Two thousand and twenty has been a transformative year in the lives of most people worldwide. This is no different for neurosurgeons. As a practicing neurosurgeon, academic department chair and chair of the Foundation for International Education in Neurological Surgery, I have found that the major issues of this year have touched every single aspect of what we do and what we stand for.
This year has given us the dual issues of the global COVID-19 pandemic and a worldwide focus on renewed campaigns for social justice to end racism of all kinds. For me, this time raises two very important questions:
- What is the relationship between health and social justice?
- How does access to health care determine the presence or absence of social justice?
I would argue that the two are directly related. The pandemic led to a global, near complete shutdown of society, economy, agriculture and jobs. The effects are variable depending on the reserves of the society affected, but in many parts of the world, such a shutdown inevitably will lead to famine, isolation, fear, anger and violence. Indeed, historically such conditions may proceed war, a deterioration of relationships between people and nations, often due to stress from a pandemic.
A specific strain for global neurosurgery has been the almost complete ban on travel. When borders shut and quarantines become instituted against travelers coming to areas, face-to-face global health activity grinds to a halt, as does the supply of necessary equipment, curriculum and education. Indeed, trainees may be restricted from traveling to their training sites, effecting graduate students, residents and post-graduate physicians worldwide. The resulting isolation and fear can lay bare millennial grievances leading to realistic concerns about international relations, such as those between China and the U.S., leading to violence close to home. The conditions have placed a much-needed magnifying glass on centuries of racism and inequalities of social justice. It’s time to assume responsibility, reflect and change.
Neurosurgery has always been a keystone in the overall structure of global health. Worldwide disparities in health care are far greater in surgical specialties than they are in medical specialties.1,2 Deaths attributed to lack of surgical access surpass those of the most common communicable diseases.1,2 Numerous nations in low- and middle-income countries possess less than one neurosurgeon per one million people.3,4,5 With the absence of neurosurgical care, there is a collapse of the trauma system, there is a collapse of care for congenital central nervous defects of children. There is an inability to care for benign tumors and trauma. Often, such care could return healthy productive patients to society and jobs. People like myself have long counseled ministers of health as to the benefits of involving specialized care like neurosurgery in their health care system to allow a complete and self-sustaining system of trauma, cancer, pain, stroke and congenital anomaly care. The landmark presentations of the Lancet Commission on global surgery and the World Bank reports in 2015 showed that this absence of lifesaving care, which could return productive citizens to society, is lacking in five billion people worldwide, with as many of 47 million avoidable deaths and a cost of 16 trillion dollars over the next 11 years.3,6 Prior to the pandemic, the Foundation for International Education in Neurological Surgery, which I chair, working with the World Health Association and the Lancet Commission was actively formalizing the process of “service through education.” This refers to the training of surgeons in their own countries by developing appropriate curriculum, equipment and championing local chairpersons to direct these programs so that they would become the program of their own country, as opposed to that of foreign entity. This has shown remarkable progress now over 100 trainees in sub-Saharan Africa, where previously there were none.7 FIENS and the Society of Neurological Surgeons brought the U.S. concept of bootcamps, standardizing education in a region like South America and then gradually spread it to Africa and Southeast Asia. “Service through education” is a concept that was both hands-on and transformative in its emphasis on partnering with the area of need in curriculum, standardization of care and acceptance of worldwide standards of quality in neurosurgery.8,9,10
While much progress was made, the COVID-19 pandemic upset all. From March 2020, when the worldwide shutdown really commenced in earnest, multiple educational offerings were postponed worldwide. The effects of change are dramatic. Boot camps were cancelled in Vietnam and Kenya. My own stroke reduction program for the Oneida Nation of Native Americans was placed on hold and worldwide patients suffered from a lack of early risk factor modification for stroke and early recognition of symptoms of cancer and tumors when they are still treatable (this project was supported by the Wisconsin Partnership Program – University of Wisconsin – Madison, Stroke Prevention in the Wisconsin Native American Population). All major societies had to rethink their efforts. The global neurosurgery education efforts were no different. While the initial period of fear and isolation stopped in-person education, a revolution in electronic and online communication rapidly took place. Numerous platforms for education were developed and FIENS has embraced not only the standard techniques, but also the specialized techniques modified by the groups InterSurgeon and Help Lightning. These allow ongoing shared conferences and even interoperative teaching with the ability to electronically place pointer instruments into the screen of a surgery half a world away for instruction and reinforcement.11,12,13
Coincidently, with the pandemic came a worldwide awareness of the need to address social injustice. Although the flashpoint was an incident in Minnesota, the roots of these problems are millennia old and worldwide.14 FIENS has always been dedicated to important principles and lessons learned. One of the most important is that anyone involved in global neurosurgery is to “First be quiet and listen.” We cannot assume that the surgeons in the high-income countries know or fully understand the needs, desires, plans and aspirations of our colleagues in low- and middle-income countries. The single most important lesson is to be present, originally in person and now electronically, and to listen. Fortunately, FIENS has always embraced a concept of bidirectional learning. In the bootcamps, it was always seen that the benefits to the teachers and the education they received were every bit as important as the benefits to the “student.” Indeed, by placing the physicians of the low- and middle-income countries in teaching roles during the bootcamps, as opposed to student roles, they assume leadership of their programs – a primary goal.10,12,15 FIENS has, therefore, convened a major online global meeting primarily for presentations from Southeast Asia, South America, Africa, Central and Caribbean Americas on the present assessment by the neurosurgeons with boots on the ground in these regions. Their understanding of their desires and needs and the effects of COVID-19 on them, is very different than those in the high-income countries. From this comes a formalization of the online communication programs and a program of bidirectional learning as opposed to simply didactics flowing from high-income to low-income countries.
Our experience has been that much can be learned in everything we do in low- and middle-income countries. Indeed, the major breakthrough of worldwide hydrocephalus care of the last 30 years came from Uganda.16 FIENS has, therefore, broadened its membership and its leadership to be truly global and to be an agent of listening, bidirectional learning and alignment of mission to develop self-sustaining systems of neurosurgical care under the direction of the people who are being served. As an agent of social justice, we must all understand that health is a basic right of all people. Our goals are to see that work in neurosurgery health care becomes an agent of change for social justice. Such lessons continually remind us of why we entered the field of medicine and neurosurgery in the first place. It is not about us, it is all about the people we serve. These are probably the most important lessons of a very difficult year of 2020, but like all crises, it will bring out the bad and the good. I see it as a period of hope. It is our obligation to choose the good, to listen and embrace a period of change for the better.
References
[expand title=”View All”]
1. M.G. Shrime, S.W. Bickler, B.C. Alkire, C. Mock. Global burden of surgical disease: an estimation from the provider perspective. Lancet Glob Health, 3 (2015), pp. S8-S9. DOI:https://doi.org/10.1016/S2214-109X(14)70384-5
2. R. Lozano, M. Naghavi, K. Foreman, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet, 380 (2012), pp. 2095-2128. https://doi.org/10.1016/S0140-6736(12)61728-0
3. J.G. Meara, A.J. Leather, L. Hagander, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet, 386 (2015), pp. 569-624. https://doi.org/10.1016/S0140-6736(15)60160-X
4. S. Mukhopadhyay, M. Punchak, A. Rattani, et al. The global neurosurgical workforce: a mixed-methods assessment of density and growth. J Neurosurg, 1 (2019), pp. 1-7. https://doi.org/10.3171/2018.10.JNS171723
5. K. Orrico. Statement of the AANS, CNS, ABNS, and SNS before the Institute of Medicine: Ensuring an Adequate Workforce for the 21st Century Available at: https://www.aans.org/pdf/Legislative/Neurosurgery%20IOM%20GME%20Paper%2012%2019%2012.pdf, Accessed 9th Dec 2012
6. S.W. Bickler, T.G. Weiser, N. Kassebaum, et al. Global burden of surgical conditions. Disease Control Priorities, 3rd ed H.T. Debas, P. Donkor, A. Gawande, D.T. Jamison, M.E. Kruk, C.N. Mock (Eds.), Essential Surgery, World Bank, Washington DC (2015), pp. 19-40. https://doi.org/10.1596/978-1-4648-0346-8_ch2
7. Kulkarni AV, Schiff SJ, Mbabazi-Kabachelor E, Mugamba J, Ssenyonga P, Donnelly R, Levenbach J, Monga V, Peterson M, MacDonald M, Cherukuri V, Warf BC. Endoscopic treatment versus shunting for infant hydrocephalus in Uganda. New England Journal of Medicine. 2017 Dec 21;377(25):2456-64. DOI: 10.1056/NEJMoa1707568
8. Dewan MC, Rattani A, Fieggen G, Arraez MA, Servadei F, Boop FA, Johnson WD, Warf BC, Park KB. Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. Executive Summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change. Journal of neurosurgery. 2018 Apr 27;130(4):1055-64. https://doi.org/10.3171/2017.11.JNS171500.
9. Dempsey KE, Qureshi MM, Ondoma SM, Dempsey RJ. Effect of geopolitical forces on neurosurgical training in Sub-Saharan Africa. World neurosurgery. 2017 May 1;101:196-202. https://doi.org/10.1016/j.wneu.2017.01.104
10. Park KB, Johnson WD, Dempsey RJ. Global neurosurgery: the unmet need. World neurosurgery. 2016 Apr 1;88:32-5. https://doi.org/10.1016/j.wneu.2015.12.048
11. J. Piquer, M.M. Qureshi, P.H. Young, R.J. Dempsey. Neurosurgery Education and Development program to treat hydrocephalus and to develop neurosurgery in Africa using mobile neuroendoscopic training. J Neurosurg Pediatr, 15 (2015), pp. 552-559. https://doi.org/10.3171/2014.10.PEDS14318
12. R.J. Dempsey. Global neurosurgery: the role of the individual neurosurgeon, the Foundation for International Education in Neurological Surgery, and “service through education” to address worldwide need. Neurosurg Focus, 45 (2018), p. E19. https://doi.org/10.3171/2018.7.FOCUS18363
13. A.V. Kulkarni, S.J. Schiff, E. Mbabazi-Kabachelor, et al. Endoscopic treatment versus shunting for infant hydrocephalus in Uganda. N Engl J Med, 377 (2017), pp. 2456-2464. DOI: 10.1056/NEJMoa1707568
14. Scheiner A, Rickard JL, Nwomeh B, Jawa RS, Ginzburg E, Fitzgerald TN, Charles A, Bekele A. Global Surgery Pro–Con Debate: A Pathway to Bilateral Academic Success or the Bold New Face of Colonialism? Journal of Surgical Research. 2020 May 10. https://doi.org/10.1016/j.jss.2020.01.032
15. R.J. Dempsey, P. Nakaji. Foundation for international education in neurological surgery (FIENS) global health and neurosurgical volunteerism. Neurosurgery, 73 (2013), pp. 1070-1071. https://doi.org/10.1227/NEU.0000000000000136
16. Lepard JR, Dewan MC, Chen SH, Bankole OB, Mugamba J, Ssenyonga P, Kulkarni AV, Warf BC. The CURE Protocol: evaluation and external validation of a new public health strategy for treating paediatric hydrocephalus in low-resource settings. BMJ Global Health. 2020 Feb 1;5(2). https://dx.doi.org/10.1136/bmjgh-2019-002100
[/expand]
[aans_authors]
