Global Neurosurgery Twinning: Duke Global Neurosurgery and Neurology’s experience in Uganda
Michael M. Haglund M.D, Ph.D., MACM1, 2, 3, Anthony T. Fuller M.D, MSc.GH1, 2, 3
1Duke University Division of Global Neurosurgery and Neurology, Durham, NC, USA 2Department of Neurosurgery, Duke Health, Durham, NC, USA
3Duke University Global Health Institute, Durham, NC, USA
Michael M. Haglund MD, PhD, MACM
Department of Neurosurgery Duke Health
4508 Hospital South
Durham, North Carolina 27710, United States
Telephone: +001 919-684-6936
DGNN was established on the foundation of partnerships with incredible determination and drive from the local team. We cannot write an article like this one without acknowledging each and every person who has contributed over the years. A list of names would unintentionally leave out important contributions. We want to acknowledge and gives thanks to every neurosurgeon, resident, neurologist, anesthesiologist, surgeon, nurse, biomedical technician, researcher, research assistant, healthcare worker, student, patient, and person who has provided support over the years. None of this would be remotely possible without each of you. From the bottom of our hearts we thank you for your support.
Global health equity is a lofty ideal with far-reaching implications.1 Embedded within this concept is the attainment of global universal health coverage, which by definition includes essential surgical care.2 While neurosurgery may not readily come to mind as a core component of essential surgical care, when examining the global surgical landscape, it becomes clear why advocacy and efforts to expand access and improve quality of neurosurgery are important.3 Traumatic brain injury, traumatic spine injury, stroke, and epilepsy are just a few of the neurosurgery conditions contributing to the global need for neurosurgical care, which is largely unmet.4 Within LMICs alone, an additional 23,300 neurosurgeons are needed to meet the demand, a number that is incredibly daunting and seemingly insurmountable.5
One approach to address the dire global neurosurgery need has been the development of twinning programs.6-8 At their core, twinning programs are described as a partnership between neurosurgical staff, usually high-income country neurosurgical staff twinning with low-income country neurosurgical staff. Many twinning efforts are encompassed within surgical camps, which consists of the twinned staff operating on as many patients as possible during a discrete period of time. Twinning is by no means a perfect solution, but it does provide care for those most desperately in need and fertile ground for long-term partnerships to flourish which do have the capacity to improve equity.
For our program at Duke University’s Division of Global Neurosurgery and Neurology (DGNN), twinning is a fundamental pillar of our “3-T’s” approach (Technology, Twinning, and Training).9 We began our partnership with the team in Uganda during our first surgical camp in 2007, and since then our partnership has continued to grow. From those initial surgical camps emerged DGNN’s core mission to “promote health in low- and middle-income countries through a multi-faceted, evidence-based, and collaborative approach to improve patient access to care and health outcomes, strengthen health systems, and inform policy”. We support this mission through research, service (which is inclusive of our original 3-T’s approach), and training. Twinning served as our catalyst for developing a long-lasting, integrated, and impactful partnership to address neurosurgery and neurology health inequities, specifically within Uganda.
DGNN, as a division, was officially founded in 2014 and at that time consisted of a handful of people at Duke University and neurosurgery staff at Mulago National Referral Hospital (MNRH) in Kampala, Uganda. Currently, DGNN has >75 members consisting of multi-disciplinary faculty, post-docs, medical students, and undergraduate students from Duke University, across the US, across the globe, and within Uganda. Our team, due to the strength of partnerships and relationships in Uganda, has been incredibly successful in its three core areas: research, service, and training.
Our research efforts were initially focused on exploring the impact of our surgical camps, and now encompasses epidemiology, clinical outcomes research, implementation research, economic effectiveness, machine learning and artificial intelligence, new clinical device integration, and policy.
Throughout the years, our team has been able to publish over 50 manuscripts and present at a multitude of US-based and international conferences. Importantly, our research has not only added value to the burgeoning field of global neurosurgery, but we have been able to bring our research results, with our Ugandan colleagues, to the highest levels of policy decision-makers in Uganda.
“My biggest appreciation has been in the area of research. Our Neurosurgical Department had almost no database and very very few research projects, if any. But with the coming of DGNN, we have been able to develop a reliable database, and have developed complex research projects. These projects have gone a long way to guide us in improving the care and welfare of our patients. It has also stimulated the desire of our young graduates to enroll into the specialized Neurosurgical Training programs.”
- Dr. John Mukasa, consultant neurosurgeon MNRH.
We believe that it is important to provide care for as many patients as possible that need care now, while developing a longer-term vision based upon sustainability and equity. Service for DGNN consists of surgical camps, donating equipment, and financially supporting neurosurgery and neurology operations in Uganda.
Since 2007, we have held 22 surgical camps with 20 in Uganda and one each in Rwanda and Kenya. Within Uganda, our 20 camps have been primarily at MNRH, but in the past 5 years we have expanded our camps to Mbarara Regional Referral Hospital in Western Uganda. Throughout all of our camps we have operated on 589 patients (~30 cases per camp), donated 114 tons of medical equipment and supplies valued at over $14 million USD, and have trained countless Ugandan neurosurgeons, anesthesiologists, nurses, biomedical technicians, and students. We have also been able to perform many complex cases (awake craniotomies, aneurysm clipping, and complex spine) that had never been performed, or in very small numbers, in Uganda. For our neurosurgery residents at Duke University, we offer them the opportunity to join us during our camps, which has become an invaluable aspect of their neurosurgery training.
“I enjoyed doing more with less in the OR and still being able to provide neurosurgical care. The experience cemented my desire to make global health a part of my professional life. I have absolutely recommended this experience to other residents. I loved my experience. I loved using my off time from residency to do something meaningful.”
- Dr. Kimberly Hoang, graduate of Duke Neurosurgery residency, 2018.
Training Ugandans to become neurosurgeons has been intrinsic to our approach from the beginning in addition to training the rest of the staff to provide high-quality care to neurosurgery patients. In partnership with MNRH, the Ugandan Ministry of Health, and College of Surgeons of East, Central and Southern Africa (COSECSA), we established a neurosurgery residency program in Uganda in 2009. Thus far, we have 5 graduates with 10 currently enrolled. Through long-term efforts by DGNN and led primarily by the Neurosurgical Society of Uganda (NSU), the first Masters of Medicine in Neurosurgery was opened for enrollment at Makerere University in 2019, and has 3 students enrolled.
Ugandan neurosurgery residents during their training are provided the opportunity for one-month observerships at Duke University, and up to three-month rotations at neurosurgical training sites outside of Uganda. DGNN fully supports the residents during these opportunities and additionally supports residents to get additional specialized training after completion of residency. Dr. Juliet Sekabunga Nalwanga, who is the first woman neurosurgeon in Uganda, recently spent a year as a clinical fellow at The Hospital for Sick Children in Toronto, Canada building her expertise in pediatric neurosurgery. DGNN has also supported consultant neurosurgeons to visit our team at Duke University for one-month, most recently Dr. John Mukasa.
“During the collaboration of DGNN, we have been able to create and start The Neurosurgical Society of Uganda (NSU). Our first CEO of NSU, Mr. Shem Opolot, was a DGNN graduate of Duke University, and was provided to us and paid a salary by DGNN. Shem has not only helped and organized our young society to high heights but has also greatly helped in soliciting fundraising.”
- Dr. John Mukasa, consultant neurosurgeon MNRH.
Significant improvements in neurosurgery access and quality of care have undoubtedly been achieved in Uganda in the midst of numerous challenges, some of which continue to hamper progress. Our challenges have provided invaluable lessons for our future endeavors and can serve as lessons for other global neurosurgery twinning programs and partnerships.
We’ve learned that for hospital-level policy change and national-level policy change, performing high-quality research is not enough. It is important to work in collaboration with the staff in the hospital while also engaging hospital administration and Ministry of Health officials. This approach allows for the results to be disseminated beyond the walls of the neurosurgery ward. Additionally, a key focus of performing research must include research skill development for the local team. This allows for the local team to have increased ownership of the projects and provides opportunities for new ideas to emerge. In recent years, DGNN has developed an approach that integrates local team members, especially students (medical students, public health students, and neurosurgery residents), into the entire research process. Within global neurosurgery, and global health in general, we must focus more of our efforts on improving local research capacity, which will bolster the next generation of healthcare providers’ ability to tangibly impact local needs.
Our surgical camps' success relies heavily on DGNN bringing donated medical supplies and equipment into Uganda. Instrumental to the success of this effort are biomedical engineers and technicians involved on both sides of the partnership. Within Uganda, we employ biomedical technicians to maintain and fix neurosurgical equipment. We learned that it is important to have a tracking system for all donated items to both better understand functional status and repair needs and to plan future donations. Another key aspect of planning donations is screening surgical camp patients as far ahead as feasibly possible, so that we know in advance equipment and supply needs which we can cross-check against our tracking system. An area that we are still grappling with is how to ensure constant supply of neurosurgical equipment and important consumable supplies that isn’t heavily dependent on foreign donations. This issue is multifactorial with the lack of medical manufacturing or distribution networks within many LMICs and governmental financial support being key contributors.
Neurosurgical resident training and education is no easy task, and becomes exponentially more challenging in LMICs. It is important to provide supplementary support to training programs, which includes, only to name a few: a location for neurosurgical residents to study, full access to printed and online neurosurgery textbooks and material, and teleconferencing sessions to discuss complex cases and neurosurgical techniques. Other key aspects for training include integrating the training with the Ministry of Health’s vision, ensuring that training goes beyond clinical so that graduates can be posted in academic centers, and thinking proactively about placement of graduates and expansion of the number of training sites. One of the most important aspects to remember is that high-quality neurosurgical care is not possible if you only focus on training neurosurgery residents.
“There is a need to expand our neurology and neurosurgery specific teams that is:
nurses, anesthetists, critical care, neuromonitoring to mention but a few.”
-Dr. Juliet Sekabunga Nalwanga, graduate of Ugandan residency, 2019.
Over the last decade the development of our collaboration has been built upon leadership in Uganda assisted by Dr. Moody Qureshi, who led the WFNS training site efforts regionally in East Africa and specifically in Kenya. To launch the first ever Division in a Neurosurgery department dedicated to global neurosurgery equity, we have had significant Departmental support; built widespread collaborations; and enlisted many talented medical and graduate students as well as neurosurgery residents both at Duke, around the US and Uganda. This ultimate team effort has released the capacity and potential in Uganda for a bright and equitable future in neurosurgical and neurology research and care.
Figure 1. The Duke Uganda team (including a few colleagues from Stanford)
Figure 2. Power outages can be frequent in developing countries. The light is from the surgeon’s headlight; the monitors are always on battery power backup.