Matthew Kirkman makes a strong case for making neurosurgery more of a priority in developing countries

Neurosurgery as a speciality has made significant progress over the past century, especially since the advent of computed tomography (CT) and microsurgery. (1) A speciality which began as one to prevent death has now become one in which morbidity can be reduced and function improved, with some centres carrying out preventive work before the development of symptoms. These advances, however, are mainly confined to industrialised countries. The gap between the standard of provision of care in developing and industrialised nations is increasing within neurosurgery as well as other specialities. Why is this?

Neurosurgery came to the developing countries over half a century ago, (2) yet the vast majority of the population in these countries do not have equity in access to it, owing to the cost of neurosurgical care, the lack of trained neurosurgeons (see Table 1), and geographical isolation of patients. Most live in rural villages, malnourished and unable to afford treatments, presenting with advanced stages of disease. Further, the overwhelming majority of surgeons live in cities, reluctant to work in rural areas, which lack the facilities they have been trained to use, schools for their children, and peers for them to talk to. (3) Hence access to neurosurgery for most in developing countries is even more limited than the figures suggest.

Table 1: The worldwide distribution of neurosurgeons [Source data: (4) and * (5)].

The morbidity caused by neurological illness is worst in the poorest people with least resources - because such illness often leads to unemployment, resulting in loss of family income, the requirement of a carer with loss of further money, and the cost of medications and other medical services. (6) Let’s not forget the stigmatisation, human rights violations and discrimination that these individuals are often subjected to.

In most developing countries priority is given to primary healthcare, because of its cost-effectiveness. Neurosurgery is expensive; the training of medical graduates, cost of equipment for a neurosurgical unit, recruitment costs of specialised support staff, as well as the funding of support services, all leads to a significant sum that would make any government think twice. Many argue that the scarce resources available should be focussed on tackling the infectious diseases and other major public health problems. So where is the incentive to provide neurosurgery?

Table 2: Statistics involving neurosurgery in developing nations.

First of all, denying access to neurosurgical services violates basic human rights, inflicting upon people some of the most devastating illness known to man. The lack of capital and labour resources in developing countries (see Table 2) leads to high mortality and morbidity, resulting in a loss of confidence from public health officials and the public that neurosurgery can achieve good outcomes. The advent of CT has led to the detection of more abnormalities and increased the neurosurgical workload in developing countries. Whilst CT scanners are supposedly cost-effective, (9) without effective treatment for the diseases identified they are neither useful nor cost-effective.

It is interesting to note that some of the commonest neurological diseases encountered in these countries result from infectious diseases, including meningitis, hydrocephalus, neurocysticercosis, encephalitis, brain abscesses and cerebral hydatid disease. (1) In developing nations, brain abscess and epidural haematoma often lead to death, hydrocephalus leads to blindness, and paraplegia results from spinal tuberculosis - all unnecessary outcomes, preventable given the right resources. In Uganda alone, at least 2000 new cases of hydrocephalus occur annually in infants under the age of one. (7) The commonest cause in East and Central Africa is neonatal infection of the central nervous system (unlike industrialised nations). This all represents a significant public health and preventative medicine issue. It should thus become clear that this is not an issue of whether to fund seemingly more important areas such as the infectious diseases, but to highlight that infectious diseases need to be tackled hand-in-hand with neurosurgical illness since they are so intimately related. Infectious diseases, however, are not the only major contributor to neurosurgical workload in these countries - other important conditions include brain tumours, sub-arachnoid haemorrhage and neural tube defects, and road traffic accidents result in epidemic levels of head injuries. Improvements in road safety, transport infrastructure and the law are some obvious but necessary ways to improve the incidence of the latter.

It appears that the problem of geographical isolation in developing countries may have a solution: in India, a global hub for information and communication technology, telemedicine is becoming increasingly popular. By ‘virtual’ consultations with doctors, often thousands of miles away, and with images, reports, voice messages and video transferred electronically, patients can be examined, investigated, monitored, and treated in cooperation with local doctors without the need for a face-to-face consultation with far-away specialists. Ninety percent of the normal patient-doctor interaction can be achieved through telemedicine. (8) Without the need for long-distance travel, it saves significant expense and affords patients the family support they need at home. Telemedicine also minimises unnecessary specialist referral, further reducing healthcare expenditure. Whilst telemedicine undoubtedly has a future in developing nations, what other interventions are necessary?

Energy needs to be garnered from within developing countries to raise awareness and form a sustained commitment to neurosurgery. By introducing their own neurosurgical training, they can reduce the ‘brain drain’ and ensure the future of neurosurgery. This necessitates help, financially and otherwise, from industrialised nations, but relying solely on outside help with the belief it is the only solution will dishearten local doctors and not bring the long-term infrastructure required. Some programmes are tackling this; for example, a team from Duke University Health System, USA visited Uganda this year with US$1million worth of equipment and donations, performing brain and spinal surgery, and providing training to ensure long-term sustainability of the project. (10) Countries lacking neurosurgeons should train general surgeons in basic live-saving neurosurgical procedures, such as treatment of brain abscesses, intracranial haematomas, and compound depressed fractures. Further, the developing world needs affordable access to a universal set of surgical instruments.

Morocco, a developing country, is one example of a success story. It has progressed from having just five neurosurgeons in 1968, to over 110 neurosurgeons (for 30 million people; a ratio of 1:290,000). (4) (11) This was achieved by adopting four principles: Encouragement of the local training of young neurosurgeons; Organisation and promotion of neurosurgery (the Moroccan Society of Neurosurgery was founded in 1984); Integration of the development of neurosurgery into the healthcare pyramid system; and stimulating research into local pathological disease. (11) In using this approach, other developing nations are more likely to create a sustainable future for neurosurgery.

Matthew A. Kirkman
Fourth year medical student
Newcastle University
matthew.kirkman@gmail.com

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