It's an honor to be here today to discuss global neurosurgery equity in education and research as part of the global neurosurgery around the world. Put on by Dr. Germano and the AANS, it's an honor to be here. My name is Michael Haglund, I'm a professor of neurosurgery and global health at Duke University and we've been working in East Africa and now starting to work in Southeast Asia with our global neurosurgery division. I'm sure this has already been shown as a slide and people have gone over it, but the problem is there's 5 billion people that really lack access to surgical care. There's about 143 additional surgeries needed and 2.2 million more surgeons, anesthetists and obstetricians needed. As you can see on this map, in East Africa, there's clearly a large need in anywhere around the world compared to other regions, period. So when we look at the world population, you look at Africa, you can see that India and China kind of blow up and we set the United States to one. When you look at the number of physicians, East Africa kind of falls into the Atlantic and the Indian Ocean. When you look at the number of neurosurgeons, it gets even worse. There's about 3,600 neurosurgeons in the US. At the time we started in 2007, there were only 565 neurosurgeons in Africa for the whole continent. It becomes even more crucial when you look at where those neurosurgeons are located. Northern Africa and South Africa are known for having a large neurosurgery population and modern neurosurgery, but all of Western, Central and East Africa only had 76 neurosurgeons. When we look at two countries, Morocco in the northern part of Africa and Uganda in the south in 2007 when we started, there was only 5 neurosurgeons in all of Uganda, but 171 in Morocco. So Morocco was more one neurosurgeon per 187,000, Uganda was 1 to 6 million. If you looked at all of East Africa, it was 1 to 10 million. Many countries did not even have a neurosurgeon and the United States is 1 to 88,000. The real problem in Uganda is, as you can see over in the far right, there's zero training centers in Uganda, whereas there's six in Morocco, so they can keep up with the explosive population growth. The real problem in Uganda also is their average age is 18, so that means they're very fertile and from 2007 to 2030, they're going to go from 30 million people to 61 million people. Now why Uganda? A pastor came to my church in 2006 and invited me to come and he said there was a real need there and I kind of go on the philosophy of Luke 12, 48, where it says, too much has been given, much more will be required, which means to me that it's about giving back. So we visited Pastor Sinyongo and the team went to Uganda on a scouting trip to see what was there and what we found was really critical. There was only one neurosurgeon for 6.6 million people. There was no technology. There's only one ventilator in the whole 1,500 bed hospital. There's no operating rooms for neurosurgery and the tools they had in the operating room included basically a bovie cautery and they did not even have anesthesia machines. They handbagged patients through their long cases and some of the ORs were still using ether. And as I already pointed out, there was no neurosurgery training program. The solution I came up with was this 4Ts technology. We started the Duke Global Health Plus program, Placement of Life-Giving Usable Surplus, and that was supported by our chancellor, the head of the Global Health Institute, and our procurement, senior vice president. Twinning, rather than just taking a neurosurgeon there, which there's nothing wrong with that, we took teams of 23 to 55 medical professions on one to two trips per year. We needed to start a training program, being the program training director at Duke and with the help of fiends and their curriculum, we set up a training program in Uganda. And this top-down approach, which basically says that if we build neurosurgery as a specialty and we say we can do safe neurosurgery in Uganda, then all the other specialties around them should benefit in a type of halo effect. In about six months in 2007 with the Duke Global Health Plus program, we were able to raise $90,000 in donation and collect $1.275 million worth of surplus equipment that we could ship over to Uganda and set up multiple operating rooms, a six-bed recovery room, an eight-bed ICU, and help out with equipment to do proper neurosurgery. This is what the recovery room looked like before we started. This is what the ICU looked like before we started. It was basically empty because they had no monitoring equipment and no ventilators that were functional. This is what it looked like after. The biggest change was in the recovery room where they just had vaporizers, not even anesthesia machines. And afterwards, on the left, you can see a drill, an operating microscope, proper suction, IV pumps, anesthesia machines with proper monitoring, Mayfield head holders, bipolars, and all the equipment drills they needed to do proper neurosurgery. We made a technology transfer, which is a second T, over a period of about 12 years. And if you look at the trips we did, we did 21 trips to East Africa and 19 trips to Uganda. And over that time, we've brought almost $14 million worth of used equipment, 114 tons, and collected about $4 million in donations to develop three neurosurgery hospitals in Uganda. We've had great benefactors from the Duke University Health System, the Chancellor, the Duke University President, the Duke Global Health Institute, our Department of Neurosurgery, Dr. Freeman and Dr. Sampson, the Chairs, and we've also had excellent corporate support. What about the twinning? Well, in twinning, between 2007 and 2019, we took 522 volunteers on 20 trips. Now, some of these were the same people, but that equated to 529 brain and spine surgeries, about 38,000 hours of donated time worth about $2.6 million. We also started a training program with the head of neurosurgery there, Michael Mahamza. We started the training program in August of 2009. Dr. Obega and Dr. Mohindu were our first two. Three more finished the next year, including the first woman neurosurgeon. So far, we have a total of 12 neurosurgeons. We now have a master's in medicine neurosurgery program at Macquarie University, which started in the fall of 2019. And we have seven more in the program, with starting a second site in 2020 in Ambarara. And our goal, which I'll show you later, is to get to 50 neurosurgeons by 2030. And our current projections look like we might even reach 64. The Ugandan residents spend six weeks at Duke in an observer ship in year four, because we feel if they come and train in the United States, they probably will stay. We train them in Uganda and have bi-monthly meetings with them to do training by myself and other neurosurgeons. And our residents from Duke Neurosurgery have the opportunity to go for one week or more one month to Uganda during their PGY-5 or six years. These are our first two graduates, Alex Mohindu and Oscar Obiga. Alex Mohindu went to get extra training in England, and Oscar Obiga went to India for extra training. Our second cohort included what we're very proud of is off to my left there is Juliet, who's the first woman neurosurgeon who actually went to Sick Kids in Toronto and is obtaining a pediatric neurosurgery fellowship and will come back and lead the pediatric neurosurgery effort at the main hospital in Kampala, Uganda. This is a proud moment for me. This is one of the cases we did on a Thursday, a large temporal lobe meningioma. What I like to see is me sitting at the end of the bed watching on the monitor and Alex Mohindu using the operating microscope and removing the tumor. Our vision is to have something like this. This is what we saw in 2013 after we've been there six years. There are four neurosurgeons in the capital city of Kampala and off in the east in Mimbali where Ben Whorf had built his amazing cure hospital for pediatrics. There was also one neurosurgeon there. We've now placed other neurosurgeons at Emberara in the southwest led by Dr. David Kitcha. Our goal is over the next multiple years is by 2030 to get to 50 neurosurgeons for 62 million people with 10 different sites around the country for neurosurgery. If each one of those neurosurgeons then trains six general surgeons to do simple neurosurgical trauma, that would lead to 350 neurosurgery trauma surgeons for 62 million people which is one neurosurgeon for every 170,000 people which is much like what Morocco had and we feel like we'll really have accomplished our goal in really changing how neurosurgery care is provided in Uganda. So you can see here in the middle line there's Uganda with 30 million and our goal is to get to 350 which makes it much like Morocco and less like it used to be in 2007. We also believe in research. We started a research team of myself and just two masters in global science students back in 2014 and we started our little group and graduated to starting under the support of John Sampson, our chairman at Duke, a division of global neurosurgery and neurology which now has almost 69 members with nine faculty, seven staff, research assistants, neurosurgery residents, Duke medical students, biomedical engineers and our partners which include about 25 people from all over the United States that are working with us in Uganda. Our main collaborators being Jerry Grant and his team at Stanford plus multiple other medical students who have joined our group and residents. Just an example of the kind of things we did in research, we like to go big or go home. We did the surgeons overseas assessment of surgical needs. Our first two graduate students, Tony Fuller who's now our associate director of the division of global neurosurgery and neurology and Tu Tran who's now an ophthalmology resident at the University of Minnesota. Study where they went to 105 different areas around the country. They went to 2,000 households with 105 enumerators and they interviewed 4,200 people to look at what the burden of overall surgical disease was in the country. What they found was it was only the fourth one done in the whole world, Nepal, Rwanda and Syria alone had had one done. But it was the largest one ever done with the most patients. What they found there was a burden of surgical disease of 10.6%, 7.4 were minor surgical procedures that needed to be done at that moment of the study and 3.2% were significant surgical procedures that needed to be done. We were able to use geographical spatial information analysis looking at where the burden was and how far it was from the nearest hospital so we could get a feel for where that was. It went down to the prevalence, where the highest prevalence was and then subtracted out where the hospitals overlap with that. You can see Kampala in the center off to the right image here disappears but in the north and Gulu in the south and Ambarara, that's the highest cluster of patients with surgical conditions but no care. So that's why we placed our second neurosurgery unit in Ambarara. We looked at follow-up. How do you follow up these patients with a group at Stanford leading the way? They did it with phone interviews. Everybody has a cell phone but not everybody has a good address in a village. We were able to come up with almost an amazing follow-up on the patients that ranged in the range of 75% follow-up. We were able to show and you see the two stars where people were treated and you can see all the different districts where patients were interviewed over the phone that had traveled to there and you can see it almost spreads through the whole country, the northernmost region and about 60% of those people had actually received health care in large. One of our really important studies that helped lead the way was what was the temporal delays along the neurosurgical care continuum after traumatic brain injury. What we found was we looked at the interval from when they were injured to when they arrived, when they received a neurosurgical evaluation, when they received their CT scan and when they went to surgery if they did go to surgery. And we found what was interesting, if you look at the mild and the moderate and the severe closed head injuries, the moderate closed head injuries had the biggest interval from CT scan to surgery while the severe head injuries were treated fairly rapidly. The problem is are those patients going to do well or not and in a limited resource setting they're placing all their resources into the severe closed head injuries and leaving a lot of the moderate ones to deteriorate and not do well because of the delays in their care. Because of that, Cyrus Elahi, who's now starting his residency at the Barrow along with our group, worked on a prognostic model to optimize traumatic brain injury care in Uganda. You look at a bunch of different data elements that we figure out, we build a prognostic model and then we look at the risk of outcome. So if a patient comes in male, heart rate 130 and a GCS of 5, we can tell from the data we've collected they have a 67% for a risk of death. Imagine the setting if you have this kind of histogram of predicted risk of bad outcome where yellow are the mild head injuries, orange are the moderate head injuries and red are the severe head injuries. It really doesn't help to operate on one of these people over by the 1.0 because they have a 100% risk of death. The problem is there's all these moderate head injuries in the middle here that could have had good outcomes but drifted toward bad outcomes because of the delays in care. So what we're able to do now, and we're building these prognostic models, is take someone who comes in and if they get conservative care, we can say there's a 98% chance of a bad outcome, i.e. death. Or if we do surgery, there's a 94%. This patient really is not helped that much by surgical care. But if one of those moderate patients comes in and they have a 98% chance of a bad outcome if they don't get surgery, but a 41% chance with surgery, those are the people we need to push to the front of the line in a limited resource set. Robert Grammer, who's off to Mass General Hospital to be a resident there, worked on an infrascanner detection of traumatic brain injuries. This is with a group in Israel. Basically, it's an ultrasound device that looks through the skull and can actually pick up superficial hematomas and changes in blood clots near the surface of the brain. You can see on this CT scan, if we compare side to side, it's near zero for the frontal, temporal, and parietal regions. But in the occipital region where there's this epidural hematoma, it shows a difference. And we feel this is a way to monitor patients. In Uganda, if you come in with a head injury, many times they cannot afford a CT scan and they have to basically purchase one. They basically go back to their village, collect a little bit of money from everybody in the village who knows this person, and they come in and get their CT scan. As you well know, in the U.S. at least, when someone has a head injury like this, they're going to get another CT scan in six hours and another one early in the morning when we kept waking them up every hour for neurochecks because they seem to be more somnolent. They can't afford that, but our idea is maybe if we have this first CT scan, we can follow that change with an infrascan. And what he found was it had a very high sensitivity and specificity level. And for bleeds less than 2.5 centimeters from the cranium and greater than 3.5 CCs in volume, it had a 94% sensitivity and a 96% specificity. It was 100% sensitive on epidurals and 97% sensitive on subdurals. And it did not miss anybody that had to go to the operating room. We also looked at the cost of care in Uganda. And what we found was one of our residents, Gigi Abdagator, who's here at Duke now, did a study where she worked with Professor Sloan, one of our economics professors who's well respected, on an observational analysis of economic costs. They looked at micro-costing with direct cost and indirect cost and looked at all the different costs that went into any surgery. Personnel, consumables, diagnostic tests, supplies, and equipment. What they found was the average cost of a surgery in Uganda, unlike here, was $542. They looked at the different surgeries, and I'll have you focus on two. Excision of a brain tumor here cost $1,200. Evacuation of a subdural hematoma or epidural hematoma was about $316. If you take the cost and compare them to the dollar cost per dally, the disability adjusted life years, you can see things like heart disease requiring long-term aspirin and beta blockers, or antiretrovirals for HIV are very expensive because you have to take those medications all the time. Even big orthopedic procedures with lots of instrumentation are very expensive. When you look at craniotomies with burr holes for subdural, craniotomies for trauma, or even craniotomies for brain tumor, they're much more like cataract surgery and bed nets for malaria than they are long-term treatments. So it's a very cost-effective surgery. And then finally, one of our areas of emphasis is in epilepsy. Dr. Tony Fuller did a very extensive study where they did something like our SOSUS study where they did a nationwide survey of now 360 districts, and they looked at over 36,000 respondents with a prevalence of the first screen and a second screen looking at what was the prevalence of epilepsy in the country. And we're now analyzing that data and going back and doing further detailed analysis of those patients that were positive with formal neurological exams and mobile EEG equipment to look for epilepsy on the EEG. Our first-ever Epilepsy Center of Excellence in Mbarara down in the southwest of Uganda, and that was led by Debra Addox, Tony Fuller, and the wonderful group of neurologists and EEG technicians which we trained at Duke to perform EEGs in the Epilepsy Center. So I want to conclude with our global health and education. We have Duke cultures, and it's well-supported. We have multiple sites in Uganda. Right now, two training sites and three different sites where they rotate. We're taking in five to seven trainees per year. We have an MMed in neurosurgery, and we have funded research for Epilepsy Centers of Excellence, our traumatic brain injury, our non-invasive monitoring, and the artificial intelligence that goes into the prognostic modeling. So I think this is all possible. I think in conclusion, I'd say it's about passion. It's about what Angela Duckworth calls GRID. It's about passion and clearly perseverance. You have to have a long-term relationship, not a one-off. You have to have the passion to make this happen, and a lot of people want to help, like all our volunteers that have gone over on the neurosurgical trips. Over 500 times we've seen volunteers go to dedicate their time and energy and effort. The health system has buy-in, giving them paid time off when they go, and we've had great support from different companies with regard to providing equipment and funding for the trips, as well as UCB Pharmaceuticals has supported our epilepsy efforts and these very detailed studies and nationwide surveys to look at epilepsy prevalence. So we're very excited about what's going on with the Duke Division of Global Neurosurgery and Neurology, and I think any health system that has people that are passionate about giving back and doing work in areas where we need global neurosurgery equity, this is a great way to spend your time and talents in these kind of efforts. Thank you very much for your attention, and I appreciate the opportunity to speak in this CME activity from the AANF.

global neurosurgery equity

access to surgical care

shortage of neurosurgeons

Uganda

training programs

underserved regions