. So with that background, we're trying to understand how obesity, just garden variety, obesity can lead to insulin resistance and all the metabolic perturbations. And I don't have time to go over all of these, but there are four leading hypotheses in this research community.  The second is inflammation, which we've touched on, perhaps mediated via the immune system. The third is impaired adipogenesis and fat storage. And the fourth is hypoxia. And it's very likely that these things are interrelated. I, for the sake of time, I'm going to focus on impaired adipogenesis and fat storage. So the hypothesis that we've been investigating is that perhaps impaired adipogenesis causes insulin resistance, just like the mouse I showed you. If you cannot, in the setting of caloric excess, ramp up your fat storage as needed, you may develop metabolic complications just like that fatless mouse. And these are human examples of something very similar. This girl on the left is a patient who has congenital lipodystrophy.   She cannot store fat. And she has, interestingly, the same metabolic characteristics as that mouse. She has glucose intolerance, hypertriglyceridemia, insulin resistance, and fatty liver. So this is a little cartoon that describes what we believe is happening in the setting of caloric excess.  And the fat cells in the setting of a caloric challenge can either get bigger or they can become more numerous. What our data shows, and other data as well from Peter Arner's group, is that the cells really can only get so big. And by the time your body mass index is 25, they're sort of maxed out. They can get a little bit bigger. Our morbidly obese patients have slightly larger fat cells, but it's not dramatically larger. And Peter Arner did this elegant work using carbon dating to show that, in fact, as people get more obese, they begin to make more fat cells. And so hyperplasia becomes important in expansion of the fat mass once you're above a normal body weight. So how does the body figure out whether the cells are getting bigger? What determines the maximum size? And what's the signal for hyperplasia? And these are all things that we don't quite understand. But there's another bit of data suggesting that once the cells get very large, they trigger maladaptive processes. They trigger inflammation. They attract, express signals that attract inflammatory cells.  And we have seen those in our subjects as well. And once these cells become disturbed, you know, they're releasing fatty acids into the circulation, which are then going into the skeletal muscle and liver. So this is our example showing that in humans, the peak diameter of these big fat cells doesn't change a lot. These three curves show the peak diameter of mature cells. And the different color lines are individuals who have BMI of 27, 35, and 50. And you can see that there's not a large difference in the peak diameter as the individuals change their body mass index tremendously. A few years ago, in collaboration with Sam Cushman at the NIH, we showed that individuals who are insulin resistant in fact did not have much bigger fat cells. Over here, we looked at their fat cells and we compared very resistant to very sensitive individuals who were similarly obese. And we found that the peak diameter was not significantly different.  And you can see it on this curve.   And we found that the insulin resistant group had an increased ratio of small to fat cells. So they have a relative increase in the number of small cells. And in association with that, they had decreased expression of genes that were important for a dipocyte differentiation, which led us to pursue the hypothesis that impaired differentiation of adipose cells in the setting of obesity may underlie the development of insulin resistance by restricting the ability or the ease with which the subcutaneous fat can store the fat, which in turn may lead to the stress on the existing mature fat cells. So here's just a slide of what we're working on now. We're actually culturing the pre-adipocytes and looking at factors that determine how well they can differentiate. And Lee Fen Lu, a new addition to our lab has become very adept with this. And what is interesting here, this is another patient of Dr. Morton's, who has visceral and subcutaneous fat at day 14 of differentiation.  So the blue is the nucleus, the green are the lipid droplets.  It does not differentiate very well. Clearly, these two depots are very different. And with Ed Engelman, we're also looking at and finding differences in inflammation and immune subsets in these two depots. So the future directions for our group, we would love to collaborate with any number of the presenters here. We're interested in finding the trigger for adipogenesis and exploring that. Some triggers may be hypoxia or ER stress due to cells that have maxed out their size or inflammation. Again, in response to probably two large cells. And then what's defective in resistant versus sensitive subjects? Is this the problem, inflammation, or could it be a differential immune response, or perhaps a differential response to hypoxia? And what are the consequences of adipogenesis that mediate insulin resistance? Does it have to do with these cells getting very large because there wasn't a new crop of small cells to help store fat? Is it increased lipolysis or is it mediated through deposition of ectopic fat? So thank you for your attention. We'll have time for questions, I think, at the end. The preceding program is copyrighted by the Board of Trustees of the Leland Stanford Junior University. Please visit us at med.stanford.edu.