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

Disclosures

Neurosurg Focus. 2018;45(4):E8 

In This Article

Discussion

International collaboration programs face two major challenges:[18] first, the enormous patient load most African hospitals encounter, which includes urgent neurosurgical conditions such as pediatric hydrocephalus and cranial and spinal trauma;[24] and second, the need to transmit high-quality neurosurgical education to local surgeons. In the last decade, several ICPs have started to collaborate in developing neurosurgery in Tanzania, with remarkable results. These ICPs' shared vision has mobilized a network of global surgeons focused on sharing resources and expertise, training neurosurgeons, and stimulating research in East Africa.

For example, Madaktari Africa started training neurosurgeons in rural Tanzania in 2006.[8] In Dar es Salaam, the Tanzania Neurosurgery Project from Weill-Cornell Medical College has organized visits by neurosurgical fellows from overseas, weekly telecast conferences with local surgeons, and a yearly Neurotrauma Meeting, currently one of the most important scientific forums for neurosurgery in East Africa.[11,23] Finally, with a different approach, the Duke East Africa Neurosurgery Program, spearheaded by Dr. Michael Haglund, has been successfully training neurosurgeons in Kampala, Uganda. Since 2015, they have also been partnering with the Mbarara Hospital, located in the Southwest region of the country.[9]

The existence of these ICPs and their mutual support and collaboration ameliorate the current status of neurosurgery in East Africa and favor a more dynamic and connected East African neurosurgical community.

Considerations When Designing an ICP: The Integrative Model

We strongly encourage all ICPs to conduct their operations under the patronage and support of larger entities such as the FIENS, WHO, or World Bank (www.worldbank.org) and to partner with existing African networks, such as the College of Surgeons of East, Central and Southern Africa (COSECSA; www.cosecsa.org), the Continental Association of African Neurological Societies (CAANS), and the Pan-African Association of Neurological Sciences (PAANS), as well as the local health authorities.

We believe that the utilization of local resources is the key to efficiency when designing an ICP. Also, sustainability requires consideration of the local social and cultural perspectives. Failure to consider such factors can lead to progressive discontent among local practitioners, resistance to new initiatives, and interpersonal distancing. Moreover, the ICP methodology needs to keep realistic expectations about the degree to which local practitioners are willing to change their practice.[22]

Intervention by the foreign team needs to be conducted with caution and respect, aiming to guide local physicians toward safer practices, while avoiding dominance, condescension, or the perpetration of deleterious cycles of dependence. Introducing smaller, progressive changes over time has true potential to improve the local situation, instead of major policy changes that threaten the status quo. Figure 4 summarizes the integrative model that we propose for an efficient ICP.

Figure 4.

International collaboration program integrative model. The flowchart describes all major elements in the conception of an ICP. The central cells (blue) describe (top to bottom) the sequential steps, options, and items that should be considered when designing an ICP. Local (yellow) and external (red) factors play important roles throughout the design and execution process, ultimately leading to effective neurosurgical education and care, sustainability, and nondependence.

Impact of the NEDF

The NEDF has operated in Zanzibar since 2004. The main objectives of this ICP are to provide neurosurgical care to the Zanzibar population and to bring neurosurgical education and train surgeons. Since 2008, 129 ISCs have attended to Zanzibar's demand for neurosurgical care. Over 597 volunteers have been deployed, and thousands of neurosurgical procedures have been performed. Since 2016, more than 1000 patients have undergone neurosurgery at the NEDI, and 9169 outpatients have received counsel and ambulatory care. Before the arrival of the NEDF, the management of pediatric hydrocephalus was available only on Tanzania's mainland, and only infants from rich families could afford a delayed flight for treatment. Most pediatric patients would die before receiving neurosurgical care. However, since 2014, 592 ventriculoperitoneal shunts have been implanted at the NEDI, neuroendoscopic procedures are now locally available, and spina bifida repair is successfully performed by local surgeons.

By 2013, the NEDI was built thanks to private efforts under the direction of Paul H. Young, José Piquer, and Mahmood M. Qureshi and led to a more dynamic relationship between NEDF and MMH. The NEDI received full endorsement by the Ministry of Health. The MMH personnel were hired at the NEDI, and the general maintenance of the building became the responsibility of the administrative department at MMH. The recruitment of local medical officers allowed the NEDF to have accurate insight into the most prevalent pathologies, the state of the management of trauma, and the overall ways into the Administration Department and the Ministry of Health of Zanzibar. These medical officers were fast-track trained to address neurosurgical emergencies in between ISCs.

One of the particularities of the NEDF as an ICP is that when it started operating in the MMH surgical theaters, no neurosurgical care was available in the region. Before the NEDF's presence in Zanzibar, patients had to be transported by air or water to the closest neurosurgical center on mainland Tanzania.

Because of the prior absence of neurosurgeons in Zanzibar, the impact of the NEDF has been an unprecedented positive change for the health of the population. For example, in 2006, only 4 cases of severe TBI were reportedly admitted to the MMH's ICU, none of which received surgical treatment or survived after the 5th day of admission. Presumably, many other cases reached the hospital that year, but none were admitted to the ICU, likely due to the absence of guidelines or experience in the management of TBI. In contrast, in 2015 alone, 129 patients were admitted to the MMH's ICU with a diagnosis of severe TBI. Of these patients, 42 underwent surgery with a mortality rate of 32.5%. Moreover, in 2017, almost 50% of the trauma surgeries were performed by local medical officers.

The operations of the NEDF have drawn the attention of intensivists, rehabilitation physicians, and other local specialists who, as part of the NEDF-MMH partnership, are now also receiving specific training and support through other medical branches of the NEDF.

The involvement of the NEDF in neurosurgical education is multilayered: 1) At the local level, the NEDF trains local surgeons and nurses through short-term volunteers (i.e., ISCs) and long-term volunteers (i.e., NCs), who develop daily academic activities. 2) At the continental level, the NEDI is accredited by COSECSA to formally train neurosurgeons. This endorsement facilitates the organization of international courses and meetings for trainees from East Africa. This allows connecting them with a global network of neurosurgical institutions, providing opportunity for trainees to benefit from participation in international meetings and enhance their clinical research skills.[5–7] 3) At the international level, the NEDF has promoted agreements between the RGZ and foreign training centers. Currently, two Zanzibari neurosurgeons are being formally trained in Egypt and in Cuba.

Progressively, the administrative structure for a self-sufficient neurosurgical center is being designed and implemented. Basic management protocols are being established, and local nurses and medical officers are becoming responsible for visiting patients, preparing the surgical list, and providing the NEDI with basic supplies. Education is the key element in the NEDF's approach to a sustainable training of neurosurgeons in Zanzibar. The NEDF will keep organizing ISCs, developing academic activities such as courses and symposiums, and enriching the neurosurgical literature on East Africa.[12,18–20]

The NED philosophy emphasizes that respect and consideration of social and cultural differences promote equality among foreign and local teams, protecting this ICP from dependency cycles and promoting neurosurgical care in Zanzibar as the responsibility of local practitioners. The NED volunteers actively seek to empower local initiatives and bring the necessary tools for them to take shape. The NEDF's objectives include leaving the management of the NEDI entirely in the hands of local practitioners in the future. From that point, the NEDF will act as a consultant entity, with less administrative responsibilities and possibly fewer ISCs per year.

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