A Decade of Progress in Global Neurosurgery
With an additional 23,300 neurosurgeons needed to address the over 5 million unmet essential neurosurgical cases presenting in low- and middle-income countries (LMICs) each year, a global approach to safe and effective neurosurgery is essential. Global neurosurgery, defined as “an area for study, research, practice, and advocacy that places priority on improving health outcomes and achieving health equity” for neurosurgical patients worldwide, has delivered tangible progress in this challenge over the past decade. The movement has facilitated the training and education of neurosurgeons, has developed cost-effective technological solutions, and has reformed healthcare systems in LMICs. For example, the Weill Cornell Neurosurgery-Tanzania Collaboration and the Duke Neurosurgery East Africa Project have excelled in specific areas of neurosurgical training and technological innovation by working closely with local healthcare organisations. Global neurosurgical outcomes monitoring, as conducted by a UK National Institute of Health Research collaboration on traumatic brain injury, will continue to provide further insight into the areas of care that require most attention and investment. While the past ten years have brought significant progress, the prioritisation of global health outcomes and equity in neurosurgical care is a particularly valuable advancement due to the benefits yet to be gained. The appreciation of safe and effective neurosurgery as a key element of universal health coverage is highly encouraging as a sign of progress towards more equitable surgical care for patients around the world.
A Decade of Progress in Global Neurosurgery
While infectious diseases have historically dominated global health strategy, safe and effective surgery has become central to the aim of improving healthcare provision globally. This shift is supported by the finding that a lack of access to surgery causes three times as many deaths as HIV/AIDS, tuberculosis and malaria combined . The deficits in surgical care are most significantly experienced in low- and middle-income countries (LMICs) and are particularly magnified in subspecialities, such as neurosurgery . However, the past decade has delivered tangible advances in global neurosurgery, whilst also providing valuable insight into evidence-based approaches towards safe and effective surgery in LMICs. Global neurosurgery has transformed the education and training of neurosurgical professionals, promoted technological innovation in search of cost-effective solutions and, most profoundly, enabled reform of LMIC healthcare systems.
In 2015, the Lancet Commission on Global Surgery found more than 5 billion people to lack access to safe, affordable, and quality surgical and anaesthetic care . The discrepancy between supply and demand of neurosurgical services is particularly grave, with an additional 23,300 neurosurgeons needed to address the over 5 million unmet essential neurological cases presenting in LMICs each year . Patients in Africa and Southeast Asia are at greatest risk of not undergoing surgery while suffering from treatable neurosurgical conditions, with annual case deficits of 2 million and 2.5 million, respectively . Over the last decade, a realisation of the gains to be made from safer pre-, intra-, and post-operative care has propelled surgery to the forefront of objectives in world health. This is reflected by the inclusion of 8 targets related to global surgery in the Sustainable Development Goals (SDGs) and the acknowledgement of emergency and essential surgical care and anaesthesia as components of universal health coverage at the 68th World Health Assembly in 2015 .
The rise of global neurosurgery has resulted in improved education and training of neurosurgical staff in LMICs . Together, education and training increase the quality-of-care patients receive, while also improving a region’s neurosurgeon-to-population ratio. The efficacy of these approaches is evidenced by the Weill Cornell Neurosurgery-Tanzania Collaboration, which led to significant increases in surgeries performed for traumatic cervical spine injury (0 to 120), hydrocephalus (100 to 800) and brain tumour (50 to 300) in Tanzania between 2007 and 2017. The programme also increased the number of neurosurgeons in the region from 2 to 8 and the number of residents from 0 to 5 . This collaboration succeeded on the basis of reciprocal education, utilisation of local resources and weekly remote case reviews. Task-shifting is another training technique used to reduce annual case deficits and involves providing non-neurosurgical professionals with the skills to perform basic neurotrauma procedures. The approach has been deployed effectively in Tanzania by Madaktari Africa, an organisation whose mission is to train and educate medical professionals in sub-Saharan Africa . The already significant advances in education and training as a result of the promotion of global neurosurgery support its position at the heart of recent progress in the clinical neurosciences.
Additionally, global interest in improving the provision of neurosurgery in LMICs has enabled cost-effective technological innovation to be implemented in the world’s poorest areas. The high burden of trauma patients in specific LMICs, such as Uganda, places significant stress on healthcare systems lacking advanced diagnostic imaging . To tackle this challenge, the Duke Neurosurgery East Africa Project developed the InfraScanner, a portable device that measures the presence, location, and volume of an intracranial haematoma. This technology expedites diagnosis in low-resource settings and decentralises neurosurgical care within LMICs . The development and deployment of cost-effective solutions under heavy financial constraints reinforces the role of global neurosurgery in advancing care for patients, not only in LMICs, but in all countries with health disparities linked to wealth.
Arguably the most critical impact of international collaboration in neurosurgical safety and efficacy has been the implementation of sustainable healthcare reform in LMICs . For example, since the beginning of the past decade, the Department of Neurosurgery at the Sick Kids Hospital in Toronto has been developing a paediatric brain disorder programme in Ukraine. Through philanthropic funding and bilateral knowledge exchanges, the programme has introduced new surgical procedures, increased patient referrals from regional centres and given rise to initiatives relating to foetal and maternal neurodevelopment . Project Medishare’s local health infrastructure and capacity-building programmes in Haiti provide further evidence of the benefits to be derived from sustainable changes to healthcare policy . Through deploying lessons learned from health systems in the developed world, these initiatives have the potential to improve neurosurgical care, while also benefitting other aspects of medical care in LMICs.
The future of global neurosurgery remains fascinating and impactful. While important progress has been made in neurosurgical education, technological deployment, and healthcare reform in LMICs, the prioritisation of global neurosurgery is a particularly significant advancement due to the benefits yet to be gained. The monitoring of neurosurgical outcomes in LMICs has greatly improved over the past decade, enabling for progress to be tracked and for empirical evidence to inform global health policy. For example, an international collaborative funded by the UK National Institute of Health Research found the observed mortality following traumatic brain injury to be 66% in Tanzania, prompting increased emphasis to be placed on the early access to treatment for neurotrauma . It is ultimately the analysis of global neurosurgical outcomes data that will determine the efficacy of this international initiative to improve access to safe and effective neurosurgical services.
In conclusion, global neurosurgery has been transformative in the education and training of neurosurgical professionals, the implementation of technological innovation in low-resource settings, and the promotion of sustainable healthcare reform in LMICs. The sheer magnitude of the disparity between the supply and demand of neurosurgical services worldwide, compounded by inequalities within and across nations, suggests that much is still to be gained from global collaboration in neurosurgery. The appreciation of safe and effective neurosurgery as a key element of universal health coverage is particularly encouraging as a sign of progress towards more equitable medical care for patients around the world.
 Park, Kee B., et al. “Global Neurosurgery: The Unmet Need.” World Neurosurgery, vol. 88, 2016, pp. 32–35., doi:10.1016/j.wneu.2015.12.048.
 Mukhopadhyay, Swagoto, et al. “The Global Neurosurgical Workforce: a Mixed-Methods Assessment of Density and Growth.” Journal of Neurosurgery, vol. 130, no. 4, 2019, pp. 1142–1148., doi:10.3171/2018.10.jns171723.
 Meara, John G., and Sarah L.M. Greenberg. “The Lancet Commission on Global Surgery Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare and Economic Development.” Surgery, vol. 157, no. 5, 2015, pp. 834–835., doi:10.1016/j.surg.2015.02.009.
 Dewan, Michael C., et al. “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, vol. 130, no. 4, 2019, pp. 1055–1064., doi:10.3171/2017.11.jns171500.
 Price, Raymond, et al. “World Health Assembly Resolution WHA68.15: ‘Strengthening Emergency and Essential Surgical Care and Anesthesia as a Component of Universal Health Coverage’—Addressing the Public Health Gaps Arising from Lack of Safe, Affordable and Accessible Surgical and Anesthetic Services.” World Journal of Surgery, vol. 39, no. 9, 2015, pp. 2115–2125., doi:10.1007/s00268-015-3153-y.
 Schmidt, Franziska A., et al. “Review of the Highlights from the First Annual Global Neurosurgery 2019: A Practical Symposium.” World Neurosurgery, vol. 137, 2020, pp. 46–54., doi:10.1016/j.wneu.2020.01.140.
 Budohoski, Karol P., et al. “Neurosurgery in East Africa: Innovations.” World Neurosurgery, vol. 113, 2018, pp. 436–452., doi:10.1016/j.wneu.2018.01.085.
 Forrester, Joseph D. “Unlikely SurgeonsA Surgeon In The Village: An American Doctor Teaches Brain Surgery In Africa By Tony Bartelme Boston (MA): Beacon Press, 2017 288 Pp., $27.95.” Health Affairs, vol. 36, no. 11, 2017, pp. 2026–2027., doi:10.1377/hlthaff.2017.0910.
 Tran, Tu M., et al. “Burden of Surgical Conditions in Uganda.” Annals of Surgery, vol. 266, no. 2, 2017, pp. 389–399., doi:10.1097/sla.0000000000001970.
 Kim, Amy Leonard. “Portable Traumatic Brain Injury Detection With Near-Infrared Technology: Infrascanner Model 2000.” Military Medicine, vol. 180, no. 5, 2015, pp. 597–598., doi:10.7205/milmed-d-14-00670.
 Romach, Myroslava K., and James T. Rutka. “Building Healthcare Capacity in Pediatric Neurosurgery and Psychiatry in a Post-Soviet System: Ukraine.” World Neurosurgery, vol. 111, 2018, pp. 166–174., doi:10.1016/j.wneu.2017.11.178.
 “Building Healthy Communities.” Project Medishare, projectmedishare.org/.
 Negida, Ahmed, et al. “Global NeuroSurg 1 Study: Determining the Global Outcomes of Traumatic Brain Injury in Low-, Middle-, and High- Income Countries: A Prospective, International Cohort Study v1 (Protocols.io.3kpgkvn).” Protocols.io, 2019, doi:10.17504/protocols.io.3kpgkvn.