To the Editor:
It is widely acknowledged that surgically treatable conditions represent a significant proportion of the world’s global burden of disease. Studies estimate this proportion to be as high as 11% to 15%, and up to one-third of the world’s population receives only 3.5% of the available surgical care.1,2 In fact, 18.6 million people die each year as a result of a lack of safe and essential surgical services, which is 3 times the number of deaths caused by HIV/AIDS, tuberculosis, and malaria.3 Thus, there has been a paradigm shift in global health that debunks the idea that surgical intervention is too costly in developing countries. We now know that surgically treatable diseases can be addressed on the global setting and be made available and even affordable to impoverished populations.3,4 Neurosurgery is no exception and, in fact, may exhibit an even greater gap in access to care. Globally, there are 14 million additional neurosurgical procedures needed and a shortage of 90 909 neurosurgeons.5 As neurosurgeons, we are relatively small in number, which means we each shoulder an even greater responsibility to address this disparity.
In the April issue of BMJ Global Health, an article titled “Global Surgery 2030: a Roadmap for High Income Country Actors” by Ng-Kamstra et al6 was released. The authors report that with the emergence of the United Nations Sustainable Development Goals, a focus has shifted to improving access to safe and quality surgical health care everywhere. The article summarizes relevant literature and conveys consensus recommendations for high-income countries, which are separated into 4 distinct categories. Although these key points are relevant to the field of neurosurgery, we face unique challenges that must be considered for progress to be made.
ROLE OF ACADEMIC CENTERS
Colleges and academic medical centers play a crucial role in this process and should be the main driving force behind support for surgical training and education of healthcare providers overseas. According to the Lancet Commission on Global Surgery,7 there needs to be at least 1.27 million new surgeons, anesthesiologists, and obstetricians by 2030 to reach conservative health-needs benchmarks. Training neurosurgeons overseas can be difficult because of a lack of time, resources, and available trainees. We must expand existing partnerships between academic centers and regional training centers in low- to middle-income countries. For example, the use of twinning programs to combine delivery of surplus equipment along with training camps, capacity building, and resident education has shown to be a great success in our own program with hospitals in Uganda.8 Surgical boot camps have demonstrated great efficacy in the education of basic skills and essential fundamental knowledge for US residents, as well as retention of that knowledge.9 This is a promising vehicle for the transference of skills and knowledge to overseas surgeons and has already seen an intercontinental expansion in recent years. To allow surgeons in high-income countries to participate in global surgery, there needs to be a foundation already in place for the flow of funding and volunteerism. For example, organizations such as the World Federation of Neurological Societies and the Foundation for International Education in Neurological Surgery have done exemplary work in creating channels for education, equipment delivery, and volunteering abroad. Additionally, with the advancements of new technologies within the arena of telemedicine and virtual skills simulators, there may be new avenues to connect and participate in the education of neurosurgeons in low- and middle-income countries.
ROLE OF INVESTORS AND DONORS
Much of the work done overseas relies on charity funds, government aid, and finances from local stakeholders. As providers, we are tasked to inform investors and donors about the cost-effectiveness of surgical-care funding and to encourage support of focused and well-informed efforts. Promoting epidemiological research from low- and middle-income countries can provide data to support neurosurgical needs and to influence investments. The most successful initiatives will be ones that have garnered interest from multiple party financiers.
ROLE OF INNOVATORS
The push for advancements in biomedical engineering may be more significant to neurosurgery compared with other fields of medicine, and much of our practice is limited by the instruments available to us. We must avoid the pitfalls of simply shipping expensive equipment and prevent dumping used or outdated devices in other countries. A contextual awareness is vital when partnering with engineers and those in the tech industry so that we can design and manufacture equipment from local resources that are tailored to the specific needs of a targeted region. Incentivizing biomedical engineers is paramount, and one strategy may be to include opportunities for private and government-funded research grants for the development of sustainable engineering design projects. Additionally, we should strive for collaboration with biomedical engineering education programs to involve graduate and undergraduate students and use existing global health biomedical engineering programs so that we can increase the production of cost-effective and practical innovations.
ROLE OF JOURNALISTS AND ADVOCATES
Promotion of the global neurosurgery agenda and integration into popular media are needed to gain support and to raise awareness for investors and other stakeholders. Traditionally, news headlines have concentrated on communicable diseases and vaccine discoveries. However, this is not an accurate description of the entire global healthcare landscape. It is our duty as part of the surgical community to educate others and to mold public opinion. It has been said that to be a neurosurgeon is to be a leader. Therefore, we must take advantage of this respect our status holds and be more active in the media in the form of op-eds, editorials, letters, interviews, or public speaking events.
It is clear that momentum has been gathered for the global surgery agenda, and change is possible now more than ever. As summarized well in a recent article, “Global Neurosurgery, the Unmet Need,” Park et al3 state: “A committed global neurosurgical community can transform the current landscape by training surgeons, advocating for the patients, and facilitating the delivery of essential and emergency neurosurgery to all those that need it.”
The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
1. Ozgediz D, Jamison D, Cherian M, McQueen K. The burden of surgical conditions and access to surgical care in low- and middle-income countries. Bull World Health Organ. 2008;86(8):646–647.
2. Ellegala DB, Simpson L, Mayegga E, et al. Neurosurgical capacity building in the developing world through focused training. J Neurosurg. 2014;121(6):1526–1532.
3. Park KB, Johnson WD, Dempsey RJ. Global neurosurgery: the unmet need. World Neurosurg. 2016;88:32–35.
4. Warf BC, Alkire BC, Bhai S, et al. Costs and benefits of neurosurgical intervention for infant hydrocephalus in Sub-Saharan Africa. J Neurosurg Pediatr. 2011;8(5):509–521.
5. Park K, Peña-Tapia P. Global Neurosurgery. Available at: https://globalneurosurgery.org/
. Accessed May 6, 2016.
6. Ng-Kamstra JS, Greenberg SLM, Abdullah F, et al. Global surgery 2030: a roadmap for high income country actors. BMJ Glob Health. 2016;1(1):e000011.
7. Lancet Commission on Global Surgery. Lancet Commission on Global Surgery. Available at: http://www.lancetglobalsurgery.org/
. Accessed May 6, 2016.
8. Haglund MM, Kiryabwire J, Parker S, et al. Surgical capacity building in Uganda through twinning, technology, and training camps. World J Surg. 2011;35(6):1175–1182.
9. Selden NR, Anderson VC, McCartney S, Origitano TC, Burchiel KJ, Barbaro NM. Society of Neurological Surgeons boot camp courses: knowledge retention and relevance of hands-on learning after 6 months of postgraduate year 1 training. J Neurosurg. 2013;119(3):796–802.