- Email: [email protected]
African Neurosurgery, the 21st-Century Challenge
Continental Editor’s Message
Mohamed El-Fiki, M.D. Professor, Department of Neurosurgery, University of Alexandria President of the Egyptian Society of Neurological Surgeons Assistant Secretary of African Federation of Neurosurgical Societies, Alexandria, Egypt
African Neurosurgery, the 21st-Century Challenge
Two major challenges facing African neurosurgery include quality and quantity, in both recourses and personnel. Discrepancy is noted between the two poles, namely, the north and south of the continent and the sub-Saharan area. Although reasonably advanced in the north and south, neurosurgery remains poorly distributed and has multiple deficiencies. The sub-Saharan region, where the demand is high and services are scarce, suffers from a similar lack of both qualified personnel and well-equipped neurosurgical facilities. Insufficient state funding and research facilities aggravate the situation and discourage the few welltrained African neurosurgeons to practice in their homeland. For those who do return home, cultural, social, economical, and political issues hinder their performance and hence the quality of neurosurgery delivered in Africa. Strategies for rectification of these handicaps are presented, including the need for high-standard local training and support from international organizations.
the 21st century (3).This report sheds light on the state of neurosurgery and its practice in Africa.
African Neurosurgery Is Not Well Recognized on the Web Neurosurgeons in Africa and their support teams are overloaded with work and are generally understaffed. A good part of African neurosurgeons’ time and effort is wasted in secretarial and other parasurgical activities that should be done by support staff. The neurosurgeons, as well as hospital administration and state authorities, concentrate more on the actual delivery of neurosurgical service itself and ignore the importance of developing a cyber image or efficient research facilities necessary for attracting researchers. This may be attributed to several factors pertinent to the continent; the impact of each varies from one part of Africa to the other. Current evaluators will ignore many wellreputed African Neurosurgical centers simply because they are not well represented or are totally absent on the Internet. Had it not been for individual efforts from both international and African colleagues, neurosurgery in Africa would not have been exposed, thanks to pioneers such as Boctor, Sorur (24), El-Gendi (7), Djhnga (6), Adeloye (1, 2), Ruberti (2), Dumas (2), El-Banhawy (2), El-Khamlichi (8-12), and Odeku and Greene (19) among others.
African Organized Neurosurgery OVERVIEW Africa covers one fifth of the earth’s total land area, and it accounts for about 14% of the world’s human population. It is the second largest continent and is inhabited by more than 900 million people (as of 2005) in 61 territories (53 countries) (27). It has been recorded that some form of neurosurgery was practiced in Africa more than 3000 years ago (4, 13, 14, 20). However, an Internet search today of reputable hospitals in Africa will show very few hospitals. One website (26) tabulates only 325 hospitals in 31 African countries. Scrolling through the site, one can find more than 7000 hospitals in the United States and Europe each (Table 1). The discrepancy illustrates the dire conditions of current health care facilities in Africa. Birth defects are prevalent. Average life expectancy is about 50 years in many sub-Saharan countries compared to 75 years in most developed countries. The 5-year infant and child mortality rate is 112/10,000 live births in the former and 8/10,000 in the latter. Neurosurgery should not be a luxury or specialty that only exists in developed countries, especially in
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There are only 12 African neurosurgical and affiliate societies, including three regional societies: the Pan African Association of Neurosurgery (PANS), the African Federation of Neurosurgical Societies (AFNS) (Figure 1) and the Neurosurgical Society of East & Central Africa (ECSA). The Neurosurgery section of the Pan African Association of Neurological Sciences (PAANS) is still considered the continental society at the World Federation for Neurological Societies (WFNS), where 97 national and continental societies were represented as of the year 2007 (3).
Shared Challenges Neurosurgery in Africa faces two major challenges, quality and quantity in both resources and qualified personnel. El-Khamlichi (8, 10, 11) reported 10 years ago a ratio of one African neurosurgeon per 1,352,000 individuals compared to 1/121,000 in Europe and 1/81,000 in North America. This is about six times the international figure of 1/230,000. He suggested the initiation of funded training for young neurosurgeons from developing countries, with scholarships in their national or continental area (Table 2). The present situation is barely different. Neurosurgical prac-
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.02.012
CONTINENTAL EDITOR’S MESSAGE
Table 1. Number of Reputable Hospitals in Different Continents Continent
Number of Countries
Number of Hospitals
Africa
31
325
America
38
6907
Table 2. Distribution of Neurosurgeons in the World Population (millions)
Neurosurgeons
6656
33,193
1:275,000
North America
570
6,546
1:81,000
405
4,422
1:123,000
World
Europe
48
7035
South America
Asia
40
2826
Central America
Oceania
7
261
Reprinted with permission from Webometrics. http://hospitals.webometrics.info/top100_ continent.asp?cont⫽africa (21).
tice in Africa is lagging behind, both in actual structural delivery and in practice conditions. Most African neurosurgeons trained in the west hardly return to practice in their homeland. The importance of inexpensive equipment cannot be underestimated. Africa is looked at as North, South, and Sub-Saharan territories with variable social, political, economic, and cultural issues that contribute to the production of the aforementioned situation. African per capita GDP varies between less than US$600 in Malawi up to US $17,000 in Equatorial Guinea. In 13 countries, it is less than US $1000 whereas in only 5 countries it is more than US $10,000. The GDP is less than US $2000 in more than half of them (27). Most African countries allocate less than 5% of their gross national income to health care, whereas the United States spends more than 15% for the same purpose. Problems of insufficient training and inadequate or inaccessible facilities, especially prevalent in sub-Saharan countries, aggravate the situation even in the two rather successful systems in northern and southern Africa.
WHAT IS NEEDED? In Africa, patients, the medical community, and the society as a whole are in great need of tailored neurosurgical services. Neurosurgery in Africa must be inexpensive, at least for a start. There is also a great need for a medical training program to produce qualified neurosurgeons. Patients in quest of neurosurgical care are scattered all over the continent. With few exceptions, only a minority of African neurosurgical patients have easy access to ready, motivated, and satisfied high-caliber neurosurgeons available to serve them. Many excellent African neurosurgeons who are very well trained and hold key positions in developed countries do not return to practice in their homeland, and thus they deprive their communities of their expertise. It is difficult for them to give up their achievements and return home to poverty, underdevelopment, and lack of facilities. Consequently, Figure 1. Logo of African Federation current and future African of Neurosurgical Societies neurosurgery leaders are
WORLD NEUROSURGERY 73 [4]: 254-258, APRIL 2010
Europe Asia Australia Africa
Ratios (adjusted)
40
185
1:358,000
900
8,856
1:121,000
3800
12,288
1:336,000
56
162
1:205,000
800
700
1:1,238,000
Reprinted with permission from El Khamlichi A: African neurosurgery: Current situation, priorities and needs. Neurosurgery 48:1344-1347, 2001 (11).
challenged to attract African neurosurgeons to return and stay and practice in their homeland.
Cultural Issues One core issue in practice neurosurgery all over Africa is the cultural image of useless neurosurgical interference, dominance of folklore medicine, tribal healers, magicians, or potion prescriptions. This is maximized by poverty, illiteracy, and poor personal hygiene. Dominance of male neurosurgeons is observed all over Africa (5). Moreover, French cultural impact is much stronger than British, since the French opened the first hospital in Senegal in 1918 (2).
North African Specifics North African countries overlook the Mediterranean and interact easily with European or American training schools. This is especially true in the northwest, where strong French influence is noted (namely Morocco, with about 120 neurosurgeons; Algeria, with about 100 neurosurgeons; and Tunisia, with about 30 neurosurgeons). Some Italian and Egyptian or Tunisian influence, in addition to the current East European impact, is present in mid–North Africa (namely Libya, with only about 10 neurosurgeons). The northeast (i.e., Egypt, with more than 350 neurosurgeons, the largest number in the continent) is tied closely to the British and American medical schools. Only recently, the German, French, and Japanese schools were introduced to Egyptian neurosurgical training. These divisions and affiliations are heavily affected by political causes of short or long periods of war, occupation, colonization, or embargo as well as liberation movements. Shortage of state funding of health care facilities and neurosurgical training is dominant in North Africa, with few exceptions. The political and socioeconomic situation in most North African countries has influenced the neurosurgical care quality in partially or totally state-funded hospitals and proper baseline insurance but not in privately owned hospitals. This has negatively influenced neurosurgical training and acquisition of modern equipment. The quality of state-run hospital facilities, especially neurosurgical intensive care unit (ICU), as well as lack of proper maintenance of expensive high-tech diagnostic and monitoring equipment drains most government funds. This leads to poor working and research environment, with a paucity of basic research facilities. Consequently, most of the research
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publications are focused on application and clinical material or case reports. Nearly no innovation in equipment came from the area, in spite of reports of some new surgical technical modifications and novel ideas. In addition, improper distribution of qualified neurosurgeons is noted all through North Africa. In Egypt, for example, where 20 angio suites, and a similar number of 64 multislice CT scanners are active, neurosurgeons are badly distributed. More than 200 neurosurgeons in the Greater Cairo area practice on a population of about 20 million, that is, 1/100,000. The ratio is nearly the same for the Alexandria governorate. In Upper Egypt, however, only 20 neurosurgeons serve a population of more than 10 million (i.e., 1 neurosurgeon/ 500,000 inhabitants). The situation is worse in certain rural areas, where most practicing qualified neurosurgeons visit the suburbs as part-timers. This is mainly related to the disparity in the standard of living between the urban and rural communities.
South African Specifics The situation in South Africa (about 150 neurosurgeons) is more or less the same but with a different social and economic background. Immigrants with close ties to the European and American political and economical systems together with African and worldwide boycott have been associated with a special situation. Ethnic differences together with political turmoil, segregation, and embargo or boycott and economic sanctions during the apartheid had deprived many areas of the high standard of neurosurgical care that was available in other areas. This has markedly been changed to a more equal distribution of neurosurgical care after national reconciliation. Postgraduate training centers, the regions of practice, and public and private sector practices have influenced patient management strategies (5). The same is true for most of the neighboring countries (15, 16) depending mainly on South African neurosurgery centers and neurosurgeons to cover their needs (16, 17). Although considered one of the most advanced centers in Africa, of about 100 publications from the University of Cape Town, only one appeared in the Lancet (which was on Craniopagus twin), and fewer than 20 are in Neurosurgery, Journal of Neurosurgery, Surgical Neurology, or British Journal of Neurosurgery, and are mostly of case reports or with one reputable neurosurgeon (25). Most North and South African neurosurgeons received their primary neurosurgical training and qualifications at least partly in their homeland (5) with some American, European, or Japanese prequalification training. Most South African neurosurgeons work in private practice whereas those in North Africa are in academic university positions (5).
Sub-Saharan African Situation As for the Sub-Saharan African countries, neurosurgical services as well as neurosurgeons are very scarce. Long periods of imperialism, civil war, poverty, and famines have plagued the area. Two of the founders of PAANS practicing in Africa during the civil war have left for good (2). Most Sub-Saharan neurosurgeons consider that North and South African neurosurgeons are not representative of African neurosurgery. The prevalent sentiment is, “Real Africa is Black Africa” (17). The dire situation there may enforce this idea because it is totally different from that in the north or south (6, 18, 23). An urgent need for neurosurgeons is noted in Mali, Chad, Gabon, Niger, Burundi, Rwanda, Somalia, Eritrea, Central Africa, Botswana, Madagascar, Tanzania, Angola, Mauritius, Mauritania, Burkina Faso, Sierra Leone, Togo, Uganda
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(18), Zaire (6), and Ethiopia. Moderate need is noted in Nigeria (22), Congo, Ghana (23), Ivory Coast, Senegal, Cameroon, Zimbabwe (16), Sudan, and Zambia (17). Major efforts are being made in Kenya and the surrounding area through the efforts of the Neurosurgical Society of Eastern and Central Africa (NSEC). Similar efforts have been made by the two newly organized African neurosurgery bodies, the African Neurosurgical Association (ANSA) and the AFNS, taking over the prolonged efforts of the neurosurgical section of PAANS (2).
Role of Organized International Neurosurgery Several geographic and socioeconomic factors interplay to produce a decent neurosurgical practice in some African nations. However, the eagerness to perfection necessitates that neurosurgeons should be given a chance for better exposure internationally in order to help them keep their knowledge and practice updated. Most of them can practice extremely well with few resources. The main deterrent is the cost of attending training courses and conferences in developed countries, such as travel expenses, hotel accommodation, and registration fees (note GPD figures above). They should be given special concessions. The WFNS initiative to provide reduced-price basic neurosurgical equipment and basic microscopes for underdeveloped countries should be expanded to all centers whether governmental or privately funded. The more recent initiative by the Foundation for International Education for Neurological Surgery (FIENS) to provided free neurosurgical equipment and instruments to neurosurgeons from developing countries according to the World Bank classification should be generalized further to all equipment manufactures to participate in an organized effort to equip neurosurgical centers in Africa with both basic and modern neurosurgical tools. Lack of financial support, especially in pediatric neurosurgery and specifically shunts for hydrocephalus, may be overcome by local cheaper alternatives (21) or endoscopy.
Suggested Personnel Support Training and education of neurosurgeons must start locally in their own communities. This should be supplemented by further training organized in selected training centers inside Anglophone or Francophone Africa in English or French and to less extent in Spanish, Portuguese, or Swahili languages (because of the paucity of reference material and less spread of these latter languages in the continent) (Figure 2). Centers for training Francophone neurosurgeons may be developed in Morocco, Algeria, or Tunisia in addition to Cameron. Centers for Anglophone neurosurgeons may be developed in South Africa, Kenya, or Egypt. This training period may vary from 3 months (to update knowledge) to up to 6 years (to be an accredited certified neurosurgeon who may train others). Several of these short rotations according to the plan put forward by the local residency training program chairman in different fields may be a substitute for a more difficult-to-obtain long fellowship (at least currently). These centers my be totally or partially funded either through international organizations (WHO, UNICEF, Rockefeller, Rothschild) or major international neurosurgical equipment and pharmaceutical companies in addition to governmental or nongovernmental organizations similar to Ambassadorial Rotary foundation fellowships. Local organizations in many of these countries can provide logistic support in addition to organizational or individual donations and charity. Such training centers have already been developed in Morocco, South Africa, and Egypt, though further uniformity and organization is needed. These training centers
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CONTINENTAL EDITOR’S MESSAGE
surgeons regarding emergency management until the patient is transferred to a properly equipped neurosurgery center. 2. Degenerative spine disorders and disc disease: in collaboration with and training interested orthopedic surgeons in degenerative spine surgery because they outnumber neurosurgeons in most African countries. The same applies for spinal trauma 3. Congenital anomalies and post–meningitis hydrocephalus: and training in the use of portable endoscopic equipment in addition to training in the safe management of open spinal dysraphism, including preventive health education 4. Surgery of peripheral nerves with stress on the management of brachial plexus lesions as a result of birth injury 5. Straightforward surgery of simple brain and spinal tumors and ruptured aneurysms 6. More advanced training in functional neurosurgery and surgery of pain
Third Option
Figure 2. Africa, largest continent, ancient civilization, misadventures neurosurgical practice and services.
may be strengthened and recognized as “local African training centers of excellence” through efforts of volunteers visiting international neurosurgeons either from the region or otherwise who may spend variable periods training local neurosurgeons on specific neurosurgical techniques. (Several U.S., Japanese, Chinese, and European universities have already started such programs at the national level.) Cooperation is required for better use of available resources through continental or regional bodies of accreditation and certification. In most of these centers, supporting staff education and training is of high priority (operating room and ward nursing staff, ICU personnel, technicians, and maintenance engineers). Neurosurgical health education of the public, local physicians, and the whole community is also a prerequisite.
Suggested Neurosurgeons’ Training Alternatives Important topics that should be included and well covered in these training centers must include the following: 1. Neuro-trauma: including training some general surgeons to perform emergency life-saving neurosurgical procedures during their general surgery residency training program. Young neurosurgeons may be trained and encouraged to give “over the phone decisions” and consultations to fellow general
A third option remains, which is advanced neurosurgical training in developed countries with the risk of failing to come back to the original African country in need. This may be negated by providing these advanced trainings to highly specialized personnel for short periods of time, ranging from 1 week to a maximum of 1 month in specialized centers for training on advanced neurosurgery. These international training centers must demonstrate a strong understanding of the socioeconomic, cultural, moral and political differences between nations.
CONCLUSION Africa is severely deprived of neurosurgical care, especially in the sub-Saharan region. Concentration of services in urban areas results in uneven delivery of services in the more privileged north and south. Several factors intermingle to produce such a situation. However, African Neurosurgery will be able to meet the challenges of the 21st century with proper use of its resources and personnel. Improvements have been recognized in several fields. Working with limited resources is mandatory for most areas. Sophisticated tertiary care centers can be centralized but they face underdevelopment and maintenance problems. Three options for training African neurosurgeons and encouraging research exist, with an emphasis on training general or orthopedic and pediatric surgeons to perform urgent neurosurgical interferences. These include short-term local training in African centers of excellence and finally sharpening certain skills through fellowships in developed countries for brief periods of time. In addition, efforts of long- and short-duration visiting neurosurgeons and proper international funding must be encouraged.
thirty years 1972-2002. Book builders, Editions Africa, Ibidan, Nigeria, 2008.
tory and the recent contribution of the endoscope. Neurosurg Rev 30:1-7, discussion 7, 2007.
1. Adeloye A: Perspectives in international neurosurgery: neurosurgery in Nigeria. Neurosurgery 13: 333-336, 1983.
3. Black PM: The future of neurosurgery: a call to leadership. Clinical Neurosurgery 54:185-191, 2007.
5. Daniel CH, Nathoo N, Osborn IJS: South African Neurosurgical Patient Management Survey. S Afr J Anaesthesia Analg 8:61-65, 2005.
2. Adeloye A, Ruberti R. (eds.): The Pan African Association of Neurological Sciences (PAANS), the first
4. Cappabianca P, de Divitiis E: Back to the Egyptians: neurosurgery via the nose. A five thousand year his-
6. Djhnga S: Perspectives in international neurosurgery: neurosurgery in Zaire. Neurosurgery 13:95-97, 1983.
REFERENCES
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7. El Gindi S: Neurosurgery in Egypt: past, present, and future-from pyramids to radiosurgery. Neurosurgery 51:789-795, discussion 795-786, 2002. 8. El Khamlichi A: African neurosurgery. Part I: Historical outline. Surg Neurol 49:222-227, 1998. 9. El Khamlichi A: Technology and neurosurgery in developing countries: experience and present situation in Morocco. Neurosurgery 45:896-900, 1999. 10. El Khamlichi A: African neurosurgery part II: current state and future prospects. Surg Neurol 49:342347, 1998. 11. El Khamlichi A: African neurosurgery: current situation, priorities, and needs. Neurosurgery 48:13441347, 2001. 12. El Khamlichi A: Neurosurgery in Africa. Clin Neurosurg 52:214-217, 2005. 13. Feldman RP, Goodrich JT: The Edwin Smith Surgical Papyrus. Childs Nerv Syst 15:281-284, 1999. 14. Furnas DW, Sheikh MA, van den Hombergh P, Froeling F, Nunda IM: Traditional craniotomies of the Kisii tribe of Kenya. Ann Plast Surg 15:538-556, 1985.
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15. Glasauer FE: Neurosurgery in Rhodesia. Surg Neurol 5:373-376, 1976. 16. Kalangu KK: Neurosurgery in Zimbabwe. Surg Neurol 46:317-321, 1996. 17. Kalangu K. Pediatric neurosurgery in Africa— present and future. Child’s Nerv Syst 16:770-775, 2000. 18. Kiryabwire JW: Neurosurgery in Uganda. Neurosurgery 20:664-665, 1987. 19. McClelland S III, Harris KS: E. Latunde Odeku: The first African American trained in the United States. Neurosurgery 60:769-772, 2007. 20. Meschig R, Schadewaldt H: Skull trepanation in Eastern Africa. Hexagon Roche 9:17-24, 1981. 21. Oakes WJ: Shunts in Africa. J Neurosurg (Pediatrics 4) 102:357, 2005. 22. Ohaegbulam SC: Geographical neurosurgery. Neurol Res 21:161-170, 1999.
24. Sorour O: Neurosurgery in Egypt. Neurosurgery 19: 142-143, 1986. 25. University of Cape Town. http://www.neurosurgery. uct.ac.za/research.html. 26. Webometrics. http://hospitals.webometrics.info/ top100_continent.asp?cont⫽africa. 27. “World Population Prospects: The 2004 Revision” United Nations (Department of Economic and Social Affairs, population division) http://en. wikipedia.org/wiki/List_of_African_countries_ and_territories#References#References.
Mohamed El-Fiki Department of Neurosurgery, University of Alexandria, Alexandria, Egypt To whom correspondence should be addressed: Mohamed El-Fiki, D.N.Ch. [email: [email protected]] Citation: World Neurosurg. (2010) 73, 4:254-258. DOI: 10.1016/j.wneu.2010.02.012 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com
23. Puplampu B: Perspectives in international neurosurgery: neurosurgery in Ghana. Neurosurgery 12: 241, 1983.
1878-8750/$ - see front matter © 2010 Published by Elsevier Inc.
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.02.012
Mohamed El-Fiki, M.D. Professor, Department of Neurosurgery, University of Alexandria President of the Egyptian Society of Neurological Surgeons Assistant Secretary of African Federation of Neurosurgical Societies, Alexandria, Egypt
African Neurosurgery, the 21st-Century Challenge
Two major challenges facing African neurosurgery include quality and quantity, in both recourses and personnel. Discrepancy is noted between the two poles, namely, the north and south of the continent and the sub-Saharan area. Although reasonably advanced in the north and south, neurosurgery remains poorly distributed and has multiple deficiencies. The sub-Saharan region, where the demand is high and services are scarce, suffers from a similar lack of both qualified personnel and well-equipped neurosurgical facilities. Insufficient state funding and research facilities aggravate the situation and discourage the few welltrained African neurosurgeons to practice in their homeland. For those who do return home, cultural, social, economical, and political issues hinder their performance and hence the quality of neurosurgery delivered in Africa. Strategies for rectification of these handicaps are presented, including the need for high-standard local training and support from international organizations.
the 21st century (3).This report sheds light on the state of neurosurgery and its practice in Africa.
African Neurosurgery Is Not Well Recognized on the Web Neurosurgeons in Africa and their support teams are overloaded with work and are generally understaffed. A good part of African neurosurgeons’ time and effort is wasted in secretarial and other parasurgical activities that should be done by support staff. The neurosurgeons, as well as hospital administration and state authorities, concentrate more on the actual delivery of neurosurgical service itself and ignore the importance of developing a cyber image or efficient research facilities necessary for attracting researchers. This may be attributed to several factors pertinent to the continent; the impact of each varies from one part of Africa to the other. Current evaluators will ignore many wellreputed African Neurosurgical centers simply because they are not well represented or are totally absent on the Internet. Had it not been for individual efforts from both international and African colleagues, neurosurgery in Africa would not have been exposed, thanks to pioneers such as Boctor, Sorur (24), El-Gendi (7), Djhnga (6), Adeloye (1, 2), Ruberti (2), Dumas (2), El-Banhawy (2), El-Khamlichi (8-12), and Odeku and Greene (19) among others.
African Organized Neurosurgery OVERVIEW Africa covers one fifth of the earth’s total land area, and it accounts for about 14% of the world’s human population. It is the second largest continent and is inhabited by more than 900 million people (as of 2005) in 61 territories (53 countries) (27). It has been recorded that some form of neurosurgery was practiced in Africa more than 3000 years ago (4, 13, 14, 20). However, an Internet search today of reputable hospitals in Africa will show very few hospitals. One website (26) tabulates only 325 hospitals in 31 African countries. Scrolling through the site, one can find more than 7000 hospitals in the United States and Europe each (Table 1). The discrepancy illustrates the dire conditions of current health care facilities in Africa. Birth defects are prevalent. Average life expectancy is about 50 years in many sub-Saharan countries compared to 75 years in most developed countries. The 5-year infant and child mortality rate is 112/10,000 live births in the former and 8/10,000 in the latter. Neurosurgery should not be a luxury or specialty that only exists in developed countries, especially in
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There are only 12 African neurosurgical and affiliate societies, including three regional societies: the Pan African Association of Neurosurgery (PANS), the African Federation of Neurosurgical Societies (AFNS) (Figure 1) and the Neurosurgical Society of East & Central Africa (ECSA). The Neurosurgery section of the Pan African Association of Neurological Sciences (PAANS) is still considered the continental society at the World Federation for Neurological Societies (WFNS), where 97 national and continental societies were represented as of the year 2007 (3).
Shared Challenges Neurosurgery in Africa faces two major challenges, quality and quantity in both resources and qualified personnel. El-Khamlichi (8, 10, 11) reported 10 years ago a ratio of one African neurosurgeon per 1,352,000 individuals compared to 1/121,000 in Europe and 1/81,000 in North America. This is about six times the international figure of 1/230,000. He suggested the initiation of funded training for young neurosurgeons from developing countries, with scholarships in their national or continental area (Table 2). The present situation is barely different. Neurosurgical prac-
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.02.012
CONTINENTAL EDITOR’S MESSAGE
Table 1. Number of Reputable Hospitals in Different Continents Continent
Number of Countries
Number of Hospitals
Africa
31
325
America
38
6907
Table 2. Distribution of Neurosurgeons in the World Population (millions)
Neurosurgeons
6656
33,193
1:275,000
North America
570
6,546
1:81,000
405
4,422
1:123,000
World
Europe
48
7035
South America
Asia
40
2826
Central America
Oceania
7
261
Reprinted with permission from Webometrics. http://hospitals.webometrics.info/top100_ continent.asp?cont⫽africa (21).
tice in Africa is lagging behind, both in actual structural delivery and in practice conditions. Most African neurosurgeons trained in the west hardly return to practice in their homeland. The importance of inexpensive equipment cannot be underestimated. Africa is looked at as North, South, and Sub-Saharan territories with variable social, political, economic, and cultural issues that contribute to the production of the aforementioned situation. African per capita GDP varies between less than US$600 in Malawi up to US $17,000 in Equatorial Guinea. In 13 countries, it is less than US $1000 whereas in only 5 countries it is more than US $10,000. The GDP is less than US $2000 in more than half of them (27). Most African countries allocate less than 5% of their gross national income to health care, whereas the United States spends more than 15% for the same purpose. Problems of insufficient training and inadequate or inaccessible facilities, especially prevalent in sub-Saharan countries, aggravate the situation even in the two rather successful systems in northern and southern Africa.
WHAT IS NEEDED? In Africa, patients, the medical community, and the society as a whole are in great need of tailored neurosurgical services. Neurosurgery in Africa must be inexpensive, at least for a start. There is also a great need for a medical training program to produce qualified neurosurgeons. Patients in quest of neurosurgical care are scattered all over the continent. With few exceptions, only a minority of African neurosurgical patients have easy access to ready, motivated, and satisfied high-caliber neurosurgeons available to serve them. Many excellent African neurosurgeons who are very well trained and hold key positions in developed countries do not return to practice in their homeland, and thus they deprive their communities of their expertise. It is difficult for them to give up their achievements and return home to poverty, underdevelopment, and lack of facilities. Consequently, Figure 1. Logo of African Federation current and future African of Neurosurgical Societies neurosurgery leaders are
WORLD NEUROSURGERY 73 [4]: 254-258, APRIL 2010
Europe Asia Australia Africa
Ratios (adjusted)
40
185
1:358,000
900
8,856
1:121,000
3800
12,288
1:336,000
56
162
1:205,000
800
700
1:1,238,000
Reprinted with permission from El Khamlichi A: African neurosurgery: Current situation, priorities and needs. Neurosurgery 48:1344-1347, 2001 (11).
challenged to attract African neurosurgeons to return and stay and practice in their homeland.
Cultural Issues One core issue in practice neurosurgery all over Africa is the cultural image of useless neurosurgical interference, dominance of folklore medicine, tribal healers, magicians, or potion prescriptions. This is maximized by poverty, illiteracy, and poor personal hygiene. Dominance of male neurosurgeons is observed all over Africa (5). Moreover, French cultural impact is much stronger than British, since the French opened the first hospital in Senegal in 1918 (2).
North African Specifics North African countries overlook the Mediterranean and interact easily with European or American training schools. This is especially true in the northwest, where strong French influence is noted (namely Morocco, with about 120 neurosurgeons; Algeria, with about 100 neurosurgeons; and Tunisia, with about 30 neurosurgeons). Some Italian and Egyptian or Tunisian influence, in addition to the current East European impact, is present in mid–North Africa (namely Libya, with only about 10 neurosurgeons). The northeast (i.e., Egypt, with more than 350 neurosurgeons, the largest number in the continent) is tied closely to the British and American medical schools. Only recently, the German, French, and Japanese schools were introduced to Egyptian neurosurgical training. These divisions and affiliations are heavily affected by political causes of short or long periods of war, occupation, colonization, or embargo as well as liberation movements. Shortage of state funding of health care facilities and neurosurgical training is dominant in North Africa, with few exceptions. The political and socioeconomic situation in most North African countries has influenced the neurosurgical care quality in partially or totally state-funded hospitals and proper baseline insurance but not in privately owned hospitals. This has negatively influenced neurosurgical training and acquisition of modern equipment. The quality of state-run hospital facilities, especially neurosurgical intensive care unit (ICU), as well as lack of proper maintenance of expensive high-tech diagnostic and monitoring equipment drains most government funds. This leads to poor working and research environment, with a paucity of basic research facilities. Consequently, most of the research
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publications are focused on application and clinical material or case reports. Nearly no innovation in equipment came from the area, in spite of reports of some new surgical technical modifications and novel ideas. In addition, improper distribution of qualified neurosurgeons is noted all through North Africa. In Egypt, for example, where 20 angio suites, and a similar number of 64 multislice CT scanners are active, neurosurgeons are badly distributed. More than 200 neurosurgeons in the Greater Cairo area practice on a population of about 20 million, that is, 1/100,000. The ratio is nearly the same for the Alexandria governorate. In Upper Egypt, however, only 20 neurosurgeons serve a population of more than 10 million (i.e., 1 neurosurgeon/ 500,000 inhabitants). The situation is worse in certain rural areas, where most practicing qualified neurosurgeons visit the suburbs as part-timers. This is mainly related to the disparity in the standard of living between the urban and rural communities.
South African Specifics The situation in South Africa (about 150 neurosurgeons) is more or less the same but with a different social and economic background. Immigrants with close ties to the European and American political and economical systems together with African and worldwide boycott have been associated with a special situation. Ethnic differences together with political turmoil, segregation, and embargo or boycott and economic sanctions during the apartheid had deprived many areas of the high standard of neurosurgical care that was available in other areas. This has markedly been changed to a more equal distribution of neurosurgical care after national reconciliation. Postgraduate training centers, the regions of practice, and public and private sector practices have influenced patient management strategies (5). The same is true for most of the neighboring countries (15, 16) depending mainly on South African neurosurgery centers and neurosurgeons to cover their needs (16, 17). Although considered one of the most advanced centers in Africa, of about 100 publications from the University of Cape Town, only one appeared in the Lancet (which was on Craniopagus twin), and fewer than 20 are in Neurosurgery, Journal of Neurosurgery, Surgical Neurology, or British Journal of Neurosurgery, and are mostly of case reports or with one reputable neurosurgeon (25). Most North and South African neurosurgeons received their primary neurosurgical training and qualifications at least partly in their homeland (5) with some American, European, or Japanese prequalification training. Most South African neurosurgeons work in private practice whereas those in North Africa are in academic university positions (5).
Sub-Saharan African Situation As for the Sub-Saharan African countries, neurosurgical services as well as neurosurgeons are very scarce. Long periods of imperialism, civil war, poverty, and famines have plagued the area. Two of the founders of PAANS practicing in Africa during the civil war have left for good (2). Most Sub-Saharan neurosurgeons consider that North and South African neurosurgeons are not representative of African neurosurgery. The prevalent sentiment is, “Real Africa is Black Africa” (17). The dire situation there may enforce this idea because it is totally different from that in the north or south (6, 18, 23). An urgent need for neurosurgeons is noted in Mali, Chad, Gabon, Niger, Burundi, Rwanda, Somalia, Eritrea, Central Africa, Botswana, Madagascar, Tanzania, Angola, Mauritius, Mauritania, Burkina Faso, Sierra Leone, Togo, Uganda
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(18), Zaire (6), and Ethiopia. Moderate need is noted in Nigeria (22), Congo, Ghana (23), Ivory Coast, Senegal, Cameroon, Zimbabwe (16), Sudan, and Zambia (17). Major efforts are being made in Kenya and the surrounding area through the efforts of the Neurosurgical Society of Eastern and Central Africa (NSEC). Similar efforts have been made by the two newly organized African neurosurgery bodies, the African Neurosurgical Association (ANSA) and the AFNS, taking over the prolonged efforts of the neurosurgical section of PAANS (2).
Role of Organized International Neurosurgery Several geographic and socioeconomic factors interplay to produce a decent neurosurgical practice in some African nations. However, the eagerness to perfection necessitates that neurosurgeons should be given a chance for better exposure internationally in order to help them keep their knowledge and practice updated. Most of them can practice extremely well with few resources. The main deterrent is the cost of attending training courses and conferences in developed countries, such as travel expenses, hotel accommodation, and registration fees (note GPD figures above). They should be given special concessions. The WFNS initiative to provide reduced-price basic neurosurgical equipment and basic microscopes for underdeveloped countries should be expanded to all centers whether governmental or privately funded. The more recent initiative by the Foundation for International Education for Neurological Surgery (FIENS) to provided free neurosurgical equipment and instruments to neurosurgeons from developing countries according to the World Bank classification should be generalized further to all equipment manufactures to participate in an organized effort to equip neurosurgical centers in Africa with both basic and modern neurosurgical tools. Lack of financial support, especially in pediatric neurosurgery and specifically shunts for hydrocephalus, may be overcome by local cheaper alternatives (21) or endoscopy.
Suggested Personnel Support Training and education of neurosurgeons must start locally in their own communities. This should be supplemented by further training organized in selected training centers inside Anglophone or Francophone Africa in English or French and to less extent in Spanish, Portuguese, or Swahili languages (because of the paucity of reference material and less spread of these latter languages in the continent) (Figure 2). Centers for training Francophone neurosurgeons may be developed in Morocco, Algeria, or Tunisia in addition to Cameron. Centers for Anglophone neurosurgeons may be developed in South Africa, Kenya, or Egypt. This training period may vary from 3 months (to update knowledge) to up to 6 years (to be an accredited certified neurosurgeon who may train others). Several of these short rotations according to the plan put forward by the local residency training program chairman in different fields may be a substitute for a more difficult-to-obtain long fellowship (at least currently). These centers my be totally or partially funded either through international organizations (WHO, UNICEF, Rockefeller, Rothschild) or major international neurosurgical equipment and pharmaceutical companies in addition to governmental or nongovernmental organizations similar to Ambassadorial Rotary foundation fellowships. Local organizations in many of these countries can provide logistic support in addition to organizational or individual donations and charity. Such training centers have already been developed in Morocco, South Africa, and Egypt, though further uniformity and organization is needed. These training centers
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surgeons regarding emergency management until the patient is transferred to a properly equipped neurosurgery center. 2. Degenerative spine disorders and disc disease: in collaboration with and training interested orthopedic surgeons in degenerative spine surgery because they outnumber neurosurgeons in most African countries. The same applies for spinal trauma 3. Congenital anomalies and post–meningitis hydrocephalus: and training in the use of portable endoscopic equipment in addition to training in the safe management of open spinal dysraphism, including preventive health education 4. Surgery of peripheral nerves with stress on the management of brachial plexus lesions as a result of birth injury 5. Straightforward surgery of simple brain and spinal tumors and ruptured aneurysms 6. More advanced training in functional neurosurgery and surgery of pain
Third Option
Figure 2. Africa, largest continent, ancient civilization, misadventures neurosurgical practice and services.
may be strengthened and recognized as “local African training centers of excellence” through efforts of volunteers visiting international neurosurgeons either from the region or otherwise who may spend variable periods training local neurosurgeons on specific neurosurgical techniques. (Several U.S., Japanese, Chinese, and European universities have already started such programs at the national level.) Cooperation is required for better use of available resources through continental or regional bodies of accreditation and certification. In most of these centers, supporting staff education and training is of high priority (operating room and ward nursing staff, ICU personnel, technicians, and maintenance engineers). Neurosurgical health education of the public, local physicians, and the whole community is also a prerequisite.
Suggested Neurosurgeons’ Training Alternatives Important topics that should be included and well covered in these training centers must include the following: 1. Neuro-trauma: including training some general surgeons to perform emergency life-saving neurosurgical procedures during their general surgery residency training program. Young neurosurgeons may be trained and encouraged to give “over the phone decisions” and consultations to fellow general
A third option remains, which is advanced neurosurgical training in developed countries with the risk of failing to come back to the original African country in need. This may be negated by providing these advanced trainings to highly specialized personnel for short periods of time, ranging from 1 week to a maximum of 1 month in specialized centers for training on advanced neurosurgery. These international training centers must demonstrate a strong understanding of the socioeconomic, cultural, moral and political differences between nations.
CONCLUSION Africa is severely deprived of neurosurgical care, especially in the sub-Saharan region. Concentration of services in urban areas results in uneven delivery of services in the more privileged north and south. Several factors intermingle to produce such a situation. However, African Neurosurgery will be able to meet the challenges of the 21st century with proper use of its resources and personnel. Improvements have been recognized in several fields. Working with limited resources is mandatory for most areas. Sophisticated tertiary care centers can be centralized but they face underdevelopment and maintenance problems. Three options for training African neurosurgeons and encouraging research exist, with an emphasis on training general or orthopedic and pediatric surgeons to perform urgent neurosurgical interferences. These include short-term local training in African centers of excellence and finally sharpening certain skills through fellowships in developed countries for brief periods of time. In addition, efforts of long- and short-duration visiting neurosurgeons and proper international funding must be encouraged.
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Mohamed El-Fiki Department of Neurosurgery, University of Alexandria, Alexandria, Egypt To whom correspondence should be addressed: Mohamed El-Fiki, D.N.Ch. [email: [email protected]] Citation: World Neurosurg. (2010) 73, 4:254-258. DOI: 10.1016/j.wneu.2010.02.012 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com
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