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The rise of Chinese neurosurgery and neurosurgery in the developing world, and scientific colonialism
Surgical Neurology 67 (2007) 323 – 325 www.surgicalneurology-online.com
Editorial
The rise of Chinese neurosurgery and neurosurgery in the developing world, and scientific colonialism In this issue of Surgical Neurology, there are 3 articles from Chinese neurosurgical groups. The articles are of very high quality. Ten years ago, we did not receive articles from China and many of the countries in the developing world. The articles in this issue are an example of the rise of neurosurgery and neurosciences in China and in the developing world. In the past year, Surgical Neurology received an increase in articles of more than 35% as compared with the previous year. This trend is occurring in many medical publications as physicians in the developing world seek to publish their observations. The trend we are seeing will continue. In 2006, the Chinese Neurosurgical Society published its first international neurosurgical journal as a supplement to Surgical Neurology. Brazil and Taiwan have done the same. What is happening in China to produce these changes? In 1995, my wife and I first went to China to start the first World Federation of Neurosurgical Courses in the country. Kintomo Takakura from Japan initiated the contact, and my teacher, Shelley Chou, a China-born United States–educated neurosurgeon who had been the chairperson of neurosurgery at the University of Minnesota and president of the American Association of Neurosurgical Surgeons, accompanied us. A number of neurosurgeons from around the world participated in this first international neurosurgical course in China. Our talks were communicated by Chinese translators. At that time, the streets of Beijing were filled with people on bicycles. There were few cars. Construction was just beginning on major buildings. We visited the Forbidden City, home of the emperors of the past, located in the center of Beijing. Its imposing red walls with many buildings inside contained what remained of the historically significant artistic creations of a 4000-year-old civilization. We climbed the Great Wall, which was built to connect the fardistant places in China so that the army could easily access the troubled spots by an elevated road. One third of the patients were treated by traditional medicine with acupuncture and herbs; the rest had access to modern medicine and science. There was little demonstrable poverty, but a glimpse of it could be seen in the many narrow alleys that came off the large streets. Few neurosurgeons from the developing world had been to China at that time. 0090-3019/$ – see front matter D 2007 Published by Elsevier Inc. doi:10.1016/j.surneu.2007.01.011
I visited a major hospital in Beijing that had one ward of 15 beds filled with patients who had acoustic neurinomas, a concentrated sample of patients I had not seen anywhere else. Radiographs were filed under the mattress of each patient. I saw no patient older than 40 to 50 years. Modern medicine was only available to the young. With 1 billion people, the scant resources for health care had to be spent on those who would be able to contribute to the society for a long time. The hospitals were simple. There were few monitoring devices, and each neurosurgical operating room had a basic microscope and a simple bipolar coagulator. The volume of surgery performed was larger than in any other place I had seen in the world, reflecting the country’s population size of 1 billion and the need to accommodate large numbers of patients. Ten years and many visits to cities throughout China later, we see that major changes have occurred. Construction cranes now populate the sky in Beijing, Shanghai, and other cities. Automobiles crowd the streets of the cities, creating traffic jams. Few people on bicycles are seen. I have seen modern operating rooms that surpass the best ones I have seen elsewhere in the world. In Shanghai, a city with many modern and beautifully designed skyscrapers, Prof Liang-fu Zhou is head of a neurosurgical service that performs 8000 surgeries a year, mostly cranial, at several hospitals. His staff numbers 100 neurosurgeons. His department, as other departments, is actively engaged in basic research. Many neurosurgeons from outside China visit and present lectures—some without translations—throughout China. There is growing contact with neurosurgery and medicine all over the world. Many Chinese neurosurgeons are receiving additional postgraduate training in other countries. Thus, it was easy to see that the scientific and medical advances have been rapid and in step with the country’s economic and industrial growth. To encourage the people to relocate inland and reduce the pressure of migration to the big cities on the coast of China, the government started the construction of 200 new inland cities, each intended for 1 million people, which will be carried out over the next 20 years. This is the largest relocation of a civilization in the history of humankind, 200 million people. To reverse its dependence on oil, a nuclear power plant is being
324
Editorial / Surgical Neurology 67 (2007) 323–325
constructed each month for the next 20 years to provide energy for this growing industrial power. These are examples of the magnitude of problems that the government faces in serving 1 billion people. We have talked with many Chinese people at all levels of society and asked about their desires in life. Many have migrated from the countryside to the city, attracted by the opportunity to make money and to have a better life than they would have in the rural communities. Uniformly, the Chinese want to have a chance to live the life they were denied for years, to acquire material goods, and to live in peace. Husbands and wives both usually work to provide income, part of which they spend to support their parents in other cities, mostly in the countryside, because there is no governmental support system for the elderly population. One year ago, you would not have received health care in China if you did not have money. Seven hundred million Chinese, 70% of the population, live in the countryside outside the big cities and do not have access to health care because they do not have the money to pay for the services. In 2006, the government recognized this problem and began to provide some support for the care of those living outside the cities. Individuals in the cities who have jobs are able to receive health care as part of their benefits from working. Although the government is communist or socialist, it does not appear to affect the lives of the Chinese directly; neither does it stop the growth of capitalism and the development of independent businesses. In our opinion, it would be virtually impossible for the government to reverse the course of this country, which is now on the path to individual freedom that so many Chinese currently enjoy. In addition, any consideration of involvement in a war would destroy the lives that many of the 1 billion people now enjoy and ruin the economy because trade with others would be stopped. This economy is vital to this huge population that now wants to have more of the opportunities that life offers. However, all is not easy. The poor people from the countryside riot against government corruption and its denial of services to them, but little of this unrest is known to the Chinese or to the rest of the world. This example is a remnant of governmental control of the press. In a country with 1 billion people, if 10% are unhappy, it means that 100 million people are not happy. No politician can enjoy that possibility. Therefore, the problems that the government faces at a time of huge change are very difficult. Some companies have given money back to doctors and hospitals that buy their equipment as a reward for their purchase. The government has attempted to stop this corruption by passing laws that are very restrictive on the purchase of new equipment. Corruption is very common in China as it is in other countries. It involves the government, the banking system, the business sector, and many aspects of life. Corruption in most countries is how many survive in a social system that frustrates opportunity. Part of the reason for this corruption in medicine is the fact that Chinese physicians are poorly paid by standards in other countries,
and it is a way for the people to make some extra money. It was very difficult for Prof Jizong Zhao, head of the Chinese Neurosurgical Society, to raise enough money for the initial issue of the Chinese Neurosurgical Supplement. Although there is great progress in Chinese neurosurgery, doctors work under difficult circumstances with little pay in taking care of the large numbers of patients who need care. When I visited Nanjing in November 2006, the main hospital there registered 10 000 outpatients each day. There is no uniform standard of training; as such, there is an uneven education among neurosurgeons in the country, a situation seen in many countries around the world. However, the Chinese are also working to correct these problems. The Brazilians, who have a similar social and economic situation, have been the most successful in the world in providing standards of care for the education of neurosurgeons. I met the head of the Chinese Medical Association. It has 1,500,000 physicians as members. It has to be the largest medical society in the world. The numbers in every area one investigates are huge because of the one billion populations base. So, when we read an article from China or from other developing countries, there is a background we must understand. In many ways, to produce a fine article in a developing country is extremely difficult because of the problems that the doctors must overcome to do this extra kind of work. Nonetheless, there are very bright people all over the world who have good ideas. The best ideas do not just come from developed countries. As a matter of fact, I see a tremendous desire among the Chinese and others from developing countries to succeed and make a better life that the government cannot provide. This desire is not present in some of the developed world because people have taken their freedom for granted, without an appreciation of how hard it was to get such freedom. The reason why the Chinese are succeeding is that they have this tremendous desire to succeed and have a better life. Why has this same desire not surfaced in Russia or in many of the Eastern European countries, in Latin America, and in other places in the world? Why is it not even seen in the more developed world? Have the socialistic systems frustrated innovation and creativity? We see a large number of new articles coming from Turkey, Taiwan, and Brazil, in addition to China. Yes, we are also seeing articles from the Middle East and a few from Africa. What does this emergence of science in the developing world mean? There are ideas to be understood coming from bright minds in many places. I have witnessed bscientific colonialismQ in meetings in which the scientists from the developed world lecture as if the developing world audience knows nothing. I have seen scientific colonialism in the conduct of the scientists from the developed world who do not select articles from the developing world for publication because the reviewers or editors do not think that science in the developing world has reached bthe developing-world standards.Q The articles are not even considered. I have seen resident candidates from the developing world rejected without consideration for the
Editorial / Surgical Neurology 67 (2007) 323–325
similar reason—that they cannot be well educated. I have seen a medical school that supported this kind of thinking. This attitude has also infected the World Federation of Neurosurgical Societies (WFNS) in its continued selection of leadership from the developed world. Are there no creative and innovative leaders from the developing world? I witnessed this bias against the developing world when, as chairperson of the nominating committee of the WFNS, I was told that those in the developing world were not able to lead a major organization. Our committee selected a leader from the developing world as a candidate for president, who was elected. There is no place for this biased thinking or philosophy in the scientific world. All people and ideas should be given fair opportunity for understanding. Some of the greatest discoveries in neurosurgery and medicine have come from people working in very difficult circumstances and in developing countries. Scientific colonialism or progress? You decide. I have just described how the Chinese are making huge strides to surpass those who are complacent. This same phenomenon of complacency has happened throughout history. It occurs
325
in academia and in business. The complacent lose, whereas those who have the desire to win do win. The accompanying editorial in this issue by Miguel Faria is a testimony to the struggle of one person to rise above his life circumstances to achieve success. Miguel escaped from Cuba with his family to come to the United States, where he became a physician, a neurosurgeon, and eventually a leader of a very proindependence antisocialist medical society. He became editor of its national publication. Miguel, the Chinese, and others are overcoming huge obstacles to succeed in this world. Are the rest of us becoming complacent? I have told the residents I teach that their competition is not the person next door but the best in the world. There is always someone who wants to succeed and who will make great sacrifices to do so. Are the rest of us willing to do that? That is the attitude that separates the victorious from the defeated. James I. Ausman, MD, PhD E-mail address: [email protected]
Editorial
The rise of Chinese neurosurgery and neurosurgery in the developing world, and scientific colonialism In this issue of Surgical Neurology, there are 3 articles from Chinese neurosurgical groups. The articles are of very high quality. Ten years ago, we did not receive articles from China and many of the countries in the developing world. The articles in this issue are an example of the rise of neurosurgery and neurosciences in China and in the developing world. In the past year, Surgical Neurology received an increase in articles of more than 35% as compared with the previous year. This trend is occurring in many medical publications as physicians in the developing world seek to publish their observations. The trend we are seeing will continue. In 2006, the Chinese Neurosurgical Society published its first international neurosurgical journal as a supplement to Surgical Neurology. Brazil and Taiwan have done the same. What is happening in China to produce these changes? In 1995, my wife and I first went to China to start the first World Federation of Neurosurgical Courses in the country. Kintomo Takakura from Japan initiated the contact, and my teacher, Shelley Chou, a China-born United States–educated neurosurgeon who had been the chairperson of neurosurgery at the University of Minnesota and president of the American Association of Neurosurgical Surgeons, accompanied us. A number of neurosurgeons from around the world participated in this first international neurosurgical course in China. Our talks were communicated by Chinese translators. At that time, the streets of Beijing were filled with people on bicycles. There were few cars. Construction was just beginning on major buildings. We visited the Forbidden City, home of the emperors of the past, located in the center of Beijing. Its imposing red walls with many buildings inside contained what remained of the historically significant artistic creations of a 4000-year-old civilization. We climbed the Great Wall, which was built to connect the fardistant places in China so that the army could easily access the troubled spots by an elevated road. One third of the patients were treated by traditional medicine with acupuncture and herbs; the rest had access to modern medicine and science. There was little demonstrable poverty, but a glimpse of it could be seen in the many narrow alleys that came off the large streets. Few neurosurgeons from the developing world had been to China at that time. 0090-3019/$ – see front matter D 2007 Published by Elsevier Inc. doi:10.1016/j.surneu.2007.01.011
I visited a major hospital in Beijing that had one ward of 15 beds filled with patients who had acoustic neurinomas, a concentrated sample of patients I had not seen anywhere else. Radiographs were filed under the mattress of each patient. I saw no patient older than 40 to 50 years. Modern medicine was only available to the young. With 1 billion people, the scant resources for health care had to be spent on those who would be able to contribute to the society for a long time. The hospitals were simple. There were few monitoring devices, and each neurosurgical operating room had a basic microscope and a simple bipolar coagulator. The volume of surgery performed was larger than in any other place I had seen in the world, reflecting the country’s population size of 1 billion and the need to accommodate large numbers of patients. Ten years and many visits to cities throughout China later, we see that major changes have occurred. Construction cranes now populate the sky in Beijing, Shanghai, and other cities. Automobiles crowd the streets of the cities, creating traffic jams. Few people on bicycles are seen. I have seen modern operating rooms that surpass the best ones I have seen elsewhere in the world. In Shanghai, a city with many modern and beautifully designed skyscrapers, Prof Liang-fu Zhou is head of a neurosurgical service that performs 8000 surgeries a year, mostly cranial, at several hospitals. His staff numbers 100 neurosurgeons. His department, as other departments, is actively engaged in basic research. Many neurosurgeons from outside China visit and present lectures—some without translations—throughout China. There is growing contact with neurosurgery and medicine all over the world. Many Chinese neurosurgeons are receiving additional postgraduate training in other countries. Thus, it was easy to see that the scientific and medical advances have been rapid and in step with the country’s economic and industrial growth. To encourage the people to relocate inland and reduce the pressure of migration to the big cities on the coast of China, the government started the construction of 200 new inland cities, each intended for 1 million people, which will be carried out over the next 20 years. This is the largest relocation of a civilization in the history of humankind, 200 million people. To reverse its dependence on oil, a nuclear power plant is being
324
Editorial / Surgical Neurology 67 (2007) 323–325
constructed each month for the next 20 years to provide energy for this growing industrial power. These are examples of the magnitude of problems that the government faces in serving 1 billion people. We have talked with many Chinese people at all levels of society and asked about their desires in life. Many have migrated from the countryside to the city, attracted by the opportunity to make money and to have a better life than they would have in the rural communities. Uniformly, the Chinese want to have a chance to live the life they were denied for years, to acquire material goods, and to live in peace. Husbands and wives both usually work to provide income, part of which they spend to support their parents in other cities, mostly in the countryside, because there is no governmental support system for the elderly population. One year ago, you would not have received health care in China if you did not have money. Seven hundred million Chinese, 70% of the population, live in the countryside outside the big cities and do not have access to health care because they do not have the money to pay for the services. In 2006, the government recognized this problem and began to provide some support for the care of those living outside the cities. Individuals in the cities who have jobs are able to receive health care as part of their benefits from working. Although the government is communist or socialist, it does not appear to affect the lives of the Chinese directly; neither does it stop the growth of capitalism and the development of independent businesses. In our opinion, it would be virtually impossible for the government to reverse the course of this country, which is now on the path to individual freedom that so many Chinese currently enjoy. In addition, any consideration of involvement in a war would destroy the lives that many of the 1 billion people now enjoy and ruin the economy because trade with others would be stopped. This economy is vital to this huge population that now wants to have more of the opportunities that life offers. However, all is not easy. The poor people from the countryside riot against government corruption and its denial of services to them, but little of this unrest is known to the Chinese or to the rest of the world. This example is a remnant of governmental control of the press. In a country with 1 billion people, if 10% are unhappy, it means that 100 million people are not happy. No politician can enjoy that possibility. Therefore, the problems that the government faces at a time of huge change are very difficult. Some companies have given money back to doctors and hospitals that buy their equipment as a reward for their purchase. The government has attempted to stop this corruption by passing laws that are very restrictive on the purchase of new equipment. Corruption is very common in China as it is in other countries. It involves the government, the banking system, the business sector, and many aspects of life. Corruption in most countries is how many survive in a social system that frustrates opportunity. Part of the reason for this corruption in medicine is the fact that Chinese physicians are poorly paid by standards in other countries,
and it is a way for the people to make some extra money. It was very difficult for Prof Jizong Zhao, head of the Chinese Neurosurgical Society, to raise enough money for the initial issue of the Chinese Neurosurgical Supplement. Although there is great progress in Chinese neurosurgery, doctors work under difficult circumstances with little pay in taking care of the large numbers of patients who need care. When I visited Nanjing in November 2006, the main hospital there registered 10 000 outpatients each day. There is no uniform standard of training; as such, there is an uneven education among neurosurgeons in the country, a situation seen in many countries around the world. However, the Chinese are also working to correct these problems. The Brazilians, who have a similar social and economic situation, have been the most successful in the world in providing standards of care for the education of neurosurgeons. I met the head of the Chinese Medical Association. It has 1,500,000 physicians as members. It has to be the largest medical society in the world. The numbers in every area one investigates are huge because of the one billion populations base. So, when we read an article from China or from other developing countries, there is a background we must understand. In many ways, to produce a fine article in a developing country is extremely difficult because of the problems that the doctors must overcome to do this extra kind of work. Nonetheless, there are very bright people all over the world who have good ideas. The best ideas do not just come from developed countries. As a matter of fact, I see a tremendous desire among the Chinese and others from developing countries to succeed and make a better life that the government cannot provide. This desire is not present in some of the developed world because people have taken their freedom for granted, without an appreciation of how hard it was to get such freedom. The reason why the Chinese are succeeding is that they have this tremendous desire to succeed and have a better life. Why has this same desire not surfaced in Russia or in many of the Eastern European countries, in Latin America, and in other places in the world? Why is it not even seen in the more developed world? Have the socialistic systems frustrated innovation and creativity? We see a large number of new articles coming from Turkey, Taiwan, and Brazil, in addition to China. Yes, we are also seeing articles from the Middle East and a few from Africa. What does this emergence of science in the developing world mean? There are ideas to be understood coming from bright minds in many places. I have witnessed bscientific colonialismQ in meetings in which the scientists from the developed world lecture as if the developing world audience knows nothing. I have seen scientific colonialism in the conduct of the scientists from the developed world who do not select articles from the developing world for publication because the reviewers or editors do not think that science in the developing world has reached bthe developing-world standards.Q The articles are not even considered. I have seen resident candidates from the developing world rejected without consideration for the
Editorial / Surgical Neurology 67 (2007) 323–325
similar reason—that they cannot be well educated. I have seen a medical school that supported this kind of thinking. This attitude has also infected the World Federation of Neurosurgical Societies (WFNS) in its continued selection of leadership from the developed world. Are there no creative and innovative leaders from the developing world? I witnessed this bias against the developing world when, as chairperson of the nominating committee of the WFNS, I was told that those in the developing world were not able to lead a major organization. Our committee selected a leader from the developing world as a candidate for president, who was elected. There is no place for this biased thinking or philosophy in the scientific world. All people and ideas should be given fair opportunity for understanding. Some of the greatest discoveries in neurosurgery and medicine have come from people working in very difficult circumstances and in developing countries. Scientific colonialism or progress? You decide. I have just described how the Chinese are making huge strides to surpass those who are complacent. This same phenomenon of complacency has happened throughout history. It occurs
325
in academia and in business. The complacent lose, whereas those who have the desire to win do win. The accompanying editorial in this issue by Miguel Faria is a testimony to the struggle of one person to rise above his life circumstances to achieve success. Miguel escaped from Cuba with his family to come to the United States, where he became a physician, a neurosurgeon, and eventually a leader of a very proindependence antisocialist medical society. He became editor of its national publication. Miguel, the Chinese, and others are overcoming huge obstacles to succeed in this world. Are the rest of us becoming complacent? I have told the residents I teach that their competition is not the person next door but the best in the world. There is always someone who wants to succeed and who will make great sacrifices to do so. Are the rest of us willing to do that? That is the attitude that separates the victorious from the defeated. James I. Ausman, MD, PhD E-mail address: [email protected]