Authored by Dylan Keusch, Industrial and Labor Relations '24
Art by Chloe Cho, Human Biology, Health, and Society '26
Imagine yourself in a terrifying, yet all too realistic, situation: a loved one, driving home from work on a snowy night, is the victim of a brutal car accident. The prognosis is grim. Your loved one needs emergency neurosurgery to survive. For many, not all hope is lost given their proximity to a hospital with a capable neurosurgeon, fully-equipped operating room, and a neurological intensive care unit.
Yet, imagine the same scenario where the nearest neurosurgeon is hours away, making any life-saving treatment unlikely. You’re forced to surrender and hope for a miracle. Most of us can’t fathom such a possibility. Living in the United States, emergency surgery is often a service that we take completely for granted. However, for most of the world’s low- to middle-income countries (LMICs), the absence of neurosurgical resources is the reality of everyday life.
As of 2016, neurologic diseases and disorders are the leading cause of disability adjusted life years and the second leading cause of death, worldwide (GBD 2016 Neurology Collaborators, 2019, pg. 1). In a 2019 article in the Journal of Neurosurgery, Harvard Medical School’s Program in Global Surgery and Social Change attempted to quantify the world’s current neurosurgical disease burden, the extent of the current neurosurgery workforce, and the resulting deficit in care. According to the team’s latest estimates, there are more than 13.8 million emergent neurosurgical cases every year, worldwide (Dewan et al., 2019, p. 1055). Without surgical intervention, these cases result in almost certain disability or death.
Given today’s limited accessibility of global neurosurgeons, there are approximately 5.2 million unmet neurosurgical cases every year (Dewan et al., 2019, p. 1055). Most alarmingly, however, 80% of these emergent neurosurgical cases occur in LMICs (Dewan et al., 2019, p. 1057). To put this into perspective, this equates to the entire Washington, D.C. area not being able to receive life-saving care.
The reality is, in LMICs, access to neurosurgical care is more than just a disparity; it’s almost nonexistent. As Dr. Myron Rolle et al. discuss in their 2021 article in Journal of Global Neurosurgery, “Low and middle-income countries suffer ratios of one neurosurgeon for every 10 million people, in which case access to neurosurgical care is no longer a right but a luxury” (p. 86). The inadequacy of neurosurgical services in LMICs, however, stretches beyond just unnecessary morbidity and mortality. According to a 2021 article in Frontiers in Surgery, “differing models predict gross domestic product (GDP) losses of between $3-4.4 trillion in LMICs due to the unmet need for neurosurgical care” (Lartigue et al., 2021, p. 2). Subpar or nonexistent neurosurgical resources, therefore, have serious economic implications as well for already struggling countries.
These findings beg the question: how can the global medical community begin to address the inequities presented by inadequate access to neurosurgery?
First and foremost, it is imperative that the global neurosurgery community improves the provision of care through meaningful education. Education, notably distinct from training, involves knowledge-sharing regarding certain conditions through lectures, videos, and more. With the goal of improving outcomes, global neurosurgery programs seek to educate previously trained neurosurgeons about new guidelines in the treatment of certain conditions. Some neurosurgeons, for example, might be presented with “first ever in country cases”, and through unique educational opportunities, patients are likely to fare better (Haglund & Fuller, 2019, p. 996).
Second, providing formal training to increase the number of surgeons in LMICs is necessary for the sustainable development of neurosurgical programs worldwide. Through visiting residencies or fellowships, advanced neurosurgical programs in high-income countries have the ability to give healthcare professionals the skills and resources to create their own training programs in their home country. NeuroKids, a program born from some of the top pediatric neurosurgeons in the United States, is an example of how training programs can effectuate better outcomes. By engaging in long-term mentorship and education through site visits and remote learning, the NeuroKids team trains surgeons in highly-advanced treatment methods for pediatric hydrocephalus, a leading cause of pediatric disability and death (NeuroKids, 2023). Giving neurosurgeons in LMICs the tools and knowledge to create such training programs sets up a long-term solution to the existing inequities in neurosurgical care.
Finally, from a macro-level perspective, improving the overall healthcare system in LMICs can be instrumental in ensuring equity across all aspects of medicine, including neurosurgery. As Dr. Steven Schiff, M.D., Ph.D., a neurosurgeon at Yale who focuses on global inequities poignantly stated in a lecture, neurosurgery is not the simple answer to public health issues. Rather, the answer lies in wide-ranging policy changes that have the greatest potential to improve the population health of LMICs. For example, Duke Global Neurosurgery and Neurology used epidemiological research to better understand the burden of surgery in Uganda. In doing so, the group, along with their Ugandan counterparts, were able to identify gaps in medical care as a whole. This research and investment inspired the Ugandan government to establish initiatives to increase rehabilitative care and community reintegration after surgery. As Haglund and Fuller (2019) write, “Global neurosurgery work falls within this mindset shift as surgery provision in its best form requires a well-functioning health system” (p. 997). In other words, it is not until the underlying dysfunction of global health systems are fixed that everyone has the potential to be healthy.
Neurosurgery is no exception: improved access and outcomes come with overall improvement of healthcare for all.
Works Cited
GBD 2016 Neurology Collaborators. (2019). Global, regional, and national burden of Neurological Disorders, 1990–2016: A systematic analysis for the global burden of disease study 2016. The Lancet Neurology, 18(5), 459–480. https://doi.org/10.1016/s1474-4422(18)30499-x
Dewan, M. C., Rattani, A., Fieggen, G., Arraez, M. A., Servadei, F., Boop, F. A., Johnson, W. D., Warf, B. C., & Park, K. B. (2019). 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, 130(4), 1055–1064. https://doi.org/10.3171/2017.11.jns171500
Rolle, M., Ammar, A., & Park, K. B. (2021). Global neurosurgery: A call to action. Journal of Global Neurosurgery, 1(1), 86–88. https://doi.org/10.51437/jgns.v1i1.33
Lartigue, J. W., Dada, O. E., Haq, M., Rapaport, S., Sebopelo, L. A., Ooi, S. Z., Senyuy, W. P., Sarpong, K., Vital, A., Khan, T., Karekezi, C., & Park, K. B. (2021). Emphasizing the role of neurosurgery within Global Health and National Health Systems: A call to action. Frontiers in Surgery, 8. https://doi.org/10.3389/fsurg.2021.690735
Haglund, M. M., & Fuller, A. T. (2019). Global neurosurgery: innovators, strategies, and the way forward. Journal of Neurosurgery, 131(4), 993–999. https://doi.org/10.3171/2019.4.jns181747
Sustainable Solutions. NeuroKids. (n.d.). Retrieved March 2, 2023, from https://neurokids.us/sustainable-solutions/