Continental Association of African Neurosurgical Societies
President, Continental Association of African Neurosurgical Societies (CAANS)
Regions across Africa had consistently been warned by the World Health Organization (WHO) that the impact of the COVID-19 pandemic would be hugely devastating in Africa, especially on account of the significant disparity of health care systems and facilities across the expansive continent with a population of just under 1.3 billion.
Governments around the Continent have been trying as best as they possibly can to prevent the kind of catastrophic impact that has occurred in countries in the Western world, notably the United States, Brazil, Italy, Spain, United Kingdom, to name the leading countries where health care systems have been massively strained. However, Africa thus far has seen a relatively less severe impact as far as actual numbers are concerned. At the time of writing (5th June 2020), Africa has registered 163,683 cases, 4,615 deaths, and 70,993 recoveries. This may give an impression that the Continent has thus far escaped the massive devastation seen in other countries. However, that would be erroneous. The Continent has the greatest number of countries in the World Bank Category of Low- and Middle-Income Countries (LMICs).
The steps that governments have taken have placed an inordinate strain on societies in Africa. The lockdown measures, curfews, social distancing rules, impact on tourism (a key income earner for many African countries), travel restrictions, and efforts to mitigate the effects of the COVID-19 pandemic have hit the Continent even harder in economic terms and in terms of running the fragile health care systems in almost all regions on the Continent. Scarce resources have had to be directed towards provision of personal protective equipment (PPE), focusing on urgent and emergency hospital admissions, and trying desperately to prevent health care workers from becoming infected. This is proving to be quite a challenge, given the low supplies of PPE and dedicated hospital spaces for patients suspected or proven to have COVID-19.
Neurosurgery on the Continent has been impacted significantly by the context described above. CAANS has taken measures to assist the neurosurgical fraternity including those enrolled in training programs. The key focus areas are the following:
CAANS developed a comprehensive survey to assess the different resources available and the impact the pandemic has had on neurosurgical practice, including the impact on training of residents, across the Continent. The Young Neurosurgeons of CAANS were particularly active in developing and conducting the survey. Over 300 responses were received form all 5 regions of the Continent (Northern, Southern, Eastern, Western, and Central). Almost all countries in Africa were represented. The results are currently being analyzed, and it is hoped that a quality publication, worthy of publication in a high impact journal, will result from this unique survey.
2. DEVELOPMENT OF GUIDELINES/PROTOCOLS
An effort led by the Editorial Coordinator of CAANS, Dr Mahmud Raji, is underway. The approach is to seek a diverse range of experts in various sub-specialty areas, selected from across the 5 regions across the Continent. Each expert has been requested to liaise with colleagues in his/her area of expertise to provide a pragmatic guideline, with particular emphasis on the practice in resource-limited environments. It was felt that taking up guidelines and protocols developed in economically-advanced regions, such in Western and European Centres, whilst valuable, may not necessarily be applicable in many centres across Africa, especially in subSaharan Africa. Such guidelines would equally highlight the deficiencies that need to be addressed, in order to better care for our patients, not only during the era of the pandemic, but also in planning and resource allocation in the future.
This aspect of neurosurgical practice in Africa has been hardest hit. Trainees in several centres have had to be asked to discontinue clinical practice. Where they have continued practice, the challenge has been the provision of medical cover for these trainees, especially where trainees are conducting their residency training in countries away from their home. The training centres have – understandably, albeit regrettably – been unable to provide medical cover for the “expatriate” trainees, citing budgetary constraints. Several trainees have therefore opted to return to their home country, awaiting the pandemic to be over. The WFNS Foundation trainees were also advised to withhold their participation at centres where they were posted for training. This is an area of great concern given the limited number of neurosurgeons on the Continent, the scarcity of both training centres and scholarships for training. It is uncertain how the scene will evolve. Many trainees may find it difficult to return to resume training, given that many have responsibilities to look after their family unit, along with members of their extended families.
For those who have had to put training on hold, every effort is being made to encourage them to participate in on-line webinars. Volunteers and Societies have undertaken many excellent initiatives. A plethora of Webinars, conducted over the Zoom platform, has been developed. Time zone differences across the globe have been a challenge. Whilst every effort is made to encourage participation, Young Neurosurgeons, particularly junior residents, may be overwhelmed by the webinars and their content. The lectures have typically been of high quality, yet have largely been a focus on “How-I-Do-IT” videos and lectures that are mainly addressed at qualified neurosurgeons or senior residents.
An urgent need has been highlighted. CAANS is developing a curriculum of graded content, of value to the junior resident, with emphasis on Neuroanatomy, Neurophysiology, Neurology, and Basic Science didactic lecture series. Not an easy task, yet doable, if sufficient effort is made towards this. Any input from established centres worldwide would be welcome.
The next challenge is to ensure a viable hands-on experience for the trainees who have lost the opportunity to be involved in live surgical training opportunities.
A proposal to seek support through the WFNS Foundation, seeking assistance from corporate vendors to provide equipment and necessary materials such as saw-bones, endoscopic equipment and models, power drills, spinal instrumentation sets etc., to centres where the trainees, with appropriate social distancing and other precautions, can be guided through on-line webinars to teach hands-on techniques. This will ensure continued learning and keep the trainees in “supervised” training, without the need to enter clinical areas where exposure to the COVID-19 virus is likely.
What is being proposed is “Outside the Box” thinking to ensure that trainees in programs in resource-challenged regions continue to receive training. It has taken over two decades to develop viable training programs in Africa. The results have thus far been gratifying, both in terms of improvement in neurosurgeon to population ratios and the reduction in brain drain, where locally trained neurosurgeons have remained in the Continent and contributed to development of neurosurgical standards in their home country. Without a significant re-think, the gains made thus far may be jeopardized.
Hence this is as much a plea for collective and collaborative initiatives, as it is a report on the impact of the COVID-19 pandemic on the practice of neurosurgery in Africa