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Impact of COVID-19 pandemic on neurosurgical residency in Sudan

Fadalla, Tarig MBBSa,; Mohamed, Afnan MBBSa; Elsayed, Mohamedzain MBBSa; Elmahdi, Muhab MDb; Elsalawi, Walid MDc

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doi: 10.1097/SR9.0000000000000044
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Neurosurgical training in Sudan is organized by Sudan’s Medical Specialization Board since 2003. Since its establishment, the program has graduated 54 Neurosurgeons; 12 of them are female Neurosurgeons. Candidates are required to complete their Internship year after receiving their MBBS degree to be legible to sit for the Neurosurgery Entry Exam (Neurosurgical MD first part exam). Successful candidates spend 6 years in the training program in which they rotate around 6 Neurosurgical centers. 18 months are spent doing elective shifts (3 mo each) and 54 months neurosurgical shifts (6 mo each). They are also required to complete compulsory courses in biostatistics, ethics, and medical professionalism. The thesis dissertation is also required as partial fulfillment before the candidate sits for the Exit exam (Neurosurgical MD second part exam). The pandemic has disturbed this process and affected neurosurgical training in the entire world; however, the toll it took on low-income countries, such as Sudan whose health care system was already suffering far exceeds that of other countries. Neurosurgical care is unequal worldwide, with up to 5 billion people from low and middle-income countries not having access to safe and affordable neurosurgery a year1.

The Neurosurgical training in Sudan was already compromised due to a scarcity of resources to perform surgeries, an inadequate number of Neurosurgeons in the country to train residents, and preexisting problems in the infrastructure of the healthcare system. On top of these preexisting problems, the pandemic came with more problems to navigate and restrictions that played a role in compromising the Neurosurgical training of residents in the country (Fig. 1).

Figure 1:
Ice berg model of impact of COVID-19 on neurosurgical training in Sudan.

The restrictions imposed by the COVID-19 pandemic have challenged previous models of neurosurgical training bringing forth the necessity to adopt emerging technological solutions2. In order to maintain social distancing and due to the lockdown many of the neurosurgical activities were canceled or spaced out. Teaching, academic meetings, lectures, and conferences were either canceled, decreased in frequency, or converted to online sessions thus compromising the in-person experience Neurosurgical trainees used to have before the pandemic. In addition to that, the number of in-patients also decreased as hospitals were trying to accommodate fewer patients, therefore, decreasing the number of cases inwards and decreasing the exposure of residents.

While e-education has been a great tool to compensate for the lack of activities and keep the training process ongoing, for trainees in Sudan, a new set of obstacles came to life. The internet services in Sudan are not only expensive but also not stable enough. That coupled with the lack of training or knowledge to properly use online mediums to host and deliver lectures online. While a solution for the theoretical aspect for education was found. No alternative was found to compensate for the practical aspect as many of the elective surgeries were canceled.

Despite the fact that emergency cases outnumber elective cases in Africa, surgery cancellations were noticeable3. In the early days of the COVID pandemic, the World Bank estimated that the cancellation of surgeries in Sub-Saharan Africa has reached 520,459 cases3. Moreover, the reasons behind the high rate of cancellation of surgeries could vary, including the restricted mobility during the lockdown, the fear of contracting COVID, and the closing of some health facilities4. The cancellation of surgeries took a huge toll on doctors in African countries like Sudan due to the low income from the governmental institutes. Fresh graduate doctor receives about 16,000 Sudanese Pounds which equals US$36.05 per month, which is below the poverty threshold (US$57 per month).

Normally they get more financial benefits from the surgeries; therefore, their finances have decreased significantly during the pandemic5. This added insult to injury when it came to the preexisting problem of staff shortage in Sudan’s health care system, even before COVID. One of the reasons contributing to staff shortages is the migration of doctors from Sudan, especially to the Gulf countries, to escape from the different difficulties in Sudan. The continuous infections, hospital admissions, and deaths from COVID-19, as so far, more than 40 Sudanese health professionals died due to COVID infection6, has reduced the number of the available doctors to provide patients with health services. Sudan’s health care system is beset with challenges, including a lack of personal protective equipment and basic pharmaceuticals. Doctors and other medical personnel were confronted with the pandemic without the necessary equipment or even protective precautions for themselves and their patients3.

Even before the pandemic, Sudan’s health system was struggling to keep up with the daily influx of Neurosurgical patients. The large number of patient presenting to the fragile system, in comparison to available services, resources, and staff, has resulted in a complete imbalance and loss of flow within these facilities. Problems faced included overcrowding of rooms, contributing to the increase if nosocomial infections therefore posing a threat to the patients in the ward by subjecting them to the possibility of postoperative infections.

Oncologists in Sudan were unable to strike a compromise between safeguarding themselves, their employees, and their patients while also performing necessary surgeries. As a result, several oncological surgeries and appointments were also postponed7,8.

The impact of the pandemic on the educational system will definitely continue for the next few years9. This includes exams that were postponed during the pandemic, the pregraduate and postgraduate exams. Regarding the pregraduate exams, universities were not able to regularly organize lectures and exams along with putting students and tutors at direct risk to contract COVID infection. Therefore, there was an obvious delay in completing the curriculum in many Sudanese medical colleges, which reflected the critical shorting of staff during the pandemic. Postgraduate exams were deferred too, as an example, membership of the royal college of surgeons part A which was planned to take place in January 2022 was postponed to an unknown date10. Objective structured clinical examination (OSCE) exams have been affected significantly due to the pandemic, organizing OSCE exams became more challenging considering the person-to-person interaction that is needed most of the time, yet, many organizations worldwide have adopted online OSCE exams to carry on with the educational process, but then again doctors in Sudan do not have the appropriate facilities required to keep up with these changes. The COVID-19 pandemic was perceived in different ways by the people of Sudan which also contributed to the difficulty faced when it came to controlling the disease. To a small but significant segment of the Sudanese population, COVID-19 is a political game that was created by political parties in bids to secure the country’s economic stability. Others argue that COVID-19 has been eradicated from the country and that the illness is simply a flu misdiagnosed as COVID-1911.

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The authors declare that they have no financial conflict of interest with regard to the content of this report.

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