I'd like to invite Dr. Reg Haight to the stage. Reg will introduce our Schneider Lecturer and moderate an interactive session for us this morning. Thank you. Thank you, Shelly. It is my great pleasure and great honor to introduce this year's Schneider Lecturers. Dr. Vlatka has chosen two Schneider Lecturers. What's interesting is that both of these people, both people have won the WNS Humanitarian Awards, Mervyn Bagan and Michael Hagelin. First, Dr. Bagan. Mervyn has been past president of the WNS in 1992-93. He's past president of Fiends. He's currently on the board of directors. He is a graduate of Dartmouth, went to Boston University, trained at Hopkins and Queen Square, later got more additional work in public health. When he retired from neurosurgery, kind of, sort of, he went to Nepal in 1995 and worked at the university teaching hospital there. They had five neurosurgeons. Dick Winn was just there, I'm informed, and now there are 65 neurosurgeons. And to me, Mervyn is really the tip of the spear in getting this started. I got to know of Mervyn's work more intimately when Dr. Shipokar came to work with us when I was at Emory. In fact, he came and worked with Dan Barrow, worked with myself, and actually we published a paper with Dr. Shipokar on C1-2 instability and fusion techniques. And so Mervyn went there, really was a mentor and got these neurosurgeons going. And so if you look back at the slides, we're up at the slides for you, established this in 1995, did a lab anectomy in 95, then did a brain tumor with a pituitary adenoma, then did instrumentation for occipital-cervical fusion with a Luque rod, and opened their ward that same year. The next year did an angiogram and clipped an aneurysm. Later that year, continued to expand, and Dr. Shipokar came to the United States, worked at different places, including with us at Emory, went back and an MRI installed, continued to do procedures, and again, expanded to other countries outside of Nepal. So when you think about Mervyn Begin in Nepal, it's just not Nepal. This is their new hospital now. They have a new MRI and a new CAT scan, and again, Mervyn and Carol, they're really a phenomenal team. You can't do it without a good spouse, and so really Mervyn and Carol went there, planted roots, continued to work in Kathmandu, Bangladesh, Uganda, and their service now has done over 5,000 neurosurgical operations, 200 to 300 cases per year. They see numerous outpatients, and they've really upped the ante as we've seen, and really, Mervyn, as you can see in these photographs, has been the backbone of this for years. So with further ado, I'd like to welcome Dr. Mervyn Begin. Thank you. I'm on lavalier, so I missed the wrong podium. The next person is Dr. Michael Haglund. Mike is an interesting guy, and I've gotten to know him fairly well over the years. He is a distinguished Duke surgery professor, went to Pacific Lutheran University, grew up in a very small town north of Seattle and is a Seattle sports fan, went to University of Washington, later got his master's in academic medicine at USC. USC to me means University of Southern California in the same way to Mike. When I live in Atlanta, they think it's South Carolina, but it's the real USC in Southern California. He's a professor of neurobiology, global health, and orthopedics. He's won numerous humanitarian awards, like Mervyn, beside the double NS award. This year alone, he won the humanitarian award at Washington University, as well as Duke. This guy is a stud. His neurosurgical group so far has published 50 peer-reviewed publications on global neurosurgery, and he's created the Ugandan Neurosurgery Program. Our second side of the lecture is Mike Haglund. Michael? This is fine? We'll come right here. I'm throwing you off. Mervyn, why don't you come over, and we'll get a photograph of you two together. I screwed this up. Thanks. Gentlemen, have a seat. This is a casual format. I'm not Sanjay Gupta, so pardon if I stammer, unlike Sanjay. We're going to get into some neurosurgical specifics first, but I'd like to ask some general questions. To everyone in this audience, why is humanitarian work important? Alex is here. His theme is the privilege of service. You two guys have really given back. Why is that pertinent to everyone here? Mervyn? Mike? I think that this idea of giving back is really a modern term. In actuality, you have to go back to the Hippocratic Oath, because when each of us finished our medical training in medical school, we took an oath swearing to Apollo, the physician, that we would honor him, that we would help him if he needed us, after he had taught us, and that we would pass on the knowledge to his children and to our children in the future who might be interested in that path in their life, and also to those individuals who wanted to become neurosurgeons or physicians. I think that, for me anyway, personally, it's a matter of my faith, really. I mean, Luke 12.48 says, Too much has been given. Much more will be required. I think that fits with Alex's theme for the thing. It doesn't matter where you're coming from, the idea of giving back and having a reason. I feel like we're all massively blessed to be born in the United States and be neurosurgeons. We all work very hard, but we live a pretty blessed life as it goes. To be able to give back and make a difference, whether it's locally in your community or whether it's internationally, is just a real honor. I always come back from these trips much more blessed than any blessing we handed out to the people that we helped. Let's drill down a little bit about what you said about local communities. When we select to give back, we have a couple selections, right? First is, do we do it with the humanities or education or medicine? And secondly, it's how big is our community? Is our community our neighborhood? Is it our city, our region? Is it our nation? Is it globally? When we sit on the AANS NREF board, it's always what is our responsibility to our AANS members and what's responsibility to our brethren of global neurosurgery and our brothers and sisters of the world. How does one select? There's a limited amount of time and resources, and we have to focus. Mike, then Merwin, how do we select? What do we give back and serve? And how big is that community? Merwin, go ahead. I think that there's limited opportunity within the country in which you're living, especially in the United States of America. But there's a great need throughout the rest of the world. And in some places, at least that I have visited in the past, there was no neurosurgery at all, where it was very primitive neurosurgery. And those, I think, were really the countries that needed the greatest help, both in terms of personnel who would go there to help teach, as well as to be able, hopefully, to be able to give them the equipment that they needed. The basic neurosurgical equipment, as well as the microscopes and the KUSAs and the endoscopic equipment. Michael? I think it's both local and global. I think that whether it's like my wife volunteering at a horse farm and feeding horses every Monday night so kids with psychological problems can ride them the rest of the week, or us going to Uganda, I think it would be both. I think the most satisfaction comes when we were in Uganda. They went from a very, very third-world, low-middle-income country. In one night, we delivered all this equipment, and the executive director of the hospital came in and said, we're no longer third world, we're first world. And just the pride they felt and the change it made in their hospital, and for the neurosurgeons who were struggling. To me, the heroes are the neurosurgeons working in Kenya and Uganda and Southeast Asia, places where they don't have anything, but they've got to try to take care of these terrible problems. And we have every toy imaginable, and we're mad when the stealth system isn't working quite right. And they don't even have a bipolar to stop bleeding in the brain. So I think that you see those people as the heroes, and anything you can do to assist them, that's, to me, where my passion kind of is to help. That's kind of interesting. When we saw the video of David Klein the other morning, here's a guy that's given service to neurosurgery all his life, and then during Katrina, and now he washes dishes at, I think it's church. It's really interesting as we go through different phases of our life. Sometimes we have money, sometimes we have time, sometimes we have neither. Right, and I was a resident, I had no time or no money. Now I'm starting to get more free time, more control of my time, and a little more money than I did as a resident. So when we look at the methods of giving back, you know, there's time, money, expertise, knowledge. How do we choose, and what are those different methods to do that? Well, I think it depends upon the country, the facility in which you're going to work. In Michael's instance, they already had neurosurgery, although it was very primitive. I had visited there several years before Michael went. But in Nepal, they did not have neurosurgery. There was only one in the country for 23 million people. And he had the usual type of practice in a developing country, which Nepal is, just as Uganda in the lowest income bank of the World Bank. And so the whole idea in Nepal was to help develop neurosurgery. So the first problem was who wanted to be a neurosurgeon? And that's where really serendipity came in, in my particular instance, because when I was getting a degree in public health after I retired, the chief of surgery at the teaching hospital in Kathmandu came to Boston. And I happened to meet him, and he said, I would like you to come and help us develop neurosurgery in Kathmandu, and particularly a teaching hospital, because there's only one neurosurgeon for 23 million people, and he works at a different hospital in a private clinic in addition to that. And so that was a real challenge. And I said to him, well, you go back. This was October, November. When you go back, you identify two people who would like to become neurosurgeons. They were already general surgeons. And I said, I will bring you instruments, and I knew I could do that because during the summer of 1993, I helped Chris Phillips in the archives at the AANS, and there was a beautiful pile of instruments with gold handles that had been donated to them. And so I called Chris, and she said, this was a year later, she said, oh, yes, you can have them because we have kept them as a donation for two years. But it was very interesting to go through the archival material, even at that time, because there were instruments that had been donated by Franklin Jelsma and Temple Fay, two of the older members, but not the initial members. Well, you know, you touch on an interesting thing. It's like teach a man to fish, but you need to know how to fish, but you have to have the tools. So we can impart knowledge, which is valuable, but knowledge with limited tools is not optimal, right? So I guess a question that I have from a very pragmatic stance, oh, Mike, I'm going to hand this to you, is, as you talked about, Merman, you've decided you wanted to teach, you wanted to educate, you have found willing participants, but how do you get the stuff? How do you get all the stuff so we can be good surgeons? And, Mike, I'm going to let you start off with this patient, if that's okay. Yeah, so this is one of my patients. I took this. It was kind of a fortunate photo. I took the photo because this was the only ventilator in Milago Hospital, which had had 1,500 beds. It was the only ventilator in the hospital. In the operating rooms, they handbagged people through cases. They used their finger to check the pulse. They had no pulse oximetry, nothing. So I took this photo of this guy. He was in a Boda-Boda motorcycle accident, had a subdural the two days before, and they'd saved his life. He was localizing on the ipsilateral side, but he was still on the ventilator. They'd used a Hudson-Brasen bit, a Giggly Saw, used a gauze to stop the bleeding, and he was alive. We came back the next morning, and he was gone. And I asked him where he was. In typical Ugandan fashion, they said, oh, there was a little hiccup. And I go, well, hiccup? I didn't realize that meant something really bad that was done. Hiccup, to me, is not that big a deal, but there it is. In the middle of the night, the power went out, and the generator kicked on right away, but for 20 minutes, the nurses didn't notice that his ventilator was still set at zero. And so 20 minutes later, he was fixed and dilated, and he passed away overnight just for the lack of monitoring equipment. So this is what the OR looked like, much like when Merwin was there two years before me. Basically a bed. That isn't an anesthesia machine. It's a vaporizer, and they had nothing. And so I went over there the first time, and I looked around, and this is just to show you where we were going to go with this, but where I started, I was a naive little child. I knew nothing. I went there and visited and saw what they had, and I looked. This is my notebook from the flight home. I wrote down what I thought we needed, and it's pretty pitiful. Like, oh, we need a headlight, an electric drill, and some bipolars. And my favorite is the very bottom line there. We need a long extension cord to hook everything up. You know what I mean? That's a pretty naive idea of what we needed. So we started collecting equipment. Usually when you see a new shiny toy outside your OR, you go, oh, are we getting a new this? Yes, you are, but you never ask, well, where does the other stuff go? Well, at Duke, it went to this surplus store, which was something like out of Raiders of the Lost Ark. It was this three-story building like this, equipment stacked everywhere, and all of a sudden you started finding, like, the old talking malice bipolar still worked. These anesthesia machines, we got 14 of these anesthesia machines. We were able to collect equipment, and basically over a decade, we've collected about $12 million worth of equipment and shipped it all over to Uganda. So it's made a, I think one of the, we talk about the three T's, technology, twinning, and training, and the one T we have to have in neurosurgery is we need technology. So we get the used equipment from Duke, and everybody has a procurement officer. You probably don't know their name. I know it's Jane Pleasance, and she's the best, my best friend, because she says, Mike, we're getting all new ventilators at Duke Regional Hospital in August. Do you want the old ones? Yes, please, I want them. And we have a program at Duke for other faculty to get that. So I think that's where we get the equipment and transfer the technology. So, Mervyn, when you went to Kathmandu, what did they have? They had basically nothing. And in the ICU, there were maybe one or two ventilators, and the ambu bag was the primary method to keep people alive because the other two ventilators were in use and they had nothing in instrumentation. We didn't have a microscope until through fiends we received a contravess and fortunately the day that it arrived and was delivered to the hospital, I saw the truck outside and I quickly stopped the workmen because they wanted to take the contravess off of the box or out of the box and there was a big sign on the wall of the box that said do not remove from the platform or you'll destroy the mechanism. And then subsequently we were able by speaking to people, the vendors in America to get the equipment that we needed, whether it was a lumbar brace or whether it was pneumatic air drills or whether it was headrest, it was just piece by piece. So how much of it comes from individual surgeons seizing control or from hospital systems or from industry itself? How do we, you know, I'm interested in the past, but I'm more interested in the future, right? Going forward, how do we as surgeons and our partners with industry right out there, how do we get more equipment and expertise to the world, Marvin? What do you think? Well, you have to initiate a relationship with the vendors. I presently have in our attic, Carol and I, about 1,000 to 2,000 bipolar forceps. Where? In our attic. In your attic. Okay. Right. So far I've distributed 60 to Nepal, but during this meeting I fortunately have spoken to several people who are going to receive shipments that they can then take abroad. Well, Mike, let me ask you a question. So you get all this equipment over, you get a bipolar and you get the anesthesia machine and it breaks. How do you support all of your biomedical engineer needs and how do you find funds for that? So I think the key thing is we ship all this equipment, and if you don't have a biomed engineer it becomes kind of giant boat anchors shortly after it gets there. You have to take over equipment that you know will work, and that means you have to have a really good relationship with your biomed engineers at your hospital. So we have two or three that go with us usually every trip. They train the biomed engineers there. They have emails between each other. We need this 25 cent part to make the ventilator work, so that keeps things running. But for like $400 or $500 a month you can basically buy a biomed engineer over there to work and keep your equipment running. $500 a month? Yes. We'll pay for a biomed engineer just for neurosurgery to keep things running, keep track of the equipment, and those are the key people that make this stuff all keep running. And stuff, you know, it's hard. I mean I remember we took a drill over there and it stopped working and my biomed engineer came in the room and he goes, I'm sorry Dr. Hagelin, this isn't going to work anymore. I go, why? And he unhooked it from the console and dumped it out and there was a ton of fluid inside the electronics. Well, okay, that thing, they didn't know how to sterilize it. So it's teaching them how to sterilize it, so when we go over and do our camps we bring people to train their people how to take good care of the equipment. Erwin? Yeah. Well, it's different when you're in a low developing country and they buy a CT machine but they don't buy a maintenance program. And the radiologists, very nice people, very capable, but they're very happy to take those patients that can no longer get a CT scan or an MRI, but particularly a CT scan at that time, to their own private CT. So it takes a while to repair equipment. Or if you're operating and suddenly there's a short circuit and the lights go out and one bulb comes back and all the bulbs have to be brought from Japan because that's how aid projects work. 90% of the aid project is to the national government, not the recipient, but the country that's donating it, whether it's USAID, whether it's JICA, or any of the others. 10% is really basically spent at the site. I'd like to get your opinion on fiends. We've all been on the board of directors of fiends. I went to Central and South America 20, 25 years ago for that. You want to tell us a little bit more about the history of fiends and Mike, fill us in on what it's doing now and how we all should work together? Go ahead. History. You're the founder. Well, actually, after World War II, there were a group of physicians who began to travel abroad and eventually they sought support from the U.S. government and then created in 1969 a 501c3 and I became a member of fiends and the chair. After we returned home in the year 2000, we returned home in 2004, I became the chair. I spent a decade traveling around to very poor countries, mostly in the low level of the World Bank, and it was very interesting to see what they had in terms of equipment. And actually, the table that Michael showed and the light, even the overhead light was not what I saw in 2004. It was just a plain wooden table and a bulb up at the top and that was basically it in Uganda. But with the resources that were available, it was just unbelievable. When you're working on a lower level and individually, you have to have the support of vendors in your own country. So, Mike, we saw the before. This is the after. So this is with a drill and a microscope and anesthesia machines. You can actually be creative also. This is the T-room in the surgical suite at Mulago. I was sitting in it one day going, you know, for a certain amount, maybe 40, 50,000, you could like turn it into an operating room. So we built them their own neurosurgery operating room and they did like over 500 cases there the next year. It was on the front page of the paper, which helps raise the level of the unit's ability. So the neurosurgeons are very proud of what they have. And the first case we did, which is not probably the wisest thing to do, was a PCOM aneurysm. I'm an epilepsy cervical spine surgeon, so I thank you. Vascular surgeons who have those webinars out there, so I did 100 aneurysms with Dr. Nguyen in Seattle, but need a little warm-up after 15 years. So I guess you can clip a PCOM aneurysm. And then the second thing we're going to talk about was the twinning. Who do you take? Mike, that's, I want to ask Merwin, that's a lot of people. And there's got to be an optimal size. So I guess, Merwin, in your experience, how many people go over, who do you take over, are the comedies too many, what's the ratio of surgeons and technicians and nurses? Mike, did that number work? No. So my first year we took 30 OR nurses, IC nurses, CRNAs, anesthesiologists, biomed engineers, recovery room nurses, and it was about 30, and that worked really well. And my philosophy of go big or go home really failed me on this one, because I took 55 the next year, and I spent most of my time herding cats and trying to make sure everybody was happy, and it really was not a very good second trip. So we've coned it down to about 25 to 30 is a really good number for a team, and having a mixture of new people, a few new people, and a lot of veterans going with you is very helpful. People you know from your OR that you can trust. Your team that you work with in the OR is very helpful. Merwin, you and I touched on this in Boston, I'm always curious from an operational standpoint, how many goes over, and when a surgeon goes over, how long do you stay? Because just to get there, there's a time lag, I mean, what's the minimum number of days? Well, what we told volunteers was that you would have to apply to go for one month, and it might take two, three days to get there, two, three days or less to get home. And the problem was that if you allowed somebody to come for a week, it was really impossible because they did not know their way around the hospital, they don't speak the language, they don't have the equipment that they've used at home. It's a question of being able to adjust yourself to the environment, rather than trying to create the environment that you have in the United States and take that to a different country. Right. But Michael's project is very different than that, and they were able to do that because they have a force behind them. They take their entire team over. So Mike, when you take your, if you go as a person, and search yourself, it's different. I think a little extra time would be helpful, but we take, think about it, we take 30 people, we spend about 80 hours, that's 2,400 hours of work that gets done. So we fly in on a Friday, get there late Saturday night, we screen patients on Sunday, operate three ORs from Monday through Friday, and then pack up Friday night at midnight, and back in the U.S. Saturday afternoon. So for the people, and Duke's been very involved too, we have people from Stanford, Jerry Grant and his team go with us, and so we have other institutions going with us, and we run three ORs, and it works pretty well. I mean, it's an intense week, but people can usually get a week off. And Duke has actually paid for people to go, they get paid time off for going. That's the deal we have with our university. So the people that go actually come home with more vacation time than when they left, because they don't work 40 hours that week, they put in about 80 hours that week. So Merwin's the tip of the spear. I mean, I think you've led the way, I really do. How do you make this sustainable? How do you create a program that will sustain where you are, and then potentially grow it? Merwin, Mike? Well, in our instance, the two general surgeons each spent 30 months with me, and then they each came to the United States and worked as residents, because they were able to pass the U.S. MLE when it was only two parts. And so one of them worked at Maricopa Medical Center in Phoenix, Arizona, and also at Emory, as you know, Sushil Shopakar, and the second gentleman went to University of Washington in Seattle for 30 months. And we knew that both of them would come home rather than try to stay in America. And then it was simply a question, when they were initially being trained, to sit there each morning and go through the necessary steps of an operation. If you're working on the spine, or if you're working on the brain, how to make an incision, where you make the incision, and layer by layer in the scalp and through the skull. To understand the anatomy of the skull, I gave them a skull and said, here, paint the various bones. Sushil did that. And then they were very absorptive in terms of receiving material and working. So Michael, how do you continue to, as he's done, go from five to 65 neurosurgeons in Uganda, Rwanda, etc.? And then mention something about your program back home, your global neurosurgery program. So we really believe you have to train the people there. If we bring them over here, Merwin was fortunate, a lot of times they will stay, they won't come home. So we're training Ugandans in Uganda. We've trained seven now, including the first woman neurosurgeon in Uganda. And we have now 12, we've gone from five to 12. We have seven more in the training program, we're hoping to get to 50 by 2030. But I think you have to train them there. I think that the other thing that's made it sustainable is my chairman, John Sampson, has been very generous. We formed this global neurosurgery division, where he gave us money, funding, along with my endowed professorship, money from corporate sponsors and fundraising. And we started with myself and two graduate students. And just to show you where it can go, it was just me and two graduate students working on data. And three years later, a year later, we had about 14. And three years later, we now have 60 people in our global neurosurgery division. We have graduate students, medical students, undergrads. We have faculty from neurology, neuropsychology. We have partners with Stanford and Jerry Grant and his residents and med students. So we have this big group that works together on research to try to help teach them research techniques and do studies. For $400 a month, you can hire a research assistant to collect every bit of data on every neurosurgery patient at a hospital. And then you can mine that database for things. A fascinating thing we found, just one little tidbit. People go there and we see the delays they have for CT scans and surgery. And we found out that the people with GCS, low GCS scores, were getting their surgery right away. And they weren't doing very well, because they were already low GCS scores. And the people that had moderate head injuries were having delayed 40, 50 hours until their surgery. If we would have done them earlier, they would have done well. The ones that did earlier in that group did really well. So how they even triage patients, I think, is really important. So what's our tidbits? We have about three minutes left. So for me, it's the three Ts. It's technology, which means we get things from our hospitals. If you do a lot of whatever, whoever provides you your drills is going to find you a drill to take with you. Whoever provides you whatever will be willing to help donate for your causes. And your reps will help you and your purchasing agents. And then the twinning is working with, I like to take a big team and teach everybody else on the team. So we teach the recovery room nurses how to evaluate patients and the ICU nurses. And then the final thing is, to do what Merwin did in Nepal, we have to be able to train people and teach them how to fish, basically. So having a training program and people like Fiends and Cosex in Africa have pre-prescribed curriculum that can work for training these residents. And our next slide. So what we've done, and our last slide, what will show this, is there's been a donor to the NREF to set up a global humanitarian fund. Mike, you want to talk about what some of these funds will be used for? Also, through generous donation, we're going to start up this fund and we're going to try to use it to use startup funds for people that want to try to go. And we have methods and techniques, and I've made tons of mistakes that you won't have to make. And two steps forward, one step back, but hopefully have support for surgical camps and funds. And like we were talking about, to support a resident for a year is only like $5,000, like in Uganda. Turns out they get paid $300 a month by the government, but they go away to peds, clinics in the afternoon, stay up all night working in ER to make another $300. So if you could give them $4,000 or $5,000, they could just worry about becoming a neurosurgeon. So I think this is a really exciting development from this meeting. I'm really excited. Thank you for your help with that. So our last slide, we'll talk about that, I think. And so there's now an NREF global humanitarian fund. It's not going to compete with Fiends. All of this is complimentary. You know, many hands make light work. And so this will be on the website in one week, or if you want to donate today, $5,000 will pay for a resident. And you can go to the booth right outside and sign up. Merwin and Mike are just barrels of information about how, if individual people want to get involved. On behalf of AAAS and Alex Volokh, the board of directors, I'd like to congratulate you both on being the Schneider lecturers. I'd like to congratulate you on the SS humanitarian awards. And we all owe you. Thank you so much. Thank you.

neurosurgery

Nepal

global neurosurgery

humanitarian work

medical equipment

Uganda

training