Bridging the Gap: Creating a Self-sustaining Neurosurgical Residency Program in Haiti

Ashish H. Shah, MD; Ernest Barthélemy, MD; Yudy Lafortune, MD; Joanna Gernsback, MD; Ariel Henry, MD; Barth Green, MD; John Ragheb, MD

Disclosures

Neurosurg Focus. 2018;45(4):E4 

In This Article

Abstract and Introduction

Abstract

Given Haiti’s longstanding socioeconomic burden and recent environmental and epidemiological catastrophes, the capacity for neurosurgery within Haiti has been limited, and outcomes for patients with neurosurgical conditions have remained poor. With few formally trained neurosurgeons (4) in a country of 10.5 million inhabitants, there is a significant need for the development of formal structured neurosurgical training. To mitigate the lack of neurosurgical care within Haiti, the authors established the first neurosurgical residency program within the country by creating an integrated model that uniquely fortifies existing Haitian neurosurgery with government sponsorship (Haitian Ministry of Health and National Medical School) and continual foreign support. By incorporating web-based learning modules, online assessments, teleconferences, and visiting professorships, the residency aims to train neurosurgeons over the course of 3–5 years to meet the healthcare needs of the nation. Although in its infancy, this model aims to facilitate neurosurgical capacity building by ultimately creating a self-sustaining residency program.

Introduction

The global burden of neurosurgical disease has been vastly underestimated as a major contributor to public health morbidity. In 2010, surgically treatable conditions contributed to nearly one-third of all deaths worldwide (16.9 million), with more than 5 billion people lacking access to timely, safe, affordable surgical care.[8,10] The inequity is especially pronounced in low- and middle-income countries (LMICs), where the vast majority of patients cannot afford access to surgical or anesthesia care. In LMICs such as Haiti, Uganda, Sierra Leone, etc., surgically treatable diseases may remain untreated in up to 25% of the population and account for at least 70% of the global burden of deaths from these conditions.[6,11] This global inequity is even more pronounced in areas of specialty surgical care such as neurosurgery, particularly pediatric neurosurgery (large disease burden necessitating highly specialized skill set), for which the capacity for care delivery in LMICs can range from being sparse to completely absent.[9] In Haiti, where access is limited for emergency or necessary surgeries, the concept of neurosurgery in particular has been relatively neglected as a subspecialty.[4] Given Haiti's long-standing socioeconomic burden and postcolonial legacy as the "poorest nation in the Western Hemisphere," and given recent environmental and epidemiological catastrophes (2010 earthquake, Hurricane Matthew, cholera epidemic), neurosurgical capacity is limited and outcomes for neurosurgical conditions have remained poor.[1,5]

Over the last 3 decades, many factors have contributed to the disparity in neurosurgical care within the country of Haiti. Excessive urban population density, rising rates of rural-to-urban migration, and an estimated 10% annual growth rate of motorized transportation all contribute to the growing number of patients requiring emergency neurosurgical care.[12] However, the burden of neurosurgical disease within the country has not been well characterized. Currently, cerebrovascular disease and neurotrauma remain the leading contributors to emergency neurological disease in Haiti, accounting for more than 15% of all emergency room (ER) visits.[1] Both of these disease entities significantly contribute to surgically preventable disability and mortality in Haiti. Although the Centers for Disease Control (CDC) estimate that the US has a similar neurological disease burden, the cumulative effect of Haiti's onerous economic challenges, lack of disease prevention, limited availability of modern equipment (implants, advanced imaging, instrumentation, etc.), and poor healthcare access exacerbates outcomes for patients with potentially treatable neurological conditions.

Currently, Haiti has very few formally trained neurosurgeons (4) for a population of 10.5 million inhabitants, which severely impairs healthcare access. Furthermore, formal neurosurgical training may be variable: on one hand, neurosurgeons may have received training in France, whereas others have participated in observerships in neighboring French islands (e.g., Martinique). Currently, the neurosurgeon provider ratio per 100,000 people is approximately 0.04 (more than 20-fold less than that of developed countries like the US).[1,14] With no structured neurosurgical care outside of the capital, Port-au-Prince, there is a significant need within the country for the development of formal neurosurgical training.

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