Global Neurosurgery

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- Colleagues and friends, thank you for joining us for another session of the virtual operating room. My name is Aaron Cohen. Our dear guest today is Dr. Gail Rosseau. She's a tremendous neurosurgeon. Among her many accolades, she is Professor of Neurosurgery at George Washington Department of Neurosurgery. She's also Adjunct Professor, at Barrow Neurological Institute for Global Neurosurgery. Importantly, she has many leadership roles, including the leadership of G4 as well as FIENS, and has tremendously contributed to improvement of neurosurgery at a worldwide level. Gail, we have worked together for years. I cannot be more honored to be working with you, and very much looking forward to learning from you today. Thank you.

- Well, thank you, Aaron. It is a pleasure to be with you again. I'm very grateful to you, and to Luke Brown for the pleasure of working with you. You know, that AANS Virtual Atlas has had really extraordinary success, and a broad reach, and I'm delighted and honored to have this opportunity to be with you again. So, let's talk about global neurosurgery, my passion. I think we first need to start, with a definition about what it is. And this, in my mind is the best definition. It was put forward in the literature by Ignatius, seen an African neurosurgeon from Cameroon, and I think it's become quite widely accepted by those of us who spend a lot of time on global neurosurgery. The definition is that global neurosurgery is the clinical and public health practice of neurosurgery, with a primary purpose of ensuring access to safe, timely, affordable neurosurgical care to all who need it. It's a little bit different than well-meaning mission trips alone. So why is it that we're hearing so much about global surgery and global neurosurgery in the last several years? Well, this is why. When the first, for the first time, a physician was named as president of the World Bank. And that was Dr. Jim Kim, who was incidentally a past Cushing order, when he was named by President Obama to be the president of The World Bank, as someone who had worked in global health, Dr. Kim issued a challenge to the world's surgeons, and said, "Please show us the economic case for investment in global surgery." And so, Lancet took this up, and formed the Lancet Commission on Global Surgery, which spent two years studying the problem, and reported their results in 2015. And here's what they found. This slide is the key takeaway messages from their 80 plus page document. And it's quite astounding. Five billion people, with a B, lack access to safe, affordable surgery. 143 million surgical procedures are undone each year, because there aren't enough surgeons. And over 80 million people face catastrophic expenditures in paying for this necessary surgery. So changing this situation, scaling up will cause a lot of money. The Lancet Commission estimated that the cost of surgical expansion over 15 years, would be on the order of $350 million. But, look at the benefits to be gained by making that investment in people, and in their health. 12.3 trillion in GDP losses will be avoided, if we make those investments in people. So, these key elements of the Lancet Commission report, led to World Health Assembly Resolution, 68.15, which called for all nations in the world, to strengthen emergency and essential surgery. That resolution passed unanimously. So now, since 2015, every nation is ramping up, and has a responsibility to publicly report what they're doing. So that's where this change comes from, and how each of the surgical disciplines are responding, is why you see so many conferences and publications about global surgery and neurosurgery. So what is our challenge in neurosurgery? We've just seen that 5 billion people do not have access to even emergency surgery. So, thanks to Michael Doan and others, the way that has been calculated to affect our discipline, is that there are more than 5 million annual, urgent, or emergent neurosurgical operations that are left undone now, because of a lack of an estimated 23,000 additional neurosurgeons that we see, need right now. So that's our challenge. And it can appear daunting, and almost beyond what any group can do. But I would remind you about what our colleagues in the pharmaceutical industry have done, and refer you to this book called "Moonshot," out this year, and written by the President of Pfizer Corporation, Dr. Albert Bourla, who notes in his dedication, that more than 5 million people died from COVID, and more than 250 million were infected. But because this organization was able to enroll nearly 50,000 patients in clinical trials, well here's what they were able to do. We all know in nine months, they developed a new type of vaccine, a messenger RNA vaccine, that has saved countless lives. And this effort was led by Dr. Bourla, who is a Greek immigrant, the child of Holocaust survivors, and he's a veterinarian. But he says that the reason why Pfizer was able to be so successful, is because they already had within their corporation, a culture of courage, excellence, equity, and joy. And I think we have all of those elements in neurosurgery. So why is global neurosurgery our Moonshot? Well, I have found over the last several years in working in this space, that I'm very inspired personally, by President Kennedy's famous Moonshot speech, which he delivered at Rice University, September 12th, 1962. So in these next several slides, I am sharing with you, the actual words from Kennedy's speech, which are in italics. And have just mildly changed them, adjusted them for our purposes in neurosurgical care. So let's go through this together. Kennedy said, "While there is strife, prejudice, and national conflict in the world, these should not exist in healthcare, which provides endless opportunities for peaceful cooperation. "But why," some say, "should we care?" "Why choose global neurosurgery as our goal?"

- We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard. Because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we're willing to accept, one we are unwilling to postpone, and one we intend to win.

- We choose to do this because it is hard. We're neurosurgeons. We like things that are difficult. We prefer things often when they are difficult. Kennedy continued. "We choose to take on the challenge and responsibility, of providing access to quality neurosurgical care for everyone. We choose to do this not because it is easy, but because it is hard. This goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, we are unwilling to postpone, and one that we intend to win." He goes on. "Our obligations to ourselves as well as others, require us to make this effort, to respond to these challenges, to solve the problems of access and quality on a global scale. The growth of our science and education will be enriched by new knowledge from previously silent voices, and untapped environments. By new techniques of learning, and mapping, and observation, by new tools and new paradigms. Our trainees and institutions, will reap the harvest of these gains." So I take inspiration from JFK and the space program, and I hope that you will too. Kennedy, in that same speech cites, "our vast scientific knowledge, our rapid progress, our mental strength," and concludes by saying that, "This unanswered challenge, and the unfinished work this represents, must stimulate our collective energy and resources, and indeed our imaginations." So that's why I call global neurosurgery our Moonshot. I also agree with what Kennedy said about why we must do this. "We cannot be deterred. No specialty, and no nation, which expects to be a leader, can expect to stay behind in the quest for highest quality healthcare for all its people. Our instruments," as Kennedy said, "must include shared knowledge, and advocacy for enlightened, scientific, and social policy." There's no time like recent, the time of recent memory when we've needed enlightened scientific and social policy. So now let's do a deeper dive on what are our instruments, our shared knowledge, the things and tools that we have available to us right now, to meet this challenge, and to succeed in our Moonshot. Well, our shared knowledge includes educational programs, and the AANS virtual platform that we're doing here, is one excellent example of the many online platforms that have been developed in a very robust way during and since COVID. And our hands-on courses, our simulations, which are very highly performing these days, new healthcare delivery systems that are making it easier to reach more people with less effort. We have field clinics and hospitals, where bi-directional, neurosurgical knowledge sharing is going on. And then an economic focus, both in the developed and the developing world, of doing more with less. We all need to get the best value out of our healthcare dollars. And then I'd like to share with you in these next two slides, two initiatives that we've published on this year, which I think will be important. One of them is neurosurgery specific public health content in our core specialty, our core competencies, and our residency programs. And the other is our virtual hybrid clinical neurosurgery training programs. So this paper published this year, looked at, started with a meta-analysis of all GME programs, and the public health training that they were doing for different specialists within the medical field. And we looked then, at what neurosurgeons are getting in our residency training program. And it became clear, that that we have an essential task in front of us, that in addition to learning how to remove pituitary tumors and clip aneurysms, we need to be able to speak with knowledge, and with expertise on those public health domains for which neurosurgery is responsible. TBI, spinal cord injury, stroke, degenerative diseases, hydrocephalus. So we're working toward improving and expanding the targeted public health training in our residency programs. We're also imagining additional new ways to train neurosurgeons. And this paper came from the result of a combined future of education and global neuro, clinical neurosurgery summit, sponsored by Weill Cornell and George Washington. And we are now waiting the response on an NIH grant application, to look at training cohorts of individuals, in the developed and the developing world together, in repair, and eventually in trauma, and other specialties as well. So stay tuned. Now our journals are among our very best instruments. And you would have to have been living under a rock to have not noticed that in the last seven years, there's been a big uptick in the number of articles that all of our journals are publishing on global neurosurgery, from "JNS Publishing Group," "World Neurosurgery," the new online open access "Journal of Global Neurosurgery" "Brain and Spine" of our European partners at the EANS. And then I'm happy to announce, that neurosurgery has a new global neurosurgery section, and I'm honored to be the section editor for that. It started in October. And we welcome your very best submission so that we can continue the momentum, and achieve the goals of our Moonshot. I'm joined in this effort by an outstanding group of global, senior and junior neurosurgical academic faculty from each of the five continents. So please, if you have interest in this area, if you are doing scholarly work in this area, get it to neurosurgery, to me, or any of my outstanding colleagues that you see pictured here. Well, our instruments, in addition to the traditional ones, of journals and educational programs, have to now include advocacy, which is something that has not been as much on our radar in recent years, but needs to be, advocacy for patients around the globe. We need to be involved in the enlightened scientific and social policy that JFK mentioned. So WHA's resolution 68.15, through the advocacy of surgeons everywhere, led to, called for strengthening emergency and essential surgery and anesthesia. And I'm very happy to share with you, that we're now approaching the first ever neurosurgeon initiated resolution at the World Health Assembly. And that is from the Global Alliance for Prevention of Spina Bifida F. And you'll hear more about that in a moment. Through the G4 alliance, the Alliance of Surgical Obstetric Trauma and Anesthesia Specialties, we've been working in our resource mobilization group, to advocate with the US government, and now have really been able to get language in the US federal budget that calls for investment through USAID in global surgery. The USAID in fact, needs to report back to Congress in 90 days, for how the USAID funds will be used for global surgery. On this, we're working to inform USAID and the government, on how to implement this policy, and we have ongoing conversations with the surgeon, well known to many of you, Dr. Atul Gawande, who is now the assistant administrator at USAID, it's Global Health Bureau. What are neurosurgeons doing with this resolution I just mentioned? Well, this slide is courtesy of Graham Fieggen, our colleague in Cape Town. But he brought to our attention, the high burden of neural tube defects in northern Tigray, to the point where there is almost an epidemic of spina bifida occurring in that area. And we wanted to understand why. I teamed up with Jeff Blount, and we looked into this, and published this paper a couple of years back, on how we could reduce the inequities, preventing neural tube defects that while always tragic, occur out of proportion in the developing world, as opposed to the developed world. So Jeff and I started this group called the Global Alliance for Prevention of Spina Bifida F., that is was at its origin, the linkage of the G4 alliance, and the International Society of Pediatric Neurosurgeons. We were then joined by ReachAnother Foundation, started by two brothers in the Netherlands, and in the Pacific Northwest, who have been working for 10 years in Ethiopia, and also joined by our colleagues in India who are working on salt fortification with folic acid. So if you look at this, there are 83 countries now, that have legislation to fortify wheat flour alone, or in combination with milled flour or rice. But there's 194 countries. So you can see, on this global map, those areas that are in white have no grain fortification legislation, and no surprise, these are the areas where the incidents and prevalence of spina bifida F, is much higher than it needs to be. So, armed with this study, a group of us put together a call to action, and summarized in "The Lancet" in May of this year, a paper that looked at the 30 years of class one evidence, that having folic acid fortification in a population, drastically reduces the number of patients born with spina bifida, as well as looking at the last 20 plus years of policy in places like Costa Rica, and the United States, where the numbers of infants born with spina bifida have drastically been reduced because of this policy. And so armed with that publication, which went to all the ministers of health at last year's World Health Assembly in Geneva, were working to make this happen. Now, here's where I must give a shout out to Kemel Ghotme, who is MD, and as of last week, MD PhD. So Dr. Ghotme is a pediatric neurosurgeon in Bogota, and a PhD in translational medicine. Here you see him speaking to the cabinet officers of his native country of Columbia, and he has been able to, while working with the Gats Biff Group, convince Columbia to champion this measure. So, the Nation of Columbia has now taken on the sponsorship of this resolution. It is on the agenda of the executive committee of WHO for January, so that we can go to a vote next year. So we've taken a page out of the, in the US, we have the CDC that has an infographic, about how important folic acid fortification has been in the United States these past 20 years, that every year because of this policy, we were able to avoid 600 to 700 births of infants with spina bifida, and to save every year, an estimated 400 to $600 million. So we've created this global information campaign, and our own infographic, and please write to me if you'd like copies for your office clinic and OR. And please join us in this campaign. So, it's beyond the scope of what we're doing now, but we also want to take on addressing the problem of global TBI as well, important to all of us in every nation. And that's going to be a big part of what is the call to action for global neurosurgery. So our instruments also include our neurosurgical organizations. Many of them are members of the G4 Alliance. So FIENS, InterSurgeon, Solidarity Bridge, Think First, the Korle Bu Neuroscience Foundation, St. Jude Hospital, the WFNS Foundation, and recently joined members, academic members include the University of Alabama at Birmingham and Barrow Neurological Institute. So there are many surgeons involved, and in particular, many neurosurgeons involved in this effort. InterSurgeon you know about, is the brain child of global neurosurgeons, global pediatric neurosurgeons, Jim Johnston, and our dear departed friend, William Harkness, who have created a way for those who have global neurosurgery resources, and those who need those resources to link together. So please go to, and sign up. Well, our instruments also include access. We have to, while being humble, recognize that neurosurgeons are often granted extraordinary access. For the last several years, there has been a neurosurgical delegation at the World Health Assembly every year. So this is a group of neurosurgeons from around the world who go there on their own nickel, and at their, on their own time, in order to advocate on behalf of the neglected surgical and neurosurgical patient. And you may recognize some faces of your colleagues there. Because the fact remains that the world, as it organizes itself around the United Nations and the World Health Organization, cannot reach the world's sustainable development goals enumerated here, without medicine and in fact, without neurosurgery. So, the groups that I'm talking about, the Global Alliance for Prevention of Spina Bifida F, and G4 alliance. It's a big tent, and we have a multi-talented team. I'm really proud to share this photograph of Priyanka Mathur, who's a third year medical student at Northwestern University, who hopes to one day work for WHO, and she has been our spokesperson for this resolution. And you see her here in Geneva, talking with Dr. Tedros, on the occasion of her presentation of the resolution last May. We have colleagues from around the world. We work with COSECSA, the College of Surgeons of Eastern, Central, and Southern Africa. And we're currently working with them and some of their principles on a very interesting policy, interesting study on policies relating to colonialism and neocolonialism, and surgical training in Africa. And it is our hope that that study will inform and enlight the future ways that we train people in neurosurgery, and in all surgical disciplines. And then here I have to give hats off, I should say, skull caps off to Jesus La Fuente, past president of the European Association of Neurological Surgeons, who when he assumed that role, wanted to know, "Well, how is the European Association of Neurosurgical Societies working with the Vatican? And it turned out, no one had ever dared to ask for a meeting with the Pope. So he did. Dr. La Fuente was granted a fairly rapid access to the Pope, and even came equipped with a bespoke OR cap for his holiness. So, the first bits of collaboration, in the terms of providing housing to African trainees in Europe are underway now. We hope that will be developed in the future. And another aspect of neurosurgical access, which is almost unprecedented, is that we are welcomed by our international colleagues for collaboration. So, here's one example. A few years ago at the beginning of COVID, we published this paper that looked at neurosurgical outcome studies by nation. And the negative space of that study, was that there were 15 nations that had never published a neurosurgical outcome study. And of course, we want to know how neurosurgery is being practiced in the entire world. So we are now directly going after, filling in those gaps by working on and publishing. Some of these are published, some are in press papers on history and current neurosurgical practice in Somaliland, Iceland, Congo, Zambia, Albania, Botswana, Greece, and Nigeria. We wanna know how neurosurgery is practiced everywhere. Our instruments include resources. The NIH is a big one in the United States. In the upper right you see that, the photograph from the University of Cambridge, which has a very sizable grant from the National Institute of Health Research, the NIH equivalent in the UK, to study global TBI. And Barrow and others are making significant donations, and committing resources in this area. If I speak about my own home institution of GW, we have two grants with Zambia alone. One is looking at TBI, TBIs throughout the lifetime, and the development of a TBI registry. Here you see me with my Zambian collaborators. And then we also have a grant on surgical training in Africa, as I mentioned. Well there are many people working in this area. I'm grateful to Jim Rutka at the University of Toronto, who recognized early on that global surgery and neurosurgery, could not make significant progress, if all of the work was being done by well-meaning neurosurgeons who were going to other places or engaging in this work, on their own vacation time and on their own budget. So Dr. Rutka developed a pathway to tenure, as a surgeon in global health. And I understand there are now six such individuals tracking through various surgical subspecialties at Toronto. And I hope this will become a template for academic programs in other departments as well. The Global Neurosurgery committee of the WFNS, has developed smart goals. You can go on its website, and look at these benchmarks, where you see dashboards that show every two years what the goals are for global neurosurgery, and how we are progressing toward those goals. So yes, providing access to neurosurgical care for the 5 billion people who don't have it currently, is a big challenge. But we're, we're making progress in bite-sized steps. But our very best instruments are, the neurosurgeons and future neurosurgeons with whom we work every day. And I have the great honor and privilege of working with these young people who are changing the world, who are recognizing that neurosurgery is, must be global, and they're making it happen. So let me, as we just looked forward, look backward to these words of Harvey Cushing, that I think speak to where we are now in global neurosurgery. Harvey Cushing said, "The capacity of man himself, is only revealed when under stress and responsibility, he breaks through his educational shell, and he may then be a splendid surprise to himself, no less than to his teacher." So, I believe that the global expansion of access to quality neurosurgical care, is a great and an honorable goal. It will be accompanied by great difficulties, but it may be accomplished, if we as neurosurgeons answer with our characteristic determination and resilience, and if we have the courage to take on this task. So, I believe that global neurosurgery, is global, is Neurosurgery's Moonshot. And with that, I'll leave you with this launch of Apollo 11, which went to the moon. Who doesn't like a great Moonshot?

- Five, four, three, two, one, zero. All engines running. Lift off. We have a lift off. 32 minutes past the hour, lift off in Apollo 11.

- So if JFK and NASA can do it, so can we. Thank you. It's been an absolute pleasure to be with you. Please contact me if you want to join, and help us with this challenge, and reach our goal, and participate in neurosurgeries Moonshot. Thank you.

- Great work. Very, very illuminating. Sincerely appreciate Gail. And it's really tremendous, your impression and your support of global neurosurgery is unparalleled. And I think it's a lesson for all of us, and the impact that such efforts can make in the lives of so many people. Using the neurosurgical atlas, we have tried to do our best to promote education, and enhance the lives of those who don't have access to the care they deserve. May I please ask you, how do you think neurosurgery, and the neurosurgical access specifically, can further expand its footprint in helping global neurosurgery? And even more sort of come closer to the patient in the operating room, to be able to guide the surgeons and help more support, especially for those countries where the expertise of neurosurgeons are very sparse?

- Yeah, I think this is an incredible resource. This kind of learning is something that, and shared knowledge is a bi-directional exchange, right? So I would have great enthusiasm for having regular meetings and updates on the neurosurgical atlas. I'd be happy to talk with you about that. But when we talk in general terms, we need 23,000 more neurosurgeons, we need to do five to 10 million more operations per year. It can become daunting. But I would take the example of what you've done, with a neurosurgical atlas, and recall that when you first talked with me and others about this, it was a huge, almost unimaginable undertaking, that you'd have videos and people who would be able to, willing to share, and that neurosurgeons and neurosurgical trainees all over the world would have access to this high quality care. And yet here we are. And so I think we need to not be discouraged or deterred. We need to recognize this is our responsibility, and that a journey of a thousand miles begins with a single step. And you're already several steps down the road with the neurosurgical atlas. And so I would be very happy to partner with you, on a regular, repeated, progressive series of updates, so that we all know what's going on in global neurosurgery, and can participate. I do believe, Aaron, that we, in the course of your career and mine, have taken on an additional core responsibility as neurosurgeons. You know, when you and I trained, we had, we knew what our core responsibility was. It was to take the best possible care of the person in front of you, and to use all of your own personal knowledge, everything you could get from the literature, from colleagues, et cetera, et cetera, bring neurosurgery's best to bear for that patient. That's still our core responsibility. But in addition, I think we have a second one, and that is, if we believe that our core responsibility is important, and that access to neurosurgical care for everyone is important, then there is a parallel or complimentary core responsibility, which is to support those efforts that bring neurosurgical care to everyone everywhere, specifically, and including neurosurgical education for our colleagues, who are trying to provide that care, with the limited resources both in education and in instruments.

- I agree. That is very well said. So I wanna really thank you for all you have done. I want to thank you for your contributions to our virtual OR series. Gail, tremendous legacy you have established, and I really look forward to having you with us in the near future.

- Thanks very much. It's a pleasure, Aaron. Thank you to you, and thank you to Luke.

- Thank you.

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