The challenges and Opportunities of Global Neurosurgery in East Africa

The Neurosurgery Education and Development Model

Andreas Leidinger, MD; Pablo Extremera, MD; Eliana E. Kim, BA; Mahmood M. Qureshi, FRCSEd(SN); Paul H. Young, MD, PhD; José Piquer, MD, PhD


Neurosurg Focus. 2018;45(4):E8 

In This Article


Clinical Results

During the study time frame, approximately 460 patients were seen by the NC in the outpatient clinic and 85 surgical procedures were performed (Figure 1 and Table 1). Conducted academic activities included daily clinical case presentations and radiological discussions and a weekly clinical session in which relevant clinical topics were discussed with local medics and nurses. Table 2 summarizes the academic talks conducted. Four ISCs were arranged by the NEDF (three groups from Spain and one from Germany) during the NC's stay. The surgical teams were composed of 5–10 healthcare professionals, including neurosurgeons, anesthesiologists, intensivists, surgical nurses, and physiotherapists. Surgical camps were composed of one clinical day and five surgical days. For some days, both theaters were simultaneously active. Academic activities such as morning lectures on relevant topics were also conducted by foreign faculty. Figure 2 summarizes the flux of international volunteers at NEDI, their time of stay, and their field of expertise.

Figure 1.

Details of surgical activity. ETV = endoscopic third ventriculostomy; NTD = neural tube defect; VPS = ventriculoperitoneal shunting. The y-axis represents the number of patients.

Figure 2.

Flux of foreign personnel during the 18-week study period. Bars represent the numbers of volunteers attending to surgical camps (1 week long). The stacked graphic area in the background represents all personnel staying longer than 1 week at the NEDI. Local surgeons were included in this graphic, but local nurses (19) and orderlies (6) were excluded, for scaling purposes.

Clinical Challenges

Workload. A high volume of patients exceeds the capacity of local physicians and surgeons at the NEDI and MMH, generating long waiting lists. Only one anesthesiologist with experience in neurosurgical and pediatric anesthesia is available at MMH. Therefore, surgery at the NEDI is performed only twice per week. Alleviating the intense workload is one of the reasons the NEDI still hosts monthly ISCs. Furthermore, a high percentage of the daily workload at MMH and NEDI is administrative or bureaucratic in nature, which restricts the amount of time local physicians can dedicate to clinical care, training, and research.

Infrastructure and Healthcare. The NEDI is functionally equipped and in better condition than most other hospitals in East Africa. Moreover, the Revolutionary Government of Zanzibar (RGZ) provides financial coverage of some medical expenses, such as CT scan and MRI acquisitions, for all patients. Still, there is a constant shortage of basic medicine and materials, most commonly film for radiograph development, laboratory reactants, gauze, sterile gloves, and plaster. Essential supplies such as oxygen, electricity, and water are unsteady and pose a potential threat to the performance of healthcare teams and ISCs. Figure 3 summarizes the availability of basic resources during the study time frame.

Figure 3.

Availability of basic resources at NEDI-MMH during the study period. Unavailability was attributable to equipment mishaps or lack of supply and is expressed as a discontinuation of each colored line.

Self-Confidence and the Value of Knowledge. Local medics and nurses are generally not confident regarding their own knowledge and expertise. Surgeons usually doubt the surgical indications and consult the NC before asserting their own medical judgment. Because of the intense workload and lack of resources at the NEDI, local personnel tend to adopt a work approach focused on individual patients, rather than understanding the general management algorithms and their clinical rationale. In this regard, theoretical knowledge that has no immediate use to improve the patient's condition is often perceived as less relevant. Hence, patient care is usually provided in response to specific symptoms and not to clinical syndromes. For example, an admitted patient who suffered acute spinal trauma with a clear sensory level and a second patient admitted as an outpatient for a scheduled lumbar canal stenosis decompression, both presenting with bilateral paresthesia, could be given equal surgical priority since both present with similar symptomatology.

To address this issue, a daily clinicoradiological discussion was introduced. Needed tools for further training were provided, such as web resources, peer-reviewed papers, and access to online webinars. Active participation of the local NEDI personnel during these academic activities seemed to increase their confidence in their daily handlings, such as the in-ward management of drip chambers of external ventricular drains or passive mobilization of bedridden patients.

Time and Priority. Local practitioners have a different understanding of the value of time. This is especially evident in the torpid management of emergencies. In general, delays in patient referral to the Emergency Department (ED), its triage, and its initial assessment are the locally accepted standard. Finally, the acquisition of diagnostic neuroimaging can also delay treatment even further. Local practitioners frequently suffer such delays and cannot expedite the slow patient circuit through the ED.

The constant need for reducing the waiting queue at the ED compels the medics to attend first to patients with less complex pathology who do not require labs or images in order to quickly reduce the volume of visitors. Critical patients are not prioritized. Furthermore, this practice motivates patients to visit a tertiary care hospital for minor ailments, contributing to the centralization of healthcare and the saturation of MMH and NEDI capacities.

Integration Between Healthcare Teams. The management of patients requiring more than one specialist, such as trauma patients, is hampered by scant communication between medical teams. For example, a severe traumatic brain injury (TBI) patient could be left waiting in the general wards prior to heart monitoring or neuroimaging acquisition, expecting the on-call intensivist to consider the patient worthy of ICU admission or not. Such an assessment could take from hours to several days. During his stay, the NC promoted a weekly session with intensivists, conducted visitation of ICU patients three days per week, and arranged a visit by the rehabilitation team at the NEDI once a week. Overall, better communication was achieved regarding individual patients, and initiatives for future cooperation between those medical teams arose. Other clinical improvement opportunities were identified during this study. Table 3 summarizes these opportunities.

Administrative Challenges

Technical Service and Repairs. Much of the medical equipment available at MMH and NEDI come from donations or the purchase of second-hand equipment thanks to private efforts under the direction of the NEDF's board committee. The hospital has no established relationship with the official suppliers. Hence, equipment tends to deteriorate faster through multiple interventions of the inexperienced local technicians. In several locations, equipment repair requires the intervention of out-sourced official providers that mostly fly in from Kenya and South Africa. The NEDF is constantly trying to reduce these delays by donating needed hardware and networking with different providers to repair broken equipment.

Document and Information Administration. Recently, the development of telecommunications in East Africa has allowed the massive diffusion of smartphones and tablets. In a context with limited access to desktop computers and storage, we recommend utilizing digital clouds for documents and formularies to be stored and shared. Furthermore, many mobile software and smartphone applications are specially designed for patient recording. The local team is interested in such resources and collaborated with the organization of digital folders and files.

Sociocultural Challenges

It is essential to recognize that the perceived role of physicians, the concept of well-being, and the value and quality of life vary across different cultures and social groups.

General Layout of the Zanzibar Archipelago. The Zanzibar archipelago is among the most diverse societies in East Africa.[3] While hosting diverse ethnicities and traditions, social cohesion is maintained around Islam, the Swahili language, and a strong community identity.[1,13,21] The coexistence of numerous minorities is maintained through strict courtesy rules and specific social spaces, tacitly defined for each collective of people.[3] A Muslim patriarchal hierarchy prevails and influences almost all aspects of daily life.[13] The majority of the population lives in rural areas where everyone plays a vital role in their community and their personal success is a function of community value. This largely explains the evident rejection and hiding of handicapped or diseased relatives who contribute less to communal tasks.[18]

In this strong community-oriented society, Zanzibari men engage in extensive heated greetings, long conversations, and a general attitude of service toward their peers. They use folk expressions such as "pole pole" or "Hakuna Matata," which mean "slowly, slowly" and "there are no problems" in Swahili, to urge their younger peers to worry only about current happenings or only those that immediately affect their communities or families, not thinking about tomorrow.[21]

Medical professionals are no exception to this laidback aspect of Zanzibari culture. They will not stress over deadlines or the many challenges to address. According to several physicians in MMH, new opportunities from the globalized world are sometimes perceived as alien and too "fast-paced" for the Zanzibari standard of living.

Role of Physicians. In Zanzibar, the popular understanding of health and disease still calls upon magic, mystic, and religious concepts.[2] The understanding of anatomical or physiological concepts by the local villagers is minimal. Consequently, the doctor-patient relationship is predominantly unidirectional, vertical, and strongly paternalistic. Doctors are expected to conduct themselves under strict social norms, and their medical skills and knowledge are rarely questioned. Also, they feel more responsible for their communities than for their patients. Thus, many physicians reject training opportunities, which may compete with the community and family time they are expected to engage in.

Some particularities exist in the manner that physicians in Zanzibar assume their responsibility over patients. As the chief of the Emergency Medicine Department commented during an interview, "In a rather small medical community, there is a deep fear of being poorly judged by their peers in case the patient dies or suffers from a complication." Moreover, among religious physicians, the fear of altering the divine plan designed for certain patients exists.