Hello, I'm Robert Dempsey, delivering the 2020 AANS talk on Global Neurosurgery Educational Opportunities and the Foundation for International Education in Neurological Surgery. This talk, given during a global pandemic, given online, is particularly important because the lessons learned in this talk about service globally through education to set up systems of care in the developing world are exactly the lessons that we need to express to try to prepare the world for such tragedies of health as a pandemic. Because neurosurgery is integral to the health system and any solution for global neurosurgery must think of a self-sustaining system of care in the developing world. To understand that, we have to start by saying that I'm from the University of Wisconsin. I have no pertinent disclosures regarding this talk. We are presently in a time when neurosurgery is thinking globally. That's very important. After years and years of very provincial type of thinking, we begin to understand that we are all intimately connected and our needs are our world's need, our global needs. And therefore, solutions must look into this. In this talk, I hope to look at the situation, the idea of education as a solution for global neurosurgery in the global health system, and the lessons learned from decades of work in that regard. The disparities of health care are well known throughout all specialties and usually are traditionally felt to be primarily infectious disease in primary care. However, a careful review shows that there's far greater disparities of distribution of health care in surgical specialties such as neurosurgery, comparing the situation in the developed world and what one might see in the tropics or equatorial parts of the world. The issue is that when you maldistribute essential surgical care in a developing country, you find a loss of supply and function to those people, which is equally as important as addressing infectious disease or nutrition. Indeed, several regions have only one neurosurgeon per million people. And absent a neurosurgical care system, what you see is a collapse of their trauma system, a lack of care for congenital defects, for tumors, for pain, for stroke. These are problems and health problems that affect every family worldwide and most of us during our lifetime. The Lancet Commission in 2015 and the World Bank and WHO priorities really addressed this in a very educational fashion for the first time. What was always felt to be an important concept became essential when they identified 45 essential surgeries, which include neurosurgery, such as trauma, congenital defects, benign tumors, CNS infections, which are a cost-effective objective. 47 million deaths per year could be obviated. Trillions of dollars over time could be recouped. And this lack of care affected 5 billion people worldwide. This is an enormous change in our thinking about health care, because essential surgery is an essential portion of that. In some ways, this lack could even overcome the previous lead of infectious disease. The Foundation for International Education in Neurological Surgery is able to supply an important component of this, but it is a foundation of partnerships. In other words, it does not exist on its own. It does nothing by itself. It works in partnerships not only with neurosurgeons, neurosurgical societies, but also governments, other medical areas, and indeed an entire health system, which must be integrated into a society of care. It is really addressing this lack of neurosurgical care by looking at an educational solution to it, as opposed to simply providing the care. In other words, service alone felt to be insufficient. But education to allow a self-sustaining system of care to be developed in the countries of need has always been its solution to the problem. It promotes education and curriculum development in neurosurgery, specifically by forming and supplying and supporting neurosurgical residencies. This means one must address the entire health system. Equipment is important in neurosurgery, and that must be applied. It must also be maintained. Material aid is important. Curriculum development. Local certification. Traditionally, this was done with volunteers working side by side with faculty and residents in the training programs. This remains an important part of an expanding number of concepts. Initially, it was education only in one specialty. It became important that this must be part of the fabric of trauma, of surgical systems, of the entire health system, if one is to emphasize the totality of care and arrive at a self-sustaining system. Milestones in postgraduate education become a new objective as one begins to model the programs developed in the developing world on those that have been developed in the high and middle-income countries. Teaching is really essential to academics, and academics is teaching. Service through education, therefore, became the principle because it was felt that service alone would not be sustainable, and indeed, in some parts of the world, dictators have literally suppressed the development of their own health system because they could point to service from outside areas which were providing that care. This, of course, would be unsustainable. Medical care and education is long, and the resources are intense. Therefore, service alone is not sustainable, but it's very difficult for a country to maintain an educational and medical system if the local needs for peace, social stability, food, and basic medical care are not met. What that means is that we need a stable middle class, a supportive government, and a situation where educated people can be successful and maintained, and we cannot do that alone. We have to build partnerships. The most important lesson learned from decades of such care in the developing world is that local doctors must take ownership. They must be involved from the beginning. If a health system is supported only by outside service, by teams basically helicoptering into a region providing episodes of care, it guarantees that the local physicians and health systems will be undervalued and will not be supported. If you involve them from the beginning, they will not be supported. What talents do we in the higher and middle income countries bring to solve this problem? One is repeated and sustained presence. Understanding that educational needs and presence often are met electronically as much as the very important personal touch and presence. Equipment is necessary. One is surprised how little is actually needed, but there are some key elements of drills, microscopes, proper lighting, sanitation, et cetera, which is important. Biomedicine has to be procured locally or by volunteers. They have to be taught how to use it, and most importantly, the local biomed people must maintain it. It's useless to donate an important microscope and have it broken and rusty. So we teach modern techniques with minimal equipment, and that's probably the first principle of fiends. We bring useful equipment and teach its use, but more importantly, the biomedical people to maintain it. And this teaches one quickly that infrastructure must extend far beyond specialty. This is my daughter on one of her volunteer trips marveling at the reusable gloves on the drying rack. We must understand that supplies and equipment locally procured are essential. We're teachers. It becomes a sustainable program when the local high-quality neurosurgical care is integrated into that health system and the local doctors, the local nurse surgeons become the teachers of the program. And it's a very enjoyable part. For years, I've been teaching in developing world, these medical students hearing of those lectures would travel across the country to be there. In this case, they finished the lecture by asking me how to throw a major league curveball, which I enjoy teaching as well. We learn certain aspects when we are present and we look at the system and we listen to what's available. And we see that the regionalization of care is essential. The developing world is collapsing onto the capital cities, thousands and millions of people there with a few doctors and nothing in the rural areas. So we began to start outreach clinics in major population centers outside of the capital. This was established in Kenya under Dr. Qureshi, where traveling physicians from Nairobi would establish the infrastructure and outreach centers so that graduates of the local training programs trained in those countries would be cited in the regional centers to decentralize neurosurgical care. It's essential if you want to have an effective trauma, cancer, or medical system throughout the country, as opposed to one that only serves a specified small number of people. Infrastructure is essential. We quickly learn that you cannot do neurosurgery without neuropathology, neuroradiology, and the equipment to supply and repair that, biomedical. Lessons learned are very important in this regard. I was taught in Kenya that with the absence of a neuropathologist would paralyze adjuvant therapy for the tumors that were removed. By training one neuropathologist for that region, we could change all of that. But unless one listens to the needs and then thinks about them and envisions a way to work in partnership with other specialties, that's hard to see. We began to develop a concept then of dyads or twinning. This is the idea of pairing a program in the developed world with a new program in the developing world. This has been successful in Tanzania, Ethiopia, Myanmar, Nigeria, Ecuador, Bolivia, many other sites. And this is a way to funnel that energy of the developed world of people with volunteerism into a focused program to support and establish a sustainable program in an area that they would continuously. In doing so, online education was developed between the U.S. and Canadian and Spanish universities in Tanzania, supporting a growing residency program and understanding the equipment needs and supplying them, but more importantly, the biomedical needs. Government support became essential. This is the president of Tanzania, the day he promised 15% of his budget would be sent into healthcare if we would help organize the entire system of care. He's been rather good to his word, up to 12% when last seen. This is the first Pantera microscope in that region of Africa donated by the president being set up. Programs become important because of the educational content and the fact that neurosurgical education is lifelong, not just for the training, but by establishing educational programs such as to the World Federation of Neurosurgical Society in the regions where we were developing training programs, a natural partnership occurred between WFNS and FEMS, where regional training centers could, in developing countries, could be established. This worked extremely well in Africa with the partnership of the American College of Surgeons to develop a focused training center in Tanzania, which would be for all specialties of surgery and staffed 12 months of the year. Zanzibar, the partnership with the Spanish group NED, meant to the establishment of a neurosurgical operating center staffed by physicians worldwide to allow the training of Tanzanian doctors and specialized neurosurgical care. This is the facility they had prior. This is the new one dedicated through this partnership of NED and the government of Tanzania. The goals, therefore, include scholarship curriculums, milestones and metrics of care, common education and boot camps, and the sources for these are many. We find, for example, that we are able to use the standards of care found in the AANS. for their educational, the senior society for their boot camp curriculum, the multiple societies for the volunteers that they provide. In doing so, we're able to maintain programs in a standardized fashion. We adopt the standards of curriculum, milestones and metrics, boot camps in the U.S. and develop them in the developing world. These are the boot camps, the first in Africa. And then prior to that, the 2015 boot camp, the first outside the United States in South America, followed by Africa, Southeast Asia, and then repeating. This has really required a joint project, WFNS, AANS, FEANS, Senior Society, to really establish that care and to show that educational standards are as important in that part of the world as anywhere else. Lessons learned in this process are essential. We've learned that global volunteerism has many facets. When one first entertains this idea, they're overwhelmed by the need. And then there's an area of time when one volunteer tries to fix everything themselves. It's only when they begin to understand that it's not about the volunteer, but about the people being served, and by leaving something lasting that's not about you, do we move on to this idea of helping the country in need to develop a self-sustaining program. And the lessons learned are many, because many of us wish to emulate heroes who went, lived there, built a hospital, a Schweitzer, but the impact, long-lasting, is more the people they inspired than the actual care they gave, or in Southeast Asia, by Dr. Du. So it's important to understand that the lessons learned from decades of global volunteerism, the lessons learned by FEANS, is that it works slowly, and there's a constant two steps forward and one step back. The need is phenomenally great. This is the waiting line for a clinic in South America. The facilities are poor, but constantly being updated, and the progress is tangible and real. The steps back are not a surprise. The developing world has many problems to overcome. These affect the health system continuously. If you are sensitive to the local culture and working with it, and your goals are their benefit, then you will succeed. You will endure. And you do it by understanding what I think are four important lessons learned. The first lesson, one, that service alone does not last. The developing world is full of these abandoned clinics, which were built in an idea that people would basically helicopter in to deliver care in episodes and then leave. That's not self-sustaining. But at the same time, as we begin to look at how could we develop a system and the number of people to provide that care, it has to be through education. So service through education has changed sub-Saharan Africa to where we now have hundreds of neurosurgeons in training or young residents or young assistant professors, where only two decades ago we had no training going on, and only people who had been trained elsewhere had returned to their country in small numbers. Now hundreds are providing the work. That's a tangible change of service through education. And the education was done locally because in doing that way, we could understand the needs, the equipment needs, the infrastructure needs. Otherwise, there'd be no reason for a person trained in England to go back to Africa if there are no facilities that they could utilize. The second lesson learned is one should never assume you know the needs of others. The most important thing when you begin to volunteer is to stop and listen. You may have read the Lancet Commission Report. You learn about the billions of people that need your help, and you decide you'll give it. But that does not make you an expert on the local situation. You become that by listening. These local doctors are absolutely brilliant about how they use their resources, how they do their surgery under difficult conditions, and you can learn much from them. And then you can participate with them on overcoming the challenges that they have. That attitude, the second lesson, is the most important one. And you learn this to be quiet, to look and listen. I learned it personally in the Amazon region when I was working to try to set up clinics in that region. I thought I knew what they needed, but I was fortunate enough to ask the local healthcare expert what was their most important need. I thought it was going to be supplies, equipment, sterilizers. And he said, no, I need more dugout canoes to bring the patients in the clinic in the Amazon. I would never have thought of that. But once you begin to listen, you understand that their needs are different than you expected, and you are there to learn. Because the second lesson about global education in neurosurgery is that we are learning as much as we are teaching. The third lesson is very little education takes place in a war zone. Fiends is not Doctors Without Borders. They do a very important service, but not a sustained one. In war, the educated can be considered a threat. This makes education quite difficult. So we must work with, partner with governments, sometimes with the military, often with the World Health Organization, the UN, and often with the major medical and surgical societies throughout the world. This man here, when I was working in Guatemala during the Civil War, has just stuck his rifle through my clinic window. You've heard of a focused neuro exam. Nothing focuses your neuro exam more than having a rifle pointed at you. The nurses literally were able to shoo him away because they were local. But this attempted intimidation, it goes on constantly in these war areas and threatens the people you're trying to train. They may be considered a threat, and fiends, therefore, must work for areas where we have local cooperation. This young lady is one of my heroes. She is training to be the first female neurosurgeon in Mali, and her biggest threat is Boko Haram, and that is a major threat, a society that is dedicated to death to education. So I tell my trainees, we have no problems. How do we help these other people? And we must, and we must protect them. You may often have to think on your feet. I once escaped one very tense situation, again, during a war zone, by putting on a juggling show for the children of the village, and that caused the gorillas that had stopped us in our jeep, our pickup truck, to say they're either crazy or harmless and let us continue to provide care in that village. But it became clear that this was an unreasonable risk for the people that I was responsible for, and then we had to drop back to achievable goals and working within the government structure. Real progress, therefore, is a structure. If you have the support of the government, the military can be something that's organizing health care as opposed to disorganizing it. A stable middle class and a look to desire will improve through education. And if that desire is important, you will be able to have that program become self-sustaining and taken over by the people of the middle class of that country, which is an essential concept. The fourth lesson, you're responsible for those you train. That is the volunteers, your own family, the patients you train. You're responsible to the families of the people. We begin to see what the social workers have taught us all along about how we must look at the entire situation. And the entire situation can be daunting unless you're prepared for it. The threats to a program such as education in the developing world are illness, transportation, civil unrest, natural disasters, and violence. Illness is my biggest concern. Dysentery, malaria, HIV, Ebola. The key is prevention. Clean water. Early on, I had one group where 18 volunteers fell sick at once. Since I neither eat or drink anything except bottled water, I was the healthy one running from room to room to try to take care of those patients and take care. So I became very strict about who's supplying the food. Is the water boiled? You are not invincible. And as a volunteer in the developing world, we don't need you sick. So you get all the shots. You get all the vaccinations. You look for all the barrier precautions. You only eat food you know about. Or you will become sick as well. Transportation is my second biggest concern. The University of Wisconsin on a medical group, not one of our surgical groups, had an accident where a train struck the bus that the med students were riding in. And we had to evacuate them and bury one. So transportation, I need to know who's driving you. Who's the volunteers? And you're not driving yourself. A professional driver is key in these developing worlds. And that makes sense because it's the secondary concern. Natural disasters are important, usually far less important than the first two I mentioned. But this happens. This is a volcano, Tungurahua, which is literally erupting right outside the hospital when I finished the OR. And the patients, the nurses said, don't worry. The lava usually flows in the other direction. I was worried. But for the next weeks, we took care of respiratory illnesses. And we had to stop our surgical schedule. Totally unexpected. Civil unrest, this is finishing a case and finding you had two armed guards because the government fell that day. This happens. We now try to anticipate this. We try not to be present during an election or upheaval, but rather to work with the government and try to be sure we assure our volunteers are safe. The threat of violence can happen. It's very unlikely if you're working with a stable middle class. But it can surprise you. On this day, my daughter was placed in an extremely dangerous situation, totally unforeseen, which we were able to get her out of. But that changes your life forever. You're responsible for the people you care about. And you care about everyone in this. So if you're going to be involved, you learn that you must protect. So what did we learn? Service with education is the lasting thing. The first rule, be quiet. I actually say shut up. Look and listen. You may think you're intelligent. The people you're working with are just as intelligent. And they have much to teach you. Third lesson, education requires stability. You can't do it alone. That's why you partner. If you raise the local middle class, the local physicians, they will be your champions, and you will educate and raise them. And fourth, your actions have responsibilities for many. This includes the people you educate, that they are safe, that they can sustain themselves in that country, that they are supported by the ancillary services, and that you are sensible about the volunteers you're responsible for and the patients you care for postoperatively. That's why your presence is sustained. When you think about this, this is the obligations of professionalism. This is the nobility that brought you into this field of neurosurgery in the first place. And it's important to understand, much as you may feel that global neurosurgery is a service, you are really the beneficiary. All of us are. By making the world a little bit better for us, we make it better for our children and for the patients that we will never see because our trainees were trained. And that's what you do in your everyday practice. Because when you do that back home, just as you do in Africa or in South America or Southeast Asia, all the work, all the leadership, it makes sense if it's a better world care for patients. And I don't just mean the one in front of you, but by training other people, you train them to care for the patients who aren't even born yet. And so this is really what is noble about neurosurgery. This is what Harvey Cushing said many decades ago. If a doctor's life be not a divine vocation, then no life is a vocation and nothing is divine. This is an opportunity to restore the nobility in neurosurgery. Service through education to approach the idea of global neurosurgery for the benefit of others. I thank you.

Global Neurosurgery

Educational Opportunities

Disparities in Healthcare

Developing World

Systems of Care

Sustainable Program