Profiles in Volunteerism: Africa and its surgical workforce crisis: defining the need for neurosurgeon volunteers

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Over the past 50 or more years, incredible progress has been made in bringing the specialty of neurologic surgery, and allied specialties, to levels of unparalleled excellence. Regrettably, however, these high levels of neurosurgical care do not extend to most people living in the developing world. Surgical Neurology has sought to direct attention toward the ever increasing need for neurosurgical care in developing countries, doing so through its Profiles in Volunteerism editorials.

Under the very capable leadership of Thomas R. Russell, MD, FACS, executive director of the American College of Surgeons (ACS), a similar commitment has been made to do everything possible in bringing improved surgical care to countries experiencing great need. Kathleen Casey, MD, director of Operation Giving Back for the ACS, is giving excellent leadership in the ACS effort to encourage surgeon volunteerism.

The August 2008 bulletin of the ACS features an excellent article on this subject, entitled “The Surgical Workforce Crisis in Africa: A Call to Action,” authored by Doruk Ozgediz, MD, MSc; Robert Riviello, MD, MPH; and Selwyn O. Rogers, MD, MPH, FACS. Because of the strong desire of these authors to help bring improved surgical care to people in developing countries, they have given permission to Surgical Neurology to restate the first 2 paragraphs of their excellent article, as follows:

It is hard to imagine a more pressing issue facing the global surgical community than ensuring the training and education of an adequate and equitably distributed surgical workforce. Currently, the World Health Organization (WHO) estimates that there is a global shortage of 4.3 million health workers, with an estimated shortage of 1 million in Africa alone. Africa bears 25 percent of the global burden of disease with only 2 percent of the world's workforce – and an even smaller proportion of this workforce is represented by surgeons. Africa may have less than 1 percent of the number of surgeons in the U.S., despite having three times the population. Furthermore, because of the lack of rigorous data, these figures are merely estimates that may significantly underestimate the gap between the burden of surgical disease and the health workforce to address that need. The world's anesthesiology and nursing workforce is similarly insufficient and mal-distributed, contributing to limited access to surgical care and compromising the availability, safety, and quality of peri-operative services.

The surgical consequences of this limited workforce are readily apparent to clinicians who have volunteered or worked in Africa. Most patients with surgical problems routinely treatable in the U.S. fail to reach a health facility or reach a facility without the capacity—either in staff or infrastructure — to care for their problems. The consequence is unparalleled morbidity and mortality that is unfathomable to clinicians who have not worked in these settings. As surgeons in an increasingly interconnected world, we must be aware of the complex factors affecting the overall global health workforce and, specifically, our potential role to improve its quantity and equitable distribution.

Attempts to help avoid, or at least deal with, this current and rapidly worsening surgical workforce crisis in Africa have been underway for a number of years. In 1996, an organization known as the Association of Surgeons of East Africa was launched with the objective of dealing with this surgical workforce crisis, and this later became the College of Surgeons of East, Central, and Southern Africa (COSECSA). The objective of this organization is primarily “…to train surgeons in the countries of this region of Africa.”

Before COSECSA, most of the surgeons in the east/central/southern region of Africa were either trained in other countries or—if trained in the region—received master of medicine degrees. According to the Web site for COSECSA, Zimbabwe, for example, reports having 150 surgical specialists of which 30 have earned master of medicine degrees and the other 120 have been trained outside the country.

Historically, many of the hospitals in more remote areas in developing countries have been Christian mission hospitals usually staffed, at least in part, by expatriate Christian doctors and nurses often committed to spending the rest of their lives in this work. Currently, fewer and fewer doctors and nurses are making this degree of commitment, with more and more of those who are going to mission hospitals to work doing so as short-term volunteers.

As a member of the Editorial Board of Surgical Neurology, I can report that when I first went to Kenya, east Africa, in 1986 as a neurosurgeon volunteer, I was told my Kenyan medical license was only the second ever granted to a neurosurgeon. This seemed remarkable considering Kenya having a population at that time of 22 million people. Over the course of the past 22 years, the number of trained neurosurgeons practicing in Kenya has increased, but as is true in many other developing countries, neurosurgical care for people who live outside major cities is almost nonexistent.

The ACS article identifies for us the fact that there is a “…surgical workforce crisis in Africa…” Also that “…facing the global surgical community…” is the issue of “…ensuring the training and education of an adequate and equitably distributed surgical workforce…” What then are we as neurosurgeons being called to do? The beginning of an answer for this question can be found in what is already being done to bring at least basic neurosurgical care to people in the remote areas of Africa and in developing countries in other places in the world.

Historically, most of the neurosurgical care in developing countries has been given by general surgeons using basic surgical skills, perhaps with some instruction by trained neurosurgeons who might have passed their way. In remote locations in developing countries, physicians and surgeons “do what they must do,” and this includes performing neurosurgical operations for which they have had little or no training. It is probable that neurosurgery in remote areas in developing countries is almost always done by surgeons who have not had neurosurgical residency training.

Richard Bransford, MD, FACS, is a highly trained general surgeon with a professional lifetime of experience rendering surgical care as a Christian mission hospital surgeon, but he now finds himself primarily doing neurosurgical operations with a vision for doing many more.

Bransford first served as a missionary surgeon in the Coromo Islands, later moving to Kijabe Mission Hospital in the Kenyan highlands west of Nairobi. As a result of seeing so many congenitally handicapped and disabled children in his general surgical practice at Kijabe, Bransford sought additional training in surgery for the orthopedically handicapped. He eventually devoted virtually full time to operating on these children.

As word of Dr Bransford's burden for the needs of these disabled children spread across Kenya and into other countries in East Central Africa, he found himself almost overwhelmed by the numbers of orthopedically handicapped children needing the surgical care he was able to give. This led to his raising funds to build the Bethany Crippled Children's Centre at Kijabe Hospital, focusing primarily on children with congenital and acquired orthopedic disabilities. The center later became a Project CURE Children's Hospital.

Bransford then turned his attention to establishing a center at Kijabe Hospital for neurologically disabled children requiring ventriculoperitoneal shunt placement and/or myelomeningocele repair. Once again, as word spread concerning Dr Bransford's interest in performing these operations, the number of children referred to him progressively increased. What began as a 36-bed ward dedicated to neurosurgical patients in November 2004 was then enlarged by 18 beds, and only 5 months later with another 13 beds being added.

Now named Bethany Kids at Kijabe, Dr Dick Bransford inserted 491 shunts and did 267 myelomeningocele repairs in 2007 alone. In addition to this neurosurgical work, he also continues to operate on children with general surgical problems such as imperforate anus, hypospadias, burn contractures, and cleft lips and/or palates. He does this work in conjunction with Dr Dan Poenaru, program director for both the general surgery and pediatric surgery programs at Kijabe.

In 2006, realizing the urgency for training young African doctors in doing these basic neurosurgical operations, Dr Bransford began to offer general surgical residents from the Pan-African Academy of Christian Surgeons (PAACS) 3-month rotations in neurosurgical operative procedures.

On the PAACS Web site, one will find it to be “…a strategic rural-based training program, offering a Christ-centered, five-year residency program certified by the Loma Linda University School of Medicine.” Candidates for the PAACS program must be African, and those admitted to the program undergo training at one of several well-established Christian hospitals in Africa, doing so under the direction of experienced, board-certified surgeons. Funding for the PAACS residency-training program is largely from individuals and is channeled through the Christian Medical and Dental Association.

Chief Executive Officer of PAACS, Dr Bruce Steffes, is a well-trained general and thoracic surgeon, who with his spouse Micky, has committed virtually full-time to doing work in Christian mission hospitals. Steffes feels strongly about the need to encourage Christian physicians and surgeons from developed countries to share their talents, abilities and experience as short-term volunteers doing work in areas of great need.

Surgeons who volunteer to work in developing countries quickly come to the realization that medical school graduates in these countries must be encouraged to stay and practice medicine where they are, resisting the temptation to move to more highly developed countries to practice. For this to occur, and for the surgical workforce crisis now in evidence in African countries to be alleviated, residency-training programs in developing countries must be established.

Through PAACS, in conjunction with Loma Linda University School of Medicine, 5-year residency training programs in general surgery are being developed in Christian hospitals in several African countries. As reported at the PAACS Web site (www.paacs.net), Dr Steve Sparks is the program director at the Mbingo Baptist Hospital in Cameroon; Dr Jim Brown is the program director at the Ngaoundere Protestant Hospital in Cameroon; Dr Russ White is the program director at Tenwek Hospital in Kenya; Dr Dan Poenaru is the program director of the general surgery program and the pediatric surgery program at Kijabe Hospital in Kenya; Dr Keir Thelander is the program director of Bongolo Hospital in Gabon; and Dr Duane Anderson is the program director at Soddo Christian Hospital in Ethiopia. David Thompson, MD, FACS, is the founder of PAACS and serves as the African director. He has direct oversight over 27 surgical residents and the 7 programs at 6 hospitals in Africa, and looks forward to the day when these programs, and those which may be developed in other hospitals, can train many more surgeons than this.

(Physicians and surgeons from developed countries who have an interest in serving as a volunteer in a hospital in a developing country can explore available opportunities by contacting Kathleen Casey, MD, FACS, Director of Operation Giving Back, at the ACS.)

Dr Bert Park, a neurosurgeon from Independence, Missouri, along with his spouse Vicki, a nurse practitioner, have had extensive experience in volunteer work. They have done work in Vietnam and in Kenya, and have served on numerous occasions at both Tenwek and Kijabe Christian Mission hospitals in Kenya.

In addition to performing neurosurgical operations, Park has raised the level of sophistication in terms of neurosurgical care in these rural mission hospitals by providing operating microscopes and necessary instruments and equipment for doing aneurysm and tumor surgery. Vicki Park has worked hard as well, developing a primary-care clinic model using primary care physicians (PCPs) and/or nurse practitioners, seeing the hundreds of patients who come each day seeking care.

This highly progressive and innovative volunteer medical mission work done by Bert and Vicki Park has had another very important side, and that is, their vision for developing programs to both train Kenyan neurosurgeons and teach general surgeons how to perform at least basic neurosurgical operations.

Dr Park has worked with Dr Bransford on a number of occasions sharing his skills in doing shunt placements and myelomeningocele repairs at Bethany Kids at Kijabe Hospital. It is Park's strong belief that “…there is no problem at all with training general and pediatric surgeons to do shunt placement operations and myelomeningocoele closure procedures, especially with the realization that only in this way can many patients receive this neurosurgical care.”

Through my own experience as a volunteer in hospitals in developing countries, I have found it true that, “when faced with a patient requiring an operation, you look to your right, then to your left, and if there is no one standing there who is better qualified, you must do the operation.”

Dr Park identifies his mission emphasis in doing short-term volunteer work in Kenya over the past 10 years as having been the training of general surgeons to do basic neurosurgical operations. Park is also supportive of the longer range program of COSECSA, which is to train and then certify academic neurosurgeons as fellows through a program that is being underwritten by Foundation for International Education in Neurological Surgery (FIENS) and the Congress of Neurological Surgeons.

Two other highly trained and highly skilled general surgeons at work in Africa as career Christian medical mission surgeons at Tenwek Mission Hospital in Kenya are Dr Mike Chupp and Dr Russ White. Although trained as a general surgeon, Dr Chupp has expanded his horizons through developing skills and expertise in doing orthopedic surgical operations, doing so because of having identified this as an area of great need.

Dr White describes the need for neurosurgical care where he practices with these words:

There are very few trained neurosurgeons in Kenya. Consequently, a great deal of the emergent care falls to the general surgeons to deal with. At Tenwek, we regularly take care of a great deal of trauma. This includes open skull fractures, traumatic subdurals and epidurals, as well as traumatic peripheral nerve injuries. Additionally, we deal with a great number of neural tube defects and hydrocephalus. I personally also take care of a fair number of spine cases—including traumatic injuries requiring stabilization, and Pott's disease of the spine requiring decompression and stabilization with bone grafting.

Most of the trauma cases need to be handled without the benefit of CT scanning. We use clinical examination, combined with skull x-rays, and have been using the “Infra-Scanner” in recent years as well. This tool uses Doppler ultrasound to detect midline shifts. We are trying to keep records of our findings, but do find it to be helpful in diagnosing intracranial bleeds after trauma. Regarding spine cases, we are occasionally able to get CT or MRI imaging, but do not require this. I will operate on Pott's cases frequently with only plain films and clinical exam.

The problem of few neurosurgeons is more complicated than one might think, and I mean by this the fact that we have a hard time convincing some patients to agree to referral to neurosurgeons in Nairobi. Often this is due to lack of funds. Another obstacle is the fear of travel to a different tribal area, and lack of knowledge of how to get around in the “big city” of Nairobi.

It seems clear to me that general surgeons in Kenya will continue to be required to manage many of the emergency and urgent neurosurgical problems, usually doing so without the benefits of what would be considered standard imaging in developed countries. Being able to practice in this way necessitates some level of experience with these problems during their training years. We are cooperating with Bert Park and others to make the dream of better neurosurgical training in rural Africa a reality.

Western neurosurgeons who come to developing countries to work as short-term volunteers will need to adapt to practicing and teaching in an environment without all the bells and whistles available at home. Here at Tenwek Mission Hospital we have a surgical residency program that is going well. Known as the “Tenwek Hospital Surgical Residency Program,” we are now recognized by the College of Surgeons of East, Central and Southern Africa, which has recently received full recognition by the Board of Medical Practitioners within Kenya. Currently, Tenwek is the only non-university program with full five-year accreditation. We are also participating with the Pan-African College of Christian Surgeons (PAACS) in this endeavor. We are finding it a very rewarding program, and I am convinced that these programs are the way forward for real progress in this part of the world, but for this to happen, more well trained and experienced volunteer surgeons are needed.

Russell E. White, MD, MPH, FACS

Medical Superintendent

Chief of Surgery and Endoscopy

Tenwek Hospital

Bomet, Kenya

Countries in Africa, and indeed in many other developing countries in the world, are experiencing a surgical workforce crisis, and this crisis will almost certainly worsen in the years ahead. The virtual absence of neurosurgical care by neurosurgeons in developing countries is a problem of great magnitude and one that we as neurosurgeons and physicians in allied specialties need to be aware of. This crisis may appear to most of us as one that is “very far away,” but it is a problem that presents in organized neurosurgery as a question, and it is this: what are we going to do about it?

Surely, the answer lies in neurosurgeon volunteerism, providing not only neurosurgical treatment to those who do not have access to it but also in establishing training programs that will help avert an even greater surgical care crisis in the future.

The surgical workforce crisis that now exists in developing countries is a crisis that has been studied, debated, and written about in the past. There are those who may find a plan for training general surgeons to do neurosurgical operations unacceptable. But the real question remains: “Are patients who can be helped by the level of neurosurgical care currently available to them by general surgeons like Dr Richard Bransford to be denied it?”

The neurosurgical care available to patients in many Christian mission hospitals stands as a powerful example of what can be done. Short-term volunteer neurosurgeons like Dr Bert Park, Dr William Rambo, and Dr Ben Warf have shown us the way. The need now is for more neurosurgeons who will volunteer to serve through the ACS Operation Giving Back program or through other organizations doing work in developing countries.

For those who wish to volunteer their time and talents in building training programs, Dr Merwyn Bagan has provided an excellent example of what can be accomplished through providing the leadership, teaching, and mentoring required. Academic neurosurgeons like Professors Jorge Lazareff, Robert Hurst, Krishan Bansal and Daniel Clark, and others have already shown us the way.

Neurosurgeons and those in allied specialties with an interest in volunteering for short-term work in developing countries are encouraged to contact Kathleen Casey, MD, at the ACS, the director of Operation Giving Back.