All surgeons must remember the main purpose for which they choose to practice this specialty: to help people. In all books about hernia, the debates are focused on the new surgical techniques developed, the discovery of new materials that can be used for the repair, and the presentation of the particular hernia cases. I believe that progress in this field comes by organizing training programs, visiting fellowships, common clinical studies, sharing knowledge, and medical support for the benefit of the patient. The idea of organizing an international collaboration should be mentioned in this book because ultimately a hernia repair will be made depending on the experience of the surgeon, the particularities of the patient, and the hospital resources.
- hernia center
- international collaboration
- certified hernia center
- benefit of the patient
Medical and scientific researches in the last few years have become increasingly global, cross-national, cross-cultural, and collaborative. This reality is a reflection of the globalization of modern day life and easy communications and movement of health professionals and patients .
Acting on principle is better to give than to receive on the following pages I want to highlight the importance of the surgeon in the society, the need for international collaboration, and the key element—teamworking.
A team is made up of individuals with different opinions. That is why it is good to leave aside the personal interests and carefully watch those that are in the interest of the project. Sharing the workload within the team is an important milestone in the evolution of the project. Teamwork is based on that—each member does what he/she is best at. Surgery is teamworking. Through international collaboration, surgeons learn how to improve the performance and accelerate progress. A vast majority of surgical practitioners come into diversified career paths that enable them to use their various abilities in a wide variety of workplace environments. Surgeons have a demanding life but they have to realize that this profession allows them to put their skills to good use and will get more satisfaction as they will get even more involved in providing services for all people in need. Getting engaged in difficult situations and trying to find the best solution to resolve them reflect two great qualities: responsibility and leadership. There are seven major settings in which surgeons can put their education, training, and skills to valuable use: private practice, academic medicine, institutional practice, hospitals, ambulatory surgery settings, government service programs, and the uniformed services. Nevertheless, the primary responsibilities of a surgeon are to serve as a leader in their profession by diagnosing a patient’s condition, performing the associated surgery, and following up with the patient to ensure continued proper care and treatment.
Many publications are available on the best surgical techniques and treatment of incisional hernias with reports of experiences and randomized clinical studies at the two extremes of the evidence scale.
Recent medical advancements have allowed hernia to be repaired through a minimally invasive approach using a robotic surgery platform. The existing robotic surgery platform features a 3D-HD visualization system that will guide the surgeon’s movement and small surgical instruments with the capabilities of moving with greater vision, precision, dexterity, and control than the human hand.
The ultimate proof of the best operative technique has, however, not yet been achieved. In practically no other field of surgery are the variability and the resulting potential aims of surgery so great .
There is a great imbalance in hernia care: in some regions, the science of prosthetic material continues to develop, being supported by the largest supply chain standards system in the world and focusing on laparoscopic or robotic technique repair, while in other countries they do not even have the basic materials to perform an open surgery. Therefore, we need to focus on raising the quality of hernia care and to maintain a balance for hernia repair in all regions bringing greater value to all patients.
All the effort of a surgeon lies in the benefit of the patient. We can achieve better outcomes for this purpose by creating an international network, specialized programs and centers which are stable and internationally recognized. Understanding and targeting the needs identified by the surgical community has cultivated a critical working environment that has had a profound effect on expanding surgical care in UE and non-UE countries.
Access to surgery is being increasingly recognized as a global health issue, as the poorest countries in the world—representing a third of the global population—only account for a small percentage of operations performed annually [3, 4].
Humanitarian surgical missions can provide the much needed care for those who are otherwise unable to receive such care because of limited local health-care resources and cost. When most people think about volunteering, they think about going to a foreign country and doing something they’ve never done before. One of the great benefits for volunteers is the possibility to combine “to be useful” with to visit and to live temporarily in a foreign country, to learn a few of things about its culture, and to meet people of different nationalities. The participation in such missions requires dedicating time and resources but offers you a new experience with a new cycle of knowledge gained. For those within a medical profession are very beneficial as they allow for diverse communication and a transfer of knowledge that can vastly help those with a primary specialization.
Successful humanitarian surgical mission requires careful planning and coordination and can be challenging for those tasked with the responsibilities to organize and lead these missions. Surgeons who go on humanitarian missions are definitely engaged in a noble cause. However, not infrequently, despite the best of intentions, errors are made in attempting to help others .
Usually, the mission must be planned long before they can be achieved. A pre-mission plan is critical prior to arrival and a contingency plan must be in place for missing mission-critical items. Majority of these collaborations are still disorganized efforts, and they vary according to the centers and universities they are originating from. There are no coherent international collaborations, and many failures have been reported . Necessary conditions and limitations of these actions are reflected in the “Seven sins of humanitarian medicine”  to which others can be added:
most missions are deployed in disadvantaged countries, most of them being non-European Union (EU);
time-limited missions: the activity of a mission lasts several days, and periodicity consists in two to three missions by year;
local doctors do not have enough time to be trained or the medical supplies that have been brought cover the hospital’s needs for short periods of time;
involves a small number of staff that often change due to availability, depending on the period and the country in which the mission will take place;
recognition of the medical licenses to practice in that country (involves administrative problems and takes a long time);
gathering the patients and the preparation for surgery and most importantly the follow-up of patients after surgery, because the surgeons who performed the surgery must return to their country and all complications must be handled by local surgeons;
sometimes, the medical resources, which are donated do not have the best quality or the medical devices, need specific legislation to be put into practice in local hospitals.
Care or service should be provided to the patient in the right way consistent with scientific knowledge and the highest-quality services.
Millions of hernia operations are performed each year, making hernia the world’s most common of all surgical operations. The increased number of patients with hernias led to the need for a specialized surgical field. In adults, the only treatment for a hernia is surgical, and there are several different approaches with different results. The aim consists on patients getting access to the care or service they need, no matter where they are, regardless of their material situation.
When deciding which surgical service to offer facility capabilities and infrastructure must be considered. A well-equipped facility is necessary to support a strong education program in undeserved areas. According to the World Health Organization Safe Surgery Initiative, operating theaters must be of adequate size, have appropriate lighting, and have dependable electricity and water to a minimum .
Advancements in health-care always come down to collaboration. It benefits both the health-care system and the population as it may provide new treatments which are probably not already available in that country .
By focusing on collaboration with institutions around the world rather than the simple provision of short-term services, hope is to promote a culture of training and investigation to be shared equally among all partners.
There are no data in the study on the integration of surgical services within a health system or as a component of health system strengthening. Conceptual models should be proposed based on the international meetings, knowledge gained across the international collaboration, infrastructure or patient population, resources and materials, and knowledge transfer tools to facilitate communication. A preliminary model presenting a concept of surgical care integration within a health system is being presented in association with various medical literature resources that further the World Health Organizations vision of a health-care system model .
What if dedicated hernia experts would collaborate through hospital networks (hernia centers) committed to providing surgical excellence and best patient outcome. The opportunity to develop this hernia center networks would provide a hernia international collaboration:
sharing knowledge and repair strategies among surgeons;
if a surgeon has doubts about a case, he may ask for guidance;
if one of the hospitals has certain shortcomings, the patient can be referred to another hospital;
practice will attentively guide the patient and caringly support him;
before surgery, the patient will be guided through the process and provided all of the information required to make informed decisions and plan for the procedure;
after surgery, follow-up by telephone or coming directly to the center will make sure that the patients are happy, healthy, and completely satisfied as returning to their normal activities;
academic publications, papers, presentations, textbooks, and letters will be issued by this hernia centers;
will enable access to part-time or temporary full-time experienced Research & Clinical Trials;
discussing cases will be done by videoconference or will be the possibility of forming an international commission composed of one member of each country, to meet twice a month to discuss all types of complex cases and to individualize patient care.
Whether the condition of one of the patients requires care from one specialist or an entire team, the surgeons work side by side with the patient explaining to him/her the entire treatment to develop a personalized care plan to treat his/her condition. In some cases, such as complex reconstructions, collaboration will be needed by working with surgeons from the Division of Plastic and Reconstructive Surgery to perform procedures and help coordinate the most appropriate course of care for the patient.
2. International hernia centers and surgical care
I want to reinforce the statement made by Dr. Halfdan Mahler: that surgery has a key role in health-care, and unfortunately although medicine has evolved so much lately by getting to work with robotics, body parts transplants, the appearance of new different surgical materials, the majority of the world’s population has no access whatsoever to skilled surgical care because of the poverty. Much more can be done if we share common goals meet in working, learning, practice, all for the benefit of the patients.
Conventional solutions are not likely to be very satisfactory. So what should the international surgical community do?
The magnitude and importance of achieving solidarity and cooperation in an interdependent world calls for a major program and considerable support. For decades, hernias have been managed by all general surgeons, but now top-tier medical systems are recognizing the value of standalone hernia centers, staffed with physicians equally adept at open surgery and minimally invasive techniques.
Hernia literature is more and more focusing on developing surgery techniques, discussion focused mostly on surgical meshes, mesh repair versus tissue repair, robotic surgery, robotic-assisted procedure versus the laparoscopic approach and so on. What about hernia health-care system? A commitment to patient care and success necessitates that the requirements be comprehensive, research-based, and verified through a rigorous site inspection?
Even if private institutions began to greatly develop the terminology of “hernia center” as not yet well understood, that is why it is more used as a marketing instrument. Google has approximately 6,560,000 links associated to “hernia center” from a single search inquiry. There are very few scientific articles in which the term “hernia center” is explained as a model of how surgical care might be integrated within a health system. As a result of this lack of factual content related to “hernia center,” it is clear that this term is being used loosely as a potential trigger to mislead patients into believing that they are getting proper treatment from certified private institutions .
I propose a new model for integrating modern surgical hernia centers network to continue pioneering independent efforts to further expand modern surgical care for patients with hernias. Many hospitals and surgery centers offer hernia repair—but most of the patients would not receive the same results and level of personal care everywhere. Hernia centers will offer a hernia repair from a leading surgeon who provides unmatched expertise and state-of-the-art treatment options. For patients, this means a positive and happy experience, a swift return to normal life, and a lower risk of discomfort and complications.
The first strategy would be the creation of hernia departments within the major hospitals in the university cities by accessing European funds or charity. The departments should be run by a team of specialized surgeons and nurses who will take charge of the patient. A platform for improving health-care delivery around the world should be created. One way to manage these expectations is to create a strategic plan that clearly outlines goals for the future and how to reach them. In every country, there are less equipped hospitals and hospitals with a high level of training and equipment. The consultants will assume the responsibility in keeping contact with all hospitals, to take charge of patients, to attend conferences, and to participate in clinical trials to collaborate for the benefit of the patients. The idea is that depending on the hospital conditions and the particularities of the case, the patient is referred to a specialist in the country or in another country. The most important is that the patient will be staying in contact with his/her surgeon.
The second suggestion would be to create specialized centers: hernia centers in each country which gather surgeons focusing on hernias. As thousands of new cases are being added each year, centers are able to offer the best possible treatment options available in all hernia-based cases. This project will provide opportunities for patients to be treated by true experts in hernia field, but also for surgeons to maintain a record of operated patients, the type of surgery performed, the complications that occurred, and the complexity of the cases with their particularities. The analysis of this information will lead to improved surgical services by creating a relevant statistic which will help us to make hernia protocols. A “hernia center” is capable of continuous improvement focused on a magnitude of experience.
Surgeons who will work in these centers will be experienced in treating primary and recurrent hernias using both open and laparoscopic methods. The hernia center will be equipped with the newest techniques and materials in hernia repair. The center should be available to patients for consultation, surgical treatment, follow-up, or just for questions, and should provide appointments and international collaboration. Hernia center should provide assistance also for emergency situations.
3. Hernia physicians
Abdominal wall reconstruction, proper care of recurring hernias, pain prevention, treating hernias with enterocutaneous fistulas, complex mesh-associated infections, and mesh reconstructions require specialized treatment plans that can be established by team members using laparoscopic and modern hernia repair techniques.
The fear of patients and inexperienced surgeons is mainly focused on how to deal with the complications that occur after surgery. Recurrence after primary hernia repair or the complexity of the case due to its particularities highlights the need for hernia experts. A surgeon has many qualities but being patient and calm can be reflected in the way patient is treated: to be listened and understood, to receive all the required answers, and to understand the treatment options they have so that they will fulfill all the recommendations received.
Multidisciplinary experts work in a team environment to serve each patient’s unique needs with an individualized care plan. The physicians not only treat patients but conduct scientific research and teach the next generation of medical professionals.
The aim of these departments/centers will be focused on finding personalized solution to help the patient to return to an active, pain-free life. The surgeons are particularly skilled in assessing hernias and determining their appropriateness for open or laparoscopic surgery.
The hernia center will offer the full range of surgical options to repair hernias. Most hernia repairs are, by surgeons’ standards, relatively straightforward and uncomplicated. Some, however, are more complex because of their size or because they occur at the site of a previous surgical incision that has not healed adequately. The hernia team will repair all types of hernias, including inguinal hernia, femoral hernia, umbilical hernia, incisional hernia, spigelian hernia, obturator hernia, epigastric hernia, hiatal hernia, and diaphragmatic hernia. Minimally invasive surgery such as laparoscopy is generally better for patients—less pain, faster recovery—but it demands additional training for the surgeon. Open inguinal hernia repairs will be possible to perform as an outpatient procedure under local anesthesia.
Surgical team should include general surgeons and plastic surgeons, as well as clinical and support professionals collaborating to provide a comprehensive care to patients. Surgeons will carefully plan surgery for each patient depending on the characteristics of the hernia and the comorbidities of the patient. Specialists are mastering the laparoscopy technique and are prepared to manage complications: hernia recurrence, pain after previous repair, hernias with enterocutaneous fistulas, mesh reconstruction, and complicated mesh-related infections.
Complex or not, all patients wish their hernia to be treated by practitioners who perform more than 200 such procedures a year, instead of, say, 20 or 30? It is this type of experience that gives to patients a greater likelihood of an uncomplicated operation and a successful outcome.
4. Things we must do for patients
Providing care for poor people, persons who are not insured, undocumented immigrants is an issue, particularly in developing countries or very poor neighborhoods from different countries. Physicians can also volunteer their time to care for these patients, and how a physician handles a situation may depend on the specific case, and the most important thing is to focus on the international collaboration.
We should place greater importance on providing preventive care: teaching patients to eat right and exercise, and compensating health-care professionals for providing that care. It is important for physicians to remove their personal agenda or bias when helping patients understand their options and make good health-care decisions. In other words, we cannot only rely on old-fashioned forms of caring for patients. It is increasingly important that we care for patients in new ways and pay health-care professionals to do so. Surgeons should place value of care as a priority, thus creating a patient-centered approach which would place a priority on the quality of care rather than volume. Safe surgery involves avoiding complications or adverse events that can arise before, during, and after surgical procedures and most importantly avoid any danger of exposure to disease while they are in a vulnerable, postoperative state. Thus, safety measures are implemented before anesthesia, before incision, during surgery, and in the provision of postoperative care.
The need for a greater regionalization of care, the use of telemedicine, and providing incentives to relocate where patient needs is the greatest merit that requires further exploration.
Existing guidelines, which often reflect the values and practices of a particular region, have not yet achieved this goal. Accurate assessment of quality in hernia repair also will require a better long-term follow-up worldwide.
The network will aim to promote a systematic guideline development and implementation which “seeks to improve the quality of health-care by promoting systematic development of clinical practice guidelines.” Professionals from all countries should join together to form networks for the rapid exchange of information on outbreaks. Networks, focusing on a wide particularity of the case, the possibility of repair, availability of medical supplies, medical strategies, and so on such as the European Working Group for Legionella Infections (EWGLI) or the European Influenza Surveillance Scheme (EISS), form the basis of international cooperation on communicable diseases within the European Union . A specific example comes from New York City about how social media, specifically the International Hernia Collaborative, has changed the way surgeons communicate and collaborate with one another to help patients . The start can be given the EHS-GREPA which has representative members from each country, including the International Hernia Collaboration (IHC) (more than 2500 members) created by panelist Brian Jacob, MD. The creation of these social media communities is invaluable for sharing knowledge and varied perspectives, social/professional support, rapid communication dissemination, and advancement of innovative solutions and improved patient care. The thing is that in one country, there are multiple centers which must communicate, and when a situation goes beyond their country should be able to get in touch with a hospital from other country for the benefit of the patient. International Patient Program should provide advanced diagnostic, medical, surgical, and rehabilitative specialty care to patients from around the world. The health-care providers will work together as a team—with each patient at its center—to provide the most effective and compassionate care, always.
5. Surgery and poverty
Surgery in low-income and middle-income countries faces implementation challenges. Compared with vaccination or antiretroviral treatment, surgery needs more infrastructures—for example, clean operating rooms, anesthesia, electrical power for monitoring equipment, and ancillary laboratory services. The infrastructure investment and the recurring cost of its maintenance might be a financial obstacle to implementation, especially when compared with complex public health interventions. The high cost, infrastructure demands, and complexity of implementing surgery compared with other public health interventions are challenges, but they are not insurmountable. In addition to providing common surgical items, medical device manufacturers could make a real impact by developing high-quality easily serviceable devices for all aspects for surgical care, instrument sterilization equipment, and monitoring machines.
Funding is a big issue which needs to be considered seriously. Every recurring incident of a hernia-related operation places a significant financial weight on the health-care system and it may even lead to further problems for the patient. Cost-benefit analysis will always report that by correctly treating the patients with proper conditions, complications will be avoided. Economic losses can be reduced by quantifying the risks, especially in groups of patients who may be more prone to complications and by applying prophylactic measures. Typical forms of economic analysis include cost analysis per individual procedure, efficient spending related to the financial values of standardized medical outcomes, and the associated social benefit that involves the reductions of cost to an individual who has undergone an operation and society as a whole. Fundamental knowledge of the financial value of health interventions is crucial for policy makers to make proper decisions related to the allocation of resources.
Although there are increasing funding opportunities, mainly via philanthropic organizations, some nongovernmental organizations (NGOs), and even governmental organizations, the sheer problem is so huge that more is continually needed. There are many different policy options to ensure the successful development of these chains of specialized centers, but what works for one country may not work for another. The EU provides funding for a broad range of projects and programs covering areas such as research & innovation or humanitarian aid. The EU has been providing humanitarian aid since 1992 in over 140 countries. EU-funded humanitarian assistance is implemented through humanitarian organizations. These are European NGOs, UN agencies, and International organizations. Because in each country the national governments manage the funding, a proposal would be that, through the European hernia society, unanimously obtain funds for each member country and form a network between centers. A project based on the work of an international team aiming to help the society has more chance to succeed.
Special attention should be paid to internationally collaborated work identified based on the creation of centers or specialized departments. With the involvement of various international organizations, policy makers, health-care managers, and other stakeholders, a collaborative approach can be achieved in order to accelerate progress toward an improved and sustainable surgical care. It can often be found that various charitable groups are primarily responsible for the proper delivery of medical and surgical care in both less developed and developing countries. Lately, many surgical organizations have appeared but who keeps track of them and their results, who monitors their outcomes, who controls them to ensure the quality of the materials used in the mission, and most of the volunteers are not hernia experts. In the published literature, we find immediate results of the mission in question, and almost all missions have very good results without complications. To determine their real collective contribution, a comprehensive database of these groups is needed.
6. Improving research
Hernia centers can improve research. Through hernia centers, surgeons will be able to record all their activity from the type of interventions, whether mesh was used or not, patient comorbidities, postoperative complications, long-term follow-up of patients, in other words, a high-quality databases. Hernia centers will be an ongoing initiative to motivate all surgeons to report their operations in order to increase the national reports. It is critical to ensure quality databases by maintaining a high registration rate. All data can be published every year or a multicentric study can be carried out which will provide scientific evidence to generate further recommendations, unanimous protocols, and guidelines. A dedication to continuous improvement and higher levels of excellence sets forth that requirements be research focused, proven through extensive site inspections and reviews.
7. Certification processes
Treating patients by nongovernmental organizations, performing surgery procedures that are not in conformance with the guidelines of the hernia societies, and by different volunteers, who are not properly trained sometimes under conditions not so favorable can lead to considerable complications for the patient and therefore additional costs for the society.
A primary necessity for valid certification of hernia centers includes a clear explanation of associated regulations and requirements and verification through either hernia societies and/or non-profit organizations to ensure the optimal quality for hernia surgery. In addition, treatment quality must be verified through a certified center and it must be acquired through mandatory participation within a quality guarantee program or registry that includes a follow-up with patients.
Certified Center of Excellence in Hernia Surgery (COEHS) means a rigorous center of excellence program based on the effectiveness of the experts—well-trained hernia surgeon members of hernia societies fully committed to hernia field and properly equipped to ensure efficiency of technical care worldwide. Hernia centers will improve the follow-up of the patients gathering data through which we can create an international database. Health-care system is changed by international protocols which are deliberated after a long research with significant impact. That is why we need hernia centers to support us by facilitating our work and especially to ensure quality treatment to all patients.
Hernia centers should be certified by the European Hernia Society (EHS)/Americas Hernia Society (AHS)/Asia Pacific Hernia Society (APHS) depending on the country in which the center will be built. Member representation and participation in these committees is of critical value and can serve as a stepping stone for senior leadership roles within the society.
German Hernia Society presents a model on how hernia centers should become certified through a Certified Hernia Center program which is very well explained in an article  published in 2014. We can also take the model of cancer institutes, which focuses only on cancer pathology. There are not many definitive consensuses in hernia field concerning prevention, which surgical technique is best, non-mesh repair versus mesh repair, robotic versus laparoscopic approach for ventral hernias, and the possibilities of repairing hernia recurrences. That is why an individualized, patient-centered approach is needed, and how can you achieve it better than by setting up hernia centers. These initiatives based on collaboration and globalization must become our future target focused on improving care for all hernia patients.
8. Next step for hernia
Although surgery requires more specialized human resources and infrastructure than many traditional public health interventions, when these challenges are met, surgery can produce health benefits with similar cost-effectiveness ratios .
There are surgeons who dedicate the majority of their surgical practice to abdominal reconstructive surgery and others who perform ventral hernia repair infrequently or refer the more complicated patient to another surgeon. No matter the patient, surgeon, or acute care facility, all HealthCare Systems need to provide value to patients for all surgical care episodes, promote collaboration across the health-care system, stimulate sharing of best practices, and initiate changes in the health management. Professional cooperation is needed. The professionals involved in its inception all share a passion for global health in addition to hernia surgery.
An important step in taking action for hernia collaboration was made by Dr. Brian Jacob, the founder of The International Hernia Collaboration Facebook™ Group being the new example of a professional-to-professional-to-industry group where exchange of information is centered on the concept of improving patient outcomes. Members, either surgeons or members of an academic institution, from all over the world, UE and non-UE, join this group, and their number is growing every day.
International Hernia Collaboration Facebook™ group demonstrates that social media can be used professionally as an extremely effective educational tool that provides rapid global collaboration with limitless possibilities, all designed to optimize patient care.
Research demonstrates that a high-volume experience results in improved patient outcomes. Task-sharing is greatly needed to grow the global surgical workforce, to enhance international collaboration, leverage technology, and optimize health systems. The challenge includes all surgeons and hospitals in a concerted effort to improve the quality of care across the board.
Creation of these institutional partnerships and trainee exchanges can enrich training, stimulate commitment to patient care, and promote the equal exchange of ideas and expertise.
I want to emphasize the role of these centers in providing a welcoming physical environment, respect for their values, empowerment and collaboration, coordination and integration of care, comfort and support, and access and navigation skills to patients and their families.
The concept is designed to help organizations deliver a consistent, safe, and high-quality approach to care—that is, an approach that reduces the risk of error and improves outcomes and customer satisfaction—by providing the following:
integrated, coordinated, patient-centered care—starting with the hernia consultation and continuing through the hernia surgeon follow-up visit;
comprehensive education of, and shared decision making with occurring along the continuum of care from hernia consultation to care of the patient (preoperative, intraoperative, and postoperative) to discharge to follow-up visit with the hernia surgeon;
consistent communication and collaboration with all health-care providers involved in the patient’s care and transitions of care—including providers on the interdisciplinary team (as well as those who are not on the team) from the hernia consultation through the follow-up visit with the surgeon;
ongoing quality improvement processes—involving the implementation of improvements to the program from the hernia consultation to the hernia follow-up visit.
The surgeon’s role is to continue to be the patient’s “provider of choice” in hernia treatment and be a global leader in hernia education and research. To align the objectives of clinicians, patients, and providers, “a greater emphasis on value is key, and achieving high-value care for patients must become the goal of health-care delivery, thereby reducing costs” .
Successful change must be locally driven by local leaders, supported by global partners through true accompaniment, global collaboration, and an emphasis on systems, not silos. Only in this way will we be able to do some action.
There is work being undertaken to have work-based assessments and a curriculum to officially recognize the benefits and learning opportunities of work abroad.
I conclude by discussing hernia surgery and hernia centers as a global health priority and possible solutions to improving surgical care globally.
Conflict of interest
No conflict of interest.
God bless all my family members who have shown so much of faith in me throughout my challenging situation in life.