Global Neurosurgery – Targets for Change

Written by: Daniel Robinson

Manchester Medical School

Global neurosurgery can be defined as an area for research, education and advocacy that aims to improve health outcomes and achieve neurosurgical care equity on a global scale (1). The World Health Organization (WHO) prioritizes illnesses based on prevalence and global impact, and thus accordingly distributes its resources. Its main development goals are focused on medical issues such as: child nutrition and immunization, malaria, HIV/AIDS, tuberculosis, tropical diseases and maternal health. Surgical diseases are relegated to a relatively inferior position, particularly neurosurgical conditions, which scarcely register (2). The Lancet report on Global Surgery estimates that 28%–32% of diseases worldwide are treatable by surgical intervention. However, as many as 5 billion people and 90% of the population in low-income countries (particularly in Central, Eastern, and Western Sub-Saharan Africa, and South Asia) lack access to basic surgical services (3).

In contrast to the developed world, where a ratio of 1 neurosurgeon per 80,000 patients can be expected, some areas of the developing world experience ratios of 1 to 10 million (4). From this, we can assume that care is delivered based on geographical location (that is, proximity to neurosurgical centres) and ability to pay. Thereby leading to further disparities in an already struggling system. The fact remains that surgery, and particularly a subspecialty such as neurosurgery, is a luxury in low- and middle-income countries (LMICs). Indeed, according to some estimates, 74% of all major surgeries worldwide are performed in the top third of the wealthiest countries (5).

Millions of individuals are afflicted by conditions, such as hydrocephalus, spine trauma, benign brains tumours, congenital anomalies, and brain abscesses that are amenable by timely neurosurgical intervention. Neonatal hydrocephalus affects approximately 6000 infants in East Africa each year, and a large number of these are secondary to postnatal bacterial infections (6). Without surgical treatment, a significant proportion will not make it past their first years of life. In Uganda, for example, the infant mortality rate is almost 10 times as high as that of the United States or the United Kingdom with 1 in 18 Ugandan children dying before their first birthday, and 1 in 11 dying before they reach the age of five (7).


An immediate method of alleviating some of this suffering is for a neurosurgeon (or small neurosurgery team) with the relevant skills and available time to travel to an area in need to perform as many procedures as possible. However, this option is not sustainable and may therefore pose an ethical dilemma (8). In order to tackle this dilemma, many organisations are increasing their efforts to incorporate education and training of local providers into their plans to tackle neurosurgical care equity.


Education is understood to be essential for developing long-term, sustainable solutions to the myriad of issues encountered in global neurosurgery. Global neurosurgery education programmes seek to improve the quality of care that is provided through skills and knowledge transfer via teaching sessions, and the delivery of various educational materials such as books and online resources (9). The Paul Farmer Global Surgery Fellowship at Harvard Medical School is a good example of an education programme in which investment is provided into educating surgical trainees in LMICs.


Another method to help solve this problem is via training schemes in an attempt to increase the number of neurosurgeons or neurosurgery-capable professionals in the country in need. This is an important step in creating a sustainable future for neurosurgery in LMICs through development of residency- or fellowship-type programmes.


Once a sufficient number of neurosurgeons have been trained, attention can be diverted towards tackling the issue of maldistribution of neurosurgeons within developing countries. That is, employing more neurosurgeons in rural areas in favour of larger cities. The Foundation of International Education in Neurological Surgery (FIENS) and World Federation of Neurosurgical Societies (WFNS) are simultaneously building infrastructure and decentralizing care for patients beyond the traditional concentration in the capital cities (10,11). They aim to provide trainee pathways, supply neurosurgical equipment and develop regional centres in various locations within LMICs. Thereby enabling direct, run-through neurosurgical training in more rural areas. In addition, FIENS and WFNS train neurosurgeons from LMICs within already established regional centres in higher income countries with the notion that they will return to establish training programmes in their home regions. Using their own initiative of which proposals are relevant to the local population, in addition to the help of FIENS and WFNS, they can ensure continuity of a program and care. The American College of Surgeons and the College of Surgeons of East, Central and Southern Africa (COSECSA) work in collaboration with FIENS and WFNS to construct multinational sub-Saharan neurosurgery training programmes and a multi-speciality infrastructure in Africa (12).


It is important to note that not only neurosurgeons need to be trained, but also the other crucial components of a neurosurgical team. Anaesthesiologists, nurses, biomedical engineers, operating room personnel and critical care services require investment. It should be a collaborative process whereby teams are trained collectively to respond to this unmet need. The partnership of the aforementioned organisations has led to synergistic growth in anaesthesia, critical care, imaging, prevention and rehabilitation services in many parts of Africa as well as South America (13).


Furthermore, the impact of the coronavirus disease (COVID-19) pandemic on the delivery of neurosurgical care in LMICs should not be understated. COVID-19 will stretch the resources of the already fragile surgical systems and thereby exacerbate the disparities in access to neurosurgical care experienced by LMICs.


Nonetheless, communication has made the world a smaller place, and most doctors have relatively good access to information. Whilst surgeons in LMICs can learn a lot from those in higher income countries, the reverse could also be said. This two-way exchanging of information could provide developed countries with cost-effective strategies that can be employed to reduce medical care expenses. Simple solutions may prove beneficial, especially as some complex systems have a tendency to break down prematurely or to be improperly implemented.


It is clear that the objective should be to resolve global inequities in neurosurgical care through education and training, and to provide the instruments and equipment to do so. Any successes are possible because the world of neurosurgery not only understands this objective, but also understands that a team effort is required to address this essential humanitarian need.

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References

1. Dare A, Grimes C, Gillies R, Greenberg S, Hagander L, Meara J et al. Global surgery: defining an emerging global health field. The Lancet. 2014;384(9961):2245-2247.

2. Prabhu V. Neurosurgery Initiatives in Global Health. World Neurosurgery. 2015;84(6):1544-1546.

3. Alkire B, Raykar N, Shrime M, Weiser T, Bickler S, Rose J et al. Global access to surgical care: a modelling study. The Lancet Global Health. 2015;3(6):e316-e323.

4. El Khamlichi A (2005) Neurosurgery in Africa. Clin Neurosurg 52:214–217.

5. Weiser T, Regenbogen S, Thompson K, Haynes A, Lipsitz S, Berry W et al. An estimation of the global volume of surgery: a modelling strategy based on available data. The Lancet. 2008;372(9633):139-144.

6. Uganda, WHO Statistical Profile, Country statistics and global health estimates, World Health Organization and United Nations partners; 2015.

7. Uganda Bureau of Statistics (UBOS) and ICF International Inc. Uganda Demographic and Health Survey 2011. ICF International Inc., Kampala, Uganda: UBOS and Calverton, MD (2012).

8. Melby M, Loh L, Evert J, Prater C, Lin H, Khan O. Beyond Medical “Missions” to Impact-Driven Short-Term Experiences in Global Health (STEGHs). Academic Medicine. 2016;91(5):633-638.

9. Haglund M, Fuller A. Global neurosurgery: innovators, strategies, and the way forward. Journal of Neurosurgery. 2019;131(4):993-999.

10. Dempsey R, Nakaji P. Foundation for International Education in Neurological Surgery (FIENS) Global Health and Neurosurgical Volunteerism. Neurosurgery. 2013;73(6):1070-1071.

11. Kahamba J, Assey A, Dempsey R, Qureshi M, Härtl R. The Second African Federation of Neurological Surgeons Course in the East, Central, and Southern Africa Region Held in Dar es Salaam, Tanzania, January 2011. World Neurosurgery. 2013;80(3-4):255-259.

12. Budohoski K, Ngerageza J, Austard B, Fuller A, Galler R, Haglund M et al. Neurosurgery in East Africa: Innovations. World Neurosurgery. 2018;113:436-452.

13. Servadei F, Rossini Z, Nicolosi F, Morselli C, Park K. The Role of Neurosurgery in Countries with Limited Facilities: Facts and Challenges. World Neurosurgery. 2018;112:315-321.

14. Mukhopadhyay S, Punchak M, Rattani A, Hung Y, Dahm J, Faruque S et al. The global neurosurgical workforce: a mixed-methods assessment of density and growth. Journal of Neurosurgery. 2019;130(4):1142-1148.

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