Letter: Global Neurosurgery: The Pakistani Perspective

Abstract

To the Editor: Lack of access to basic surgical care poses a challenge on resource-constrain health care delivery in Pakistan. The delay between onset of symptoms and seeking health care, lack of knowledge regarding treatment options, and financial constraints limit access to surgical care in Pakistan. This lack of accessibility poses a threat 3 times greater than AIDS, malaria, and tuberculosis combined.1 The incidence of trauma and maternal mortality ratio are staggeringly high. The burden of trauma-related deaths is significantly high in Pakistan causing 42 deaths per 100 000 and contributing to 6% of all deaths.2 There is a severe dearth of surgical and anesthesia-related epidemiological data. The Lancet Commission on Global Surgery puts the figure around 5 billion, which is the number of people around the world who are unable to receive timely and safe surgical care. Globally in 2016, 276 million neurosurgical cases were reported and was the second leading cause of death with 9 million deaths.3 Most of these people reside in low- and middle-income countries (LMICs) such as Pakistan where health care does not have the same resources as in high-income countries. In Pakistan, there is an annual deficit of 17 million surgeries because of a dearth of health care professionals and an overrun health system that has led to inaccessibility of surgical services, especially for the poor and those in rural areas.2 The main hurdles in the path of achieving optimal neurosurgical health care in LMICs are lack of specialized neurosurgeons (1 neurosurgeon being available for 720 000 people in Pakistan), insufficient equipment, poor research culture, high cost of neurosurgical care, disparity in public and private hospitals care, and lack of interest by health officials to establish new and improve pre-existing neurosurgical departments.2,4,5 Nine years after the seminal paper by Zafar and McQueen, the situation is still dire with a total of 177 in training residents, 43 approved supervisors, and in total 274 neurosurgeons and significant efforts are needed to improve access to safe, effective, equitable, and affordable neurosurgical care in Pakistan.2 THE SITUATION IN PAKISTAN Neurosurgical Training in Pakistan In Pakistan, the field of neurosurgery has failed to establish itself as an attractive entity. There is no proper system of guidance or counseling for aspiring doctors which has led to oversaturation of some specialties compared with neurosurgery. Although aspirants want to become neurosurgeons, students are afraid that they do not have the capability to be neurosurgeons or will not be trained well enough. There are financial disincentives because the salary is uniform among all surgical specialties. There are addressable factors that desensitize students who wish to pursue neurosurgery. Although we all agree that love of the specialty should be the paramount, we must be cognizant of the social factors that provide push, pull, stay, and stick forces. This chronic shortage of neurosurgeons and trained staff is widespread in third world countries such as Pakistan. Surgical specialty preference is dependent to a great degree on the outcome of the surgical procedure. Lack of Infrastructure We have estimated 42 neurosurgery centers, 1500 neurosurgery beds, and 150 qualified practicing neurosurgeons till 2011 which has not improved much. With 170 million population, a ratio of 1 neurosurgeon/1 130 000 is a very small number. The worldwide total number of neurosurgeons is approaching 50 000, and the ratio is 1 neurosurgeon/230 000 people.6 Africa has a ratio of 1 neurosurgeon/1 352 000 people, while the ratio is 1 neurosurgeon/121 000 people in Europe and 1 neurosurgeon/81 000 people in North America.5 Since 2016, the situation has slightly improved by the ratio of 1 neurosurgeon/720 000 people here. This ratio is still 8 to 10 times lower than in western countries.5 Many hospitals in Pakistan, because of shortage of neurosurgeons, are unable to provide neurosurgical care to patients and thus have no other option but to refer patients to other neurosurgical unit. These units perform all types of operations ranging from emergency craniotomies to elective tumor resections to minimally invasive spinal procedures, but the limited number of doctors and supporting staff face tremendous challenges to cater for the massive influx of patients. Neurosurgery has for long remained a neglected sector, the extent of which can be gauged by the fact that equipment shortage and malfunctioning is a usual occurrence. Many hospitals have 1 MRI and 1 computed tomography scan machine to fulfill the demands of a very large patient population. Like Pakistan, low- and middle-income countries have a weak research culture. Lack of advocacy, funding, and mentorship are the key factors why our health chassis lags the rest of the world. A Ray of Light The national vision for surgical care (National Surgical and Anesthetic Plan) was approved finally making Pakistan the first country in South Asia to adopt it. We developed the Comprehensive Recommendations for Management of Brain and Spine Injuries in LMICs to provide neurosurgical care within 4 hours of trauma. Above all, currently a “neurosurgical revolution” is the need of the hour in Pakistan.

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