On Increasing Neurosurgical Capacity in the Developing World

I met Tony Fuller while doing research for my own medical school search. His voice hummed through the Skype line, soft and unphased by the delayed connection. The call was about Duke medical school where Tony has just one more year and Duke Global Health Institute where he completed his master’s degree in 2015. Needless to say, I was thoroughly impressed by Tony’s work and by extension, the kind of international engagement Duke provides for its MD and Master’s students.

Tony’s work centered around a five month study of Mulago National Referral and Teaching Hospital in the capital city of Kampala, Uganda and a seven-year twinning program between Mulago and Duke Hospital to expand neurosurgical capacity.

Tony and his partner in crime, Tu Tran, adapted a study done in Sierra Leone and Nepal, the Surgeon Overseas Survey (SOSAS), to study the surgical conditions in Uganda. The purpose of the survey was to better understand the in-country burden of surgical conditions.

Tony and Tran found that “3.5 million Ugandans—10.7 percent of the population—need a surgical consultation but cannot access care for a variety of reasons.” (1)

In an article for Research Gate Tony demonstrates how this is reflective of a continent-wide dearth in surgical capacity: “Of the 565 neurosurgeons in Africa in 2007, 485 were in northern Africa (Egypt, Morocco, Algeria, and Tunisia) and South Africa, which results in a neurosurgeon : inhabitant ratio of 1 : 358,000. However, in East Africa only 27 neurosurgeons were available to treat 270 million people, a 1 : 10 million ratio of neurosurgeon to inhabitants. Many countries do not even have one neurosurgeon.” (2)

In many ways this survey became a needs-based analysis. Tony and Tu Tran did not fail to identify the root cause of the problem, which was that many Lower-Middle Income Countries (LMIC) also lack resources and a sufficient health care workforce. Surgical capacity is complex and, therefore, a higher order issue. Neurosurgery, a subspeciality, represents an even smaller slice of the population but, as Tony writes, “the increases in population, trauma and road traffic accidents in nearly all LMICs leave people in need without any chance of meaningful treatment unless neurosurgical capacity can be increased.”

The solution started with Michael Haglund, a professor of Neurosurgery, Neurobiology and Global Health at Duke Medical School. Tony joined the program in 2011 to help refine its three prong approach: Technology, Twinning, and Training.

The first step, technology, involves quite the innovative redistribution of resources. Many medical facilities order necessary machines and then have to quickly update them with the newest advances. These perfectly functional but slightly older machines are then thrown away. Duke checks these machines for worthiness and sets them aside for such projects.

In 2007, the first year of the Mulago/ Duke Global Health Program partnership, 1400 pieces of equipment worth over $1,200,000 were delivered. In his article, Tony observed the need for adequate training around these devices to ensure longevity.

This leads me to the twinning and training program. Up to twice a year Dr. Haglund leads a team of 20-55 medical professionals, which includes doctors, nurses, Operating Room nurses, Intensive Care Unit staff, IT personnel, students, and medical equipment management staff. Then, a Duke person is paired with someone who does comparable work at Mulago. Teams run camps for a week at a time to pass along best practices. So training becomes part of the twinning program.

Tony describes how the complexity of the cases being taken-on by the Ugandan doctors rose dramatically over the first seven years of the program: “The cases that used to be the ‘training cases’ of large complex brain and spinal cord tumors combining the Duke and Ugandan neurosurgeons were now being performed entirely by the Ugandan neurosurgeons.”

Another essential part of the program is “task-shifting,” empowering other neurosurgeons to properly diagnosis, and to both run operative procedures, and proper postoperative neurosurgical care.

This frees-up neurosurgeons, newly trained by Duke partners, to focus on more complex cases. This type of knowledge transfer is key to proliferating the effects of the program. Students become teachers very quickly.

The greatest challenge for the program is sustainability. This means funding.

We can link this conversation back to Dr. Dube’s talk on using healthcare investments to build infrastructure. Ultimately, the greatest challenge with any Global Health endeavor is designing it so that one day it can stand on its own two feet. In Uganda, health financing reaches neurosurgery only after its been funneled through the Ministry of Finance, then the Ministry of Health, then Mulago Hospital, and then finally the Department of Surgery.

According to Tony, funding for neurosurgery depends on how much the Department of Surgery wants to invest in it.

The issue is complicated by the fact that the external aid that the neurosurgical department gets from Duke creates a disincentive for the Department of Surgery; it would appear that neurosurgery is already being taken care of.

Their big plan to answer this challenge is to start a Ugandan Neuroscience Institute. This will allow neurosurgery to be recognized and independently funded through the government rather than through the Department of Surgery.

I am most impressed and inspired by the type of change a young medical student can be capable of bringing in this day and age. Over the phone, Tony was extremely modest and told me the facts of the Duke Global Health Institute’s involvement with Mulago Hospital matter-of-factly. But in reality, he and his team showed great resilience every step of the way: “Personally I feel as though the most important part of setting something like this up, is being adaptable but always with a focus on the end goal. With this focus we’ve been able to meet challenges as they arise, think of challenges and solutions before they occur, and have been able to eliminate some challenges all together.”

It is this type of integrity around sustainability, intelligence around building-up local medical capacity and humility that the world of Global Health requires.  Moreover, proof of concept could mean modifying this approach for other much needed specialty fields in LMIC.

This work will outlive the professor and students that started it.


Work Cited:

1. Cover Photo: Zanzibar, 2016.

2.  https://globalhealth.duke.edu/media/blogs/diaries/running-around-kampala

3. Building neurosurgical capacity in low and middle income countries. Available from: https://www.researchgate.net/publication/284103789_Building_neurosurgical_capacity_in_low_and_middle_income_countries [accessed May 17, 2016].


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