Global neurosurgery

Short description: Global health subspecialty

Global neurosurgery is a field at the intersection of public health and clinical neurosurgery. It aims to expand provision of improved and equitable neurosurgical care globally.[1]

## Contents

* 1 Definition and history
* 2 Burden of diseases amenable to neurosurgery
* 3 Practice
* 3.1 Advocacy
* 3.2 Education
* 3.3 Policy
* 3.4 Research
* 3.5 Service delivery
* 4 References

## Definition and history

Global neurosurgery is "the clinical and public health practice of neurosurgery with the primary purpose of ensuring timely, safe, and affordable neurosurgical care to all who need it."[2] The term global neurosurgery was first used in 1995 by Canadian neurosurgeon Dwight Parkinson to describe comprehensive clinical neurosurgery care in Manitoba;[3] however, the field as defined today was born in the mid-2010s.[4] The modern definition of global neurosurgery was born from a combination of global health and neurosurgery. Hence, global neurosurgery is conceived as a subspecialty of global health within global surgery[broken anchor].[2][5]

## Burden of diseases amenable to neurosurgery

Around 22.6 million people are affected by diseases amenable to neurosurgery each year, and 13.8 million require surgical intervention.[6] The burden of diseases amenable to neurosurgery is disproportionately distributed globally, with low- and middle-income countries bearing more than 78.1% of cases.[6] Low- and middle-income countries lack the workforce, infrastructure, funding, and data needed to address the disease burden.[6][7][8][9][10] High-income country patients, especially in rural areas and from economically-disadvantaged backgrounds, face unique challenges in accessing safe, timely, and affordable neurosurgical care.[11] For this reason, most global neurosurgery work has focused on access to care in low- and middle-incomce countries despite the global nature of disparities in accessing neurosurgical care.[12]

## Practice

Global neurosurgery practice involves advocacy, education, policy, research, and service delivery.[2] The components of global neurosurgery practice are interdependent but global neurosurgeons tend to focus their practice on one or two of them. This trend has allowed for specialization within the field and greater collaboration between individuals and institutions.[12]

### Advocacy

Advocacy efforts happen at the international, regional, and local levels and in collaboration with health initiatives that share similar goals with global neurosurgery - universal health coverage and sustainable development. Internationally, global neurosurgery advocacy groups participate in high-level health policy events like the World Health Assembly and the United Nations General Assembly.[13] Global neurosurgery advocates have contributed to numerous high-level decisions including folate fortification, detection and management of congenital malformations, and injury prevention.[13][14] Locally, global neurosurgery advocacy groups are constituted of health workers and other patient advocates. These groups affect local decision making but they are equally active internationally. Many local advocacy groups are members of international advocacy groups like the G4 Alliance,[15][14] People and Organisations United for Spina Bifida and Hydrocephalus (PUSH!) Global Alliance,[16] and International Federation Spina Bifida and Hydrocephalus (IFSBH).[17] Local global neurosurgery advocacy groups work within these international organizations to coordinate advocacy efforts regionally and globally.

### Education

Global neurosurgery education focuses on two aspects. First, global neurosurgery educators train specialists to serve under-resourced regions. The training focuses primarily on safe and quality service delivery within underserved communities. These global neurosurgery education efforts can be divided into non-specialized and specialized training. Non-specialized training or education for task-sharing/-shifting targets non-specialized healthcare workers such as general surgeons, clinical officers, and general practitioners.[18][19] Non-specialized training is especially important in increasing access to essential and emergency neurosurgical care rapidly.[20] Non-specialized training, unlike specialized training, can be done in shorter periods, with larger cohorts, and with fewer resources.[19] Specialized neurosurgery training can last anywhere from a few months to 8 years depending on the training level.[21] Postgraduate medical fellowships in one of the neurosurgical subspecialties are open to graduate neurosurgery residents/registrars and can last between three and 24 months. On the other hand, neurosurgery residencies last between 4 and 8 years.[22]

The other focus of global neurosurgery education is fellowships that introduce trainees to global and public health concepts. Global neurosurgery fellowships are relatively new but increasingly popular with institutions like Cambridge,[23] Cornell,[24] Duke,[25] Harvard,[26] and the University of Cape Town[27] offering specialized training.[28]

### Policy

Global neurosurgeons contribute significantly to the design and implementation of health policies that improve access to safe, timely, and affordable neurosurgical care globally. Prime examples of global neurosurgery policy efforts include the comprehensive health policy guidelines for traumatic brain and spine injuries[29][30] and for spina bifida and hydrocephalus.[31] The comprehensive policy guidelines address challenges that affect the patient continuum of care and suggest solutions for every component of the healthcare system.[29][30][31] These documents were designed for policymakers in areas with a large burden of diseases amenable to neurosurgery. Traumatic brain and spine injuries were chosen because they constitute more than 47.1% of the global neurosurgical disease burden while hydrocephalus and spina bifida were chosen for their deleterious impact on children.[6]

### Research

Research is an indispensable aspect of global neurosurgery practice called academic global neurosurgery.[2] Academic global neurosurgery has a broad focus and uses concepts from epidemiology, health economics, health policy, health services, health systems, implementation & dissemination science, and patient safety & quality improvement research.[2] Academic global neurosurgery's exponential growth since 2016 is the result of increased interest and support from the neurosurgical community characterized by the creation of an ad-hoc committee within the World Federation of Neurosurgical Societies,[32] publication of special issues in reputable peer-reviewed journals,[33][34] creation of a specialized journal,[35] and the creation of global neurosurgery centers.[12] Academic global neurosurgery identifies challenges to accessing neurosurgical care and proposes solutions that increase access to care.[12] The evidence generated by academic global neurosurgery informs the other aspects of global neurosurgery practice.

### Service delivery

Service delivery is the oldest component of global neurosurgery practice and can be traced back to the colonial era when surgeons would deliver care in colonies.[21][36] Global neurosurgery aims to reduce barriers to essential and emergency neurosurgery procedures such as those needed for acute stroke, neural tube defects, traumatic brain injuries, and traumatic spine injuries.[37][38]

Low- and middle-income country patients have worse outcomes than their high-income country counterparts because they regularly face barriers to accessing timely and safe neurosurgical care.[39][40][10]

The workforce deficit in low- and middle-income countries constitutes a significant barrier to receiving care. Although former colonies have trained local neurosurgeons since their independence, the neurosurgical workforce density in many low- and middle-income countries remains below the World Federation of Neurosurgical Societies' recommendation of 1 neurosurgeon per 200,000 people.[41] In addition, the majority of low- and middle income countries have geographical disparities in the neurosurgical workforce with most neurosurgeons working in urban areas whereas the majority of people in these countries are rural-dwellers.[19] In addition, surgical non-governmental organizations from high-income countries help fill the service delivery gap in some low- and middle-income countries.[42] Although most neurosurgical non-governmental organizations offer short-term service delivery in low- and middle-income countries, some like CURE International offer long-term care.[43]

The neurosurgical workforce in low- and middle-income countries has increased gradually in the past decade thanks to targeted efforts from the global neurosurgery community. For example, the World Federation of Neurosurgical Societies supports the training of aspiring neurosurgeons from understaffed countries through scholarships at accredited centers in Africa, Asia, and South America.[44][45][46][21][47]

Young neurosurgeons from under-resourced regions who have been trained in advanced neurosurgical techniques report their patients do not get safe and timely care because of inadequate infrastructure.[19] Access to neurosurgical infrastructure can be assessed summarily using the World Federation of Neurosurgical Societies facility three-tier classification or using hospital assessment tools.[48] The World Federation of Neurosurgical Societies facility three-tier classification groups facilities into level 1 (equipment for emergency neurosurgery procedures), level 2 (equipment to perform basic microneurosurgical procedures), and level 3 (equipment for complex and advanced neurosurgery).

## References

1. ↑ Bath, Michael; Bashford, Tom; Fitzgerald, J E (October 2019). "What is 'global surgery'? Defining the multidisciplinary interface between surgery, anaesthesia and public health". BMJ Global Health 4 (5). doi:10.1136/bmjgh-2019-001808. PMID 31749997.
2. ↑ 2.0 2.1 2.2 2.3 2.4 Kanmounye, Ulrick Sidney; Esene, Ignatius N (27 August 2021). "Letter: Global Neurosurgery Scope and Practice". Neurosurgery Open 2 (3). doi:10.1093/neuopn/okab025.
3. ↑ Parkinson, Dwight (May 1995). "Early history of neurosurgery in Manitoba: threads in the tapestry of world neurosurgery". Journal of Neurosurgery 82 (5): 900–906. doi:10.3171/JNS.1995.82.5.0900. PMID 7714620.
4. ↑ Park, Kee B.; Johnson, Walter D.; Dempsey, Robert J. (1 April 2016). "Global Neurosurgery: The Unmet Need" (in en). World Neurosurgery 88: 32–35. doi:10.1016/j.wneu.2015.12.048. ISSN 1878-8750. PMID 26732963.
5. ↑ Andrews, Russell J. (November 2020). "What's in a Name? "Global Neurosurgery" in the 21st Century". World Neurosurgery 143: 336–338. doi:10.1016/j.wneu.2020.07.233. PMID 32781142.
6. ↑ 6.0 6.1 6.2 6.3 Dewan, Michael C.; Rattani, Abbas; Fieggen, Graham; Arraez, Miguel A.; Servadei, Franco; Boop, Frederick A.; Johnson, Walter D.; Warf, Benjamin C. et al. (April 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. doi:10.3171/2017.11.JNS171500. PMID 29701548.
7. ↑ Gnanakumar, Sujit; Abou El Ela Bourquin, Bilal; Robertson, Faith C.; Solla, Davi J. Fontoura; Karekezi, Claire; Vaughan, Kerry; Garcia, Roxanna M.; Hassani, Fahd Derkaoui et al. (October 2020). "The World Federation of Neurosurgical Societies Young Neurosurgeons Survey (Part I): Demographics, Resources, and Education". World Neurosurgery: X 8. doi:10.1016/j.wnsx.2020.100083. PMID 33103109.
8. ↑ Robertson, Faith C.; Gnanakumar, Sujit; Karekezi, Claire; Vaughan, Kerry; Garcia, Roxanna M.; Abou El Ela Bourquin, Bilal; Derkaoui Hassani, Fahd; Alamri, Alexander et al. (October 2020). "The World Federation of Neurosurgical Societies Young Neurosurgeons Survey (Part II): Barriers to Professional Development and Service Delivery in Neurosurgery". World Neurosurgery: X 8. doi:10.1016/j.wnsx.2020.100084. PMID 33103110.
9. ↑ Kanmounye, Ulrick S.; Robertson, Faith C.; Thango, Nqobile S.; Doe, Alvin Nah; Bankole, Nourou Dine Adeniran; Ginette, Pape Aicha; Ondoma, Solomon; Balogun, James A. et al. (28 May 2021). "Needs of Young African Neurosurgeons and Residents: A Cross-Sectional Study". Frontiers in Surgery 8. doi:10.3389/fsurg.2021.647279. PMID 34124134.
10. ↑ 10.0 10.1 Nguembu, Stéphane; Kanmounye, Ulrick Sidney; Tétinou, Francklin; Djiofack, Dylan; Takoukam, Régis (July 2020). "Barriers to Management of Nontraumatic Neurosurgical Diseases at 2 Cameroonian Neurosurgical Centers: Cross-Sectional Study". World Neurosurgery 139: e774–e783. doi:10.1016/j.wneu.2020.04.162. PMID 32376382.
11. ↑ Rahman, Sarah; McCarty, Justin C.; Gadkaree, Shekhar; Semco, Robert S.; Bi, Wenya Linda; Dhand, Amar; Jarman, Molly P.; Ortega, Gezzer et al. (July 2021). "Disparities in the Geographic Distribution of Neurosurgeons in the United States: A Geospatial Analysis". World Neurosurgery 151: e146–e155. doi:10.1016/j.wneu.2021.03.152. PMID 33831612.
12. ↑ 12.0 12.1 12.2 12.3 Kanmounye, Ulrick Sidney; Sebopelo, Lorraine Arabang; Keke, Chiuyu; Zolo, Yvan; Senyuy, Wah Praise; Endalle, Genevieve; Takoukam, Régis; Sichimba, Dawin et al. (11 March 2021). "Mapping Global Neurosurgery Research Collaboratives: A Social Network Analysis of the 50 Most Cited Global Neurosurgery Articles". Neurosurgery Open 2 (2). doi:10.1093/neuopn/okab006.
13. ↑ 13.0 13.1 Rosseau, Gail; Johnson, Walter D.; Park, Kee B.; Hutchinson, Peter J.; Lippa, Laura; Andrews, Russell; Servadei, Franco; Garcia, Roxanna M. (April 2020). "Global neurosurgery: continued momentum at the 72nd World Health Assembly". Journal of Neurosurgery 132 (4): 1256–1260. doi:10.3171/2019.11.JNS191823. PMID 31952031.
14. ↑ 14.0 14.1 Kanmounye, Ulrick Sidney; Shenaman, Natalie; Ratel, Marj; Park, Kee B.; Woodrow, Sarah; Olubunmi, Comrade Lawal Aiyedun; Tharin, Suzanne; Khan, Tariq et al. (23 April 2021). "A Seat at the Table: Representation of Global Neurosurgery in the G4 Alliance" (in en). Journal of Global Neurosurgery 1 (1): 73–77. doi:10.51437/jgns.v1i1.29. ISSN 2745-2379. http://198.12.226.205/index.php/jgn/article/view/237.
15. ↑ "Member Organizations" (in en-US). https://www.theg4alliance.org/about-g4-alliance-member-organizations.
16. ↑ "Our Member Organisations" (in en). http://www.pu-sh.org/about-us/our-member-organisations.
17. ↑ "Our Members Archive" (in en-BE). https://www.ifglobal.org/members/.
18. ↑ Robertson, Faith C. et al. (April 2020). "Task-Shifting and Task-Sharing in Neurosurgery: An International Survey of Current Practices in Low- and Middle-Income Countries". World Neurosurgery: X 6. doi:10.1016/j.wnsx.2019.100059. PMID 32309800.
19. ↑ 19.0 19.1 19.2 19.3 Robertson, Faith C. et al. (April 2020). "Global Perspectives on Task Shifting and Task Sharing in Neurosurgery". World Neurosurgery: X 6. doi:10.1016/j.wnsx.2019.100060. PMID 32309801.
20. ↑ Robertson, Faith C.; Briones, Richard; Mekary, Rania A.; Baticulon, Ronnie E.; Jimenez, Miguel A.; Leather, Andrew J.M.; Broekman, Marike L.D.; Park, Kee B. et al. (April 2020). "Task-Sharing for Emergency Neurosurgery: A Retrospective Cohort Study in the Philippines". World Neurosurgery: X 6. doi:10.1016/j.wnsx.2019.100058. PMID 32309799.
21. ↑ 21.0 21.1 21.2 Kato, Y.; Liew, B. S.; Sufianov, A. A.; Rasulic, L.; Arnautovic, K. I.; Dong, V. H.; Florian, I. S.; Olldashi, F. et al. (December 2020). "Review of global neurosurgery education: Horizon of Neurosurgery in the Developing Countries". Chinese Neurosurgical Journal 6 (1): 19. doi:10.1186/s41016-020-00194-1. PMID 32922948.
22. ↑ "Volunteer Toolkit". http://www.fiens.org/new-page-2.
23. ↑ "NIHR Global Health Research Group on Neurotrauma" (in en-US). https://neurotrauma.world/about.
24. ↑ "Global Health Neurosurgery Fellowship". https://neurosurgery.weill.cornell.edu/education/neurosurgical-fellowships/global-health-neurosurgery-fellowship.
25. ↑ "Duke Global Neurosurgery & Neurology" (in en-US). https://www.dukeglobalneurosurgery.com/.
26. ↑ "Paul Farmer Global Surgery Research Fellowship" (in en). https://www.pgssc.org/paul-farmer-global-surgery-fellowship.
27. ↑ "Education" (in en). http://www.globalsurgery.uct.ac.za/education-6.
28. ↑ Rolle, Myron L.; Zaki, Mark; Parker, Tariq; Berger, Connor; Knowlton, Harrison; Kerry, Vanessa; Nahed, Brian (1 September 2020). "Global Neurosurgery Education in United States Residency Programs" (in en). World Neurosurgery 141: e815–e819. doi:10.1016/j.wneu.2020.06.039. ISSN 1878-8750. PMID 32540290. https://www.sciencedirect.com/science/article/abs/pii/S1878875020312973.
29. ↑ 29.0 29.1 Corley, Jacquelyn; Barthélemy, Ernest J.; Lepard, Jacob; Alves, Jose Luis; Ashby, Joanna; Khan, Tariq; Park, Kee B. (December 2019). "Comprehensive Policy Recommendations for Head and Spine Injury Care in Low- and Middle-Income Countries". World Neurosurgery 132: 434–436. doi:10.1016/j.wneu.2019.08.240. PMID 31810143.
30. ↑ 30.0 30.1 "Comprehensive Policy Recommendations for Head and Spine Injury Care in LMICs". https://docs.wixstatic.com/ugd/d9a674_1ba60c38a07341a7bbbe8b1e3f0ff507.pdf.
31. ↑ 31.0 31.1 "Comprehensive Policy Recommendations for the Management of Spina Bifida & Hydrocephalus in Low- & Middle-Income Countries". https://www.chyspr.org/.
32. ↑ "Global Neurosurgery Committee of the WFNS" (in en). https://globalneurosurgery.org/.
33. ↑ "Prioritizing Global Neurosurgery in the Focus of Global Public Health: The ethical, financial and clinical necessities | Frontiers Research Topic". https://www.frontiersin.org/research-topics/16838/prioritizing-global-neurosurgery-in-the-focus-of-global-public-health-the-ethical-financial-and-clin.
34. ↑ "Reducing Inequities in Global Neurosurgery Delivery". Neurosurgical Focus 45 (4). Oct 2018. ISSN 1092-0684. https://thejns.org/focus/view/journals/neurosurg-focus/45/4/neurosurg-focus.45.issue-4.xml.
35. ↑ "Journal of Global Neurosurgery". Journal of Global Neurosurgery 1 (1). 2022. doi:10.51437/jgns.v1i1. ISSN 2745-2379.
36. ↑ Dada, Olaoluwa Ezekiel; Karekezi, Claire; Mbangtang, Celestin Bilong; Chellunga, Edwin Samwel; Mbaye, Thioub; Konan, Landry; Adeniran Bankole, Nourou Dine; Merci Kabulo, Katenga Dieu et al. (July 2021). "State of Neurosurgical Education in Africa: A Narrative Review". World Neurosurgery 151: 172–181. doi:10.1016/j.wneu.2021.05.086. PMID 34058355.
37. ↑ Debas, H. T.; Donkor, P.; Gawande, A.; Jamison, D. T.; Kruk, M. E.; Mock, C. N. (2015-03-23). "Surgery and Trauma Care". in Debas, Haile T. (in en). Disease Control Priorities, Third Edition (Volume 1): Essential Surgery. The World Bank. doi:10.1596/978-1-4648-0346-8. ISBN 978-1-4648-0346-8. https://dcp-3.org/sites/default/files/chapters/DCP3_Essential Surgery_Ch3.pdf. Retrieved 2022-07-22.
38. ↑ Debas, H. T.; Donkor, P.; Gawande, A.; Jamison, D. T.; Kruk, M. E.; Mock, C. N. (2015-03-23). "Surgical Interventions for Congenital Anomalies". in Debas, Haile T. (in en). Disease Control Priorities, Third Edition (Volume 1): Essential Surgery. The World Bank. doi:10.1596/978-1-4648-0346-8. ISBN 978-1-4648-0346-8. https://dcp-3.org/sites/default/files/chapters/DCP3_Essential Surgery_Ch8.pdf. Retrieved 2022-07-22.
39. ↑ Biccard, Bruce M.; Madiba, Thandinkosi E.; Kluyts, Hyla-Louise; Munlemvo, Dolly M.; Madzimbamuto, Farai D.; Basenero, Apollo; Gordon, Christina S.; Youssouf, Coulibaly et al. (21 April 2018). "Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study". Lancet 391 (10130): 1589–1598. doi:10.1016/S0140-6736(18)30001-1. ISSN 1474-547X. PMID 29306587.
40. ↑ Vaca, Silvia D; Kuo, Benjamin J; Nickenig Vissoci, Joao Ricardo; Staton, Catherine A; Xu, Linda W; Muhumuza, Michael; Ssenyonjo, Hussein; Mukasa, John et al. (2019). "Temporal Delays Along the Neurosurgical Care Continuum for Traumatic Brain Injury Patients at a Tertiary Care Hospital in Kampala, Uganda". Neurosurgery 84 (1): 95–103. doi:10.1093/neuros/nyy004. ISSN 0148-396X. PMID 29490070.
41. ↑ Kanmounye, Ulrick Sidney; Lartigue, Jean Wilguens; Sadler, Samantha; Yuki Ip, Ho Kei; Corley, Jacquelyn; Arraez, Miguel Angel; Park, Kee (October 2020). "Emerging Trends in the Neurosurgical Workforce of Low- and Middle-Income Countries: A Cross-Sectional Study". World Neurosurgery 142: e420–e433. doi:10.1016/j.wneu.2020.07.067. PMID 32688040.
42. ↑ Ng-Kamstra, Joshua S.; Riesel, Johanna N.; Arya, Sumedha; Weston, Brad; Kreutzer, Tino; Meara, John G.; Shrime, Mark G. (August 2016). "Surgical Non-governmental Organizations: Global Surgery's Unknown Nonprofit Sector". World Journal of Surgery 40 (8): 1823–1841. doi:10.1007/s00268-016-3486-1. ISSN 1432-2323. PMID 27008646.
43. ↑ "CURE International". https://cure.org/.
44. ↑ "Our Training Centers". https://wfnsfoundationgazette.com/our-training-centers-2-2.
45. ↑ "Our Training Centers". https://wfnsfoundationgazette.com/our-training-centers-2.
46. ↑ "How to standardize further training of international students? Tips from our Neurosurgery Department - West China hospital, sichuan university - West China hospital, sichuan university". http://www.wchscu.cn/details/50314.html.
47. ↑ Dada, Olaoluwa Ezekiel; Karekezi, Claire; Mbangtang, Celestin Bilong; Chellunga, Edwin Samwel; Mbaye, Thioub; Konan, Landry; Adeniran Bankole, Nourou Dine; Merci Kabulo, Katenga Dieu et al. (July 2021). "State of Neurosurgical Education in Africa: A Narrative Review". World Neurosurgery 151: 172–181. doi:10.1016/j.wneu.2021.05.086. PMID 34058355. https://www.sciencedirect.com/science/article/abs/pii/S1878875021007816.
48. ↑ Kanmounye, Ulrick Sidney; Ghomsi, Nathalie C.; Djiofack, Dylan; Tétinou, Francklin; Nguembu, Stéphane; Zolo, Yvan; Esene, Ignatius (10 April 2020). "The Implications of Global Neurosurgery for Low- and Middle-income Countries: The Case of Cameroon" (in en). Iranian Journal of Neurosurgery 6 (2): 93–100. doi:10.32598/irjns.6.2.7. https://irjns.org/article-1-209-en.html. Retrieved 4 December 2021.

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