Challenges in Global Neurosurgery

Clinical Pearls

Approximately 80% of the world's population in more than 100 developing countries will share the same fate of limited availability of standard neurosurgery.
Limitations commonly encountered in a low-income setting include ignorance and illiteracy, lack of political will from government as well as private sectors, a low number of practitioners in the neurosurgical workforce, limited availability of neurosurgical equipment and supporting services, uneven distribution of resources, brain drain, poor referral mechanisms, and almost nonexistent rehabilitation services.
Limited access to modern diagnostic tests helps make a physician an astute clinician. Physicians learn to be flexible in regard to work attitudes and cooperation, and they greatly develop the skill of improvisation, coordination, and organization. There is a huge scope of research on many disease conditions endemic to these countries.
Neurosurgery in developing countries is still a true general neurosurgery with subspecialty services limited to a handful of centers. Emphasis on cost-effective approaches, the rational use of available resources, and an increased reliance on the clinical judgment can help in the development of neurosurgery in these regions.
A neurosurgeon trained and practicing in the developed country should be well aware of the limitations and potential opportunities before working in such places.
There is an urgent need for a concerted effort on the part of individuals, communities, governmental and nongovernmental organizations, and international partners to uplift the standard of neurosurgery by modifying factors in the sociocultural, economic, and political areas.

Global neurosurgery refers to the development of neurosurgical services in developing countries. By convention, low- and middle-income countries are collectively referred to as developing countries. For the fiscal year 2016, the World Bank defines a low-income country as having a per capita gross national income (GNI) of $1045 or less in 2014, and it defines middle-income countries as having a per capita GNI of between $1045 and $12,736. Many countries in Asia, Sub-Saharan Africa, and some countries in Central America fall into this category. It is estimated that more than 80% of the world's population lives in more than 100 developing countries.

It is worth noting that even in developed countries there can be marked inequality in the level of care in different regions. Increased rurality is associated with a lesser degree of care. For example, only about ten percent of physicians practice in rural America despite the fact that nearly one-fourth of the population lives in these areas.

Neurosurgery is a medical specialty that requires highly expensive equipment and specialized staff if it is to be practiced well. Recovery from trauma and surgery to the central nervous system takes time and needs sophisticated rehabilitation that is rarely available in the developing world. In impoverished countries the options for patients who require complex neurologic interventions are limited and many patients cannot be treated at all. The challenge of global neurosurgery is therefore very great.

Challenges in the Work Environment

Lack of Political Will

Policy makers in the developing countries give neurosurgery a low public health priority with the resultant gross inadequacies at all levels of care. The impact of neurosurgery on a country needs to be restudied and given more priority than currently is the case. There has been some progress in recent years with health and safety legislation. The introduction of helmet laws for motorcyclists, mandatory seat belts for drivers and front seat passengers of motor vehicles, and zero tolerance for drunk driving are some welcome signs in many developing countries.

Uneven Distribution of Resources

Distribution of available neurosurgical resources varies greatly in different parts of the country. The majority of neurosurgeons and allied specialists tend to concentrate on major cities. For example, out of 43 registered neurosurgeons in Nepal as of 2015, 34 are located in Kathmandu. In an ideal world there would be central and regional services on a “hub and spoke” model, with simple cases treated in the periphery and complex cases referred on to the center. Poor transport infrastrucure combined with the reluctance of doctors to work away from the center, as well as weak central government, makes such a rational distribution of neurosurgical services very difficult to achieve in practice.

Insufficient Human Capacity

A fundamental prerequisite for any viable medical system is its professional workforce. Lack of infrastructure, the rigorous and prolonged training period, limited availability of training in the country, and long and unpredictable working hours have largely discouraged many young and aspiring doctors from taking up neurosurgery as a career in the developing world. The median number of neurosurgeons per 100,000 population is 0.01 in Africa and 0.03 in Southeast Asia compared to 0.76 in the Americas and 1.02 in Europe.

Medical migration is an important contributor to the growing health care workforce crisis. Despite various provisions to ensure that the trainee returns to the home country after overseas training, a substantial number of medical professionals stay abroad. Establishing local training with the support of visiting experts may help to limit this problem.

In the absence of a dedicated neurosurgery infrastructure, care in a general surgery setup is a feasible option for underprivileged people. Care by general surgeons of some neurosurgical cases—especially trauma—is a feasible option in developing countries. However, it needs judicious use of resources and understanding of limitations and constraints.

There are many international organizations working to promote neurosurgery in developing countries. The leaders in such countries should build a strong network with these organizations so that local capacity can be strengthened. This can include the donation of the essential instruments, subscriptions to journals, sponsorship for participating in conferences, and short-term training programs.

Increased Workload

Neurosurgeons in developing countries face a complex challenge. First, the infectious and congenital diseases, which are endemic to these regions, make for a substantial workload and often consume resources that are in short supply. Second, rapid urbanization has led to an epidemic of cranial and spinal trauma. Third, the advent of modern diagnostic equipment has usually outstripped the ability to treat the conditions diagnosed—such as tumors and strokes—which are increasingly seen. In many places there are no dedicated neurosurgery operating rooms (ORs) or intensive care units (ICUs). The neurosurgical service must often compete with other surgical specialties for the availability of ORs and ICUs. A huge backlog of untreated cases is not uncommon.

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