The implementation of a national paediatric oncology protocol for neuroblastoma in South Africa

Purpose
The aim of the World Health Organization-International Paediatric Oncology Society is to improve childhood cancer survival in low- and middle-income countries to 60% by 2030. This can be achieved using standardised evidence-based national treatment protocols for common childhood cancers. The aim of the study was to describe the development and implementation of the SACCSG NB-2017 neuroblastoma (NB) treatment protocol as part of the treatment harmonisation process of the South African Children’s Cancer Study Group.

Methods
The Consolidated Framework for Implementation Research was used to identify factors that could influence the implementation of the national NB protocol as a health care intervention. The evaluation was done according to five interactive domains for implementation: intervention characteristics, inner setting, outer setting, individual or team characteristics and the implementation process.

Results
The protocol was developed over 26 months by 26 physicians involved in childhood cancer management. The process included an organisational phase, a resource identification phase, a development phase and a research ethics approval phase. Challenges included nationalised inertia, variable research ethical approval procedures with delays and uncoordinated clinical trial implementation.

Conclusion
The implementation of the national NB protocol demonstrated the complexity of the implementation of a national childhood cancer treatment protocol. However, standardised paediatric cancer treatment protocols based on local expertise and resources in limited settings are feasib

Neurosurgery in Egypt from ancient Egyptians to Modern Neurosurgery, African Perspective

Neurosurgery has been practiced for more than 12,000 years worldwide. Cranial and transnasal approaches to the brain have been practiced for variable religious, mystical, or therapeutic purposes in ancient civilizations of Africa and specifically in Egypt (1). Ancient Egyptian medicine is documented in the paintings on the walls of temples and numerous papyri (figure 1) (2-4).

Ancient Egyptian medicine dates to 3500 BC when Athotis (Hor-Aha), the second king of the first dynasty, was found to have in his tomb the first “Book of the Dead” that was later quoted with modifications till it reached “Practical Medicine and Anatomic Book” in Ani’s papyrus

The Concept and Current State of Neurosurgery in Southeast Europe

The term “Southeast Europe” was introduced by Austrian researcher Johann Georg von Hahn in the 19th century as a broader term than the traditional “Balkans,” designating the region settled by several different nations, mostly alike, but also richly diverse. The most appropriate definition describes the inhabitants as the people geographically, demographically, and culture related to Southeast Europe (1).

Contemporary neurosurgery in the Southeast Europe region has recently witnessed remarkable progress, guided by the “Think globally, act locally” concept as an essential driving force. This slogan has long been in use in environmental contexts and has been gaining increased significance in various disciplines over the past decades. In international education, this slogan was first introduced in 1950 and popularized by Stuart Grauer in 1989 (2). Neurosurgeons in Southeast Europe genuinely implement the concept of thinking globally and acting locally, working together to expand the horizons to the benefit of our patients and our well-being and recognition in the modern world. This mini-review aims to highlight the development and progress of the Southeast Europe neurosurgical society (SeENS) as a regional neurosurgical society dedicated to neurosurgical education, research, capacity building, and exchanging experiences within the Southeast region of Europe.

The Importance of Collaboration in Global Neurosurgery

Collaboration, the kind built upon mutual respect, trust, and a shared vision, is the only reasonable approach to the immense challenges faced by the field of global neurosurgery. We must develop collaborations that foster the free flow of knowledge and resources to ensure that all patients, regardless of geographic location, have access to timely, safe, affordable, and effective neurosurgical care. Developing global, multi-institutional collaborations requires that all parties confront the realities of racism, colonialism, paternalism, and many other isms along with the true magnitude of the problem. Over the past two decades, our Duke Global Neurosurgery and Neurology (DGNN) team has strived to live up to these ideals. We are constantly adapting and evolving our collaborative approach.

DGNN’s initial collaborative work brought together Makerere University College of Health Sciences, Mulago National Referral Hospital, and Duke Health to provide direct neurosurgical care to patients in Uganda. Our shared principles of twinning guided our care delivery (pairing team members for bilateral knowledge exchange), training (developing new neurosurgeons in Uganda), and technology (providing the necessary equipment to perform neurosurgery) (1). This approach has led to 25 neurosurgery camps, over 500 total camp operations, over 5 tons of donated medical equipment and consumables, the establishment of neurosurgery residency programs, three neurosurgery units, and has more than tripled the number of neurosurgeons in Uganda, to date (2,3). Building, maintaining, and strengthening trust is the most important factor that underpins our collaboration’s success. Trust has been built through open and honest conversations, shared decision-making responsibilities, consistency over the years, and the shared vision of improving access to neurosurgery for all Ugandans.

Foundation for International Education in Neurosurgery: The Next Half-Century of Service Through Education

The Foundation for International Education in Neurological Surgery (FIENS) was founded in 1969, decades before globalization became a worldwide phenomenon (1–3). Initially, efforts were focused on service delivery in under-resourced areas via short mission trips by individual neurosurgeons. The wisdom of furthering the impact by creating sustainable training programs in partnership with host organizations developed over time (3). FIENS is a neurosurgeons foundation working in partnership with various organizations to increase global access to neurosurgery missions through the principle of “service through education (3).” FIENS shifted its focus from a service delivery-centered approach to an approach centered on global health systems strengthening by emphasizing local neurosurgery resident education and residency program development (3). It has become clear that the integration of neurosurgical efforts within the local health system amplifies the overall impact of FIENS initiatives by promoting sustainable change through collaborative action in the service of local health system goals. From this point forward, initiatives coordinated by FIENS incorporated local stakeholders and workforce in addition to mechanisms for service delivery, health infrastructure, information management, governance, and funding.

Additionally, FIENS-supported trainees expressed the need for ongoing support in the early stages of their careers. In response, the Foundation expanded its scope to include postgraduate education, evolved, as global health organizations must, understand that lasting impact occurs through teaching, leading to self-sustaining health systems in regions of need.

The Role of Young Neurosurgeons in Global Surgery: A Unified Voice for Health Care Equity

Health care equity pursues the elimination of health disparities or inequalities. One of the most significant challenges is the inequality shaped by policies, for which systemic change is needed. Historically, non-surgical pathologies have received greater political priority than surgical pathologies, but we have begun to see a paradigm shift over the past decade. In 2010, Shrime et al. showed that 32.9% of all global deaths were attributed to surgically related conditions, which equated to three times more deaths than that due to non-surgical pathologies such as tuberculosis, malaria, and HIV/AIDS combined (1). When the Lancet Commission on Global Surgery was published in 2015 (2), a new era in global health emerged. The message was clear: surgical diseases could no longer be neglected. The report emphasized the importance of systems-level improvements in service delivery, workforce training, financing, information management, infrastructure, health policy, and governance.

In neurosurgery, over five million patients present with treatable conditions each year but do not have access to surgical intervention (3). Most of these patients live in low- and middle-income countries (LMICs), particularly in Africa and South-East Asia. For a hospital to offer neurosurgical services, substantial investment in infrastructure and human resources is required. Hence, most neurosurgical services tend to be concentrated in tertiary hospitals or academic centers located in cities or urban regions. Moreover, the comprehensive management of a patient’s neurosurgical disease relies heavily on a functioning health care system, often requiring a multidisciplinary team approach, whether in children or adults.

A Seat at the Table: Representation of Global Neurosurgery in the G4 Alliance

The Global Alliance for Surgical, Obstetric, Trauma and Anaesthesia Care (G4 Alliance, http://www.theg4alliance.org/) is the preeminent global surgery advocacy organization (1) dedicated to eliminating disparities in surgical care around the world. A coalition of over 60 non-profit organizations, professional societies, academic centers, and other groups, the G4 Alliance represents civil society interests in global surgery from the grassroots to the international level. The organization convenes its membership to address common interests and concerns, facilitates knowledge and resource sharing, builds consensus and alignment, and conducts outreach with multilateral organizations, donors, and other global health programs and advocacy initiatives. In a sector characterized by diverse actors and fragmentation of care delivery, scholarship, and funding (2,3), the G4 Alliance provides communication and coordination around a common surgical and health system strengthening agenda. The purpose of this paper is to highlight the multiple organizations that specifically contribute to neurosurgical advocacy within the G4 Alliance.

Global Neurosurgery: the role of WFNS Foundation

The World Federation of Neurosurgical Societies (WFNS) is the largest neurosurgical organization gathering more than 49.000 neurosurgeons belonging to almost all existing neurosurgical societies worldwide, created in 1955 to promote neurosurgery camaraderie among neurosurgeons. In 90’s beginnings, the visionary leadership of professor “Pepe” Martin-Rodriguez and professor Madjid Samii made possible the creation of the WFNS Foundation; its mission can be defined as an improvement of neurosurgical care in developing countries (education, training and, intraoperative neurosurgical technology), with the vision to become the worldwide leader neurosurgical organization in the promotion of education and neurosurgical care in that countries. It is essential to mention the name of professor Armando Basso, who exemplarily created the modern and current Foundation structure that nowadays is helping thousands of patients and neurosurgeons.

The Executive Board governs the WFNS Foundation (seven persons, three of them being the President, Secretary, and Treasurer of WFNS). Also, it has the support of the Advisory Board, composed of a group of neurosurgeons who enthusiastically contribute to WFNS Foundation goals. A few years ago, a strategic plan was devised considering the Foundation’s activity based on three pillars: Education, the development of a network of training centers, and the provision of neurosurgical equipment to developing countries. Recent publications (1–6) have pointed out the current unmet needs in developing countries, hence the interest of WFNS Foundation to comply with the context and definition of Global Neurosurgery (“the clinical and public health practice of neurosurgery with the primary purpose of ensuring timely, safe, and affordable neurosurgical care to all who need it”).

Global Neurosurgery and the Congress of Neurological Surgeons: Collaboration, Innovation, and Opportunity to Improve Care, Education, and Access.

Global neurosurgery encompasses the neurosurgical care and public health efforts to ensure timely and safe neurosurgical care access for all who need it (1). Over the past several decades, global neurosurgery has been championed by many individuals, which has led to a broader interest in developing larger collaborative, sustainable neurosurgical care efforts. On a national level, neurosurgical educational opportunities have grown through courses, online education, and fellowships. Given the growing global burden of neurosurgical disease, there is a significant opportunity and need for worldwide neurosurgery and neurosurgical education worldwide, especially in low- and middle-income countries (LMICs).
To advance global neurosurgery from an educational standpoint, the Congress of Neurological Surgeons (CNS), American Association of Neurological Surgeons (AANS), World Federation of Neurological Surgeons (WFNS), and other international neurosurgical societies have successfully developed programming. The CNS has led with a robust educational platform and offerings for neurosurgeons through in-person courses, fellowships, webinars, online case databases (2), publications, guidelines, and virtual grand rounds. SANS online education and questions modules offer neurosurgeons the ability to learn and self-test to advance their fund of knowledge, education, and continuing education

Role of North America and AANS in Global Neurosurgery

Approximately 28% of the global burden of disease is surgical (1). There is an estimated deficit of 90,909 neurosurgeons globally, who must care for an additional 14 million neurosurgical patients annually (2). In a study published by Alkire et al. on global access to surgical care, it was revealed that approximately two-thirds of the world’s population, comprising 4.8 billion people, do not have access to timely, affordable, or safe surgical care. The study also concluded that 99.3% of Lower-Income Countries (LICs) and 96.7% of Lower Middle-Income Countries (LMICs) populations do not have access to safe surgery (3).

Historically, global health policies focused on specific issues like access to healthcare and outcomes of infectious disease treatment and vaccinations. In January 2014, the Lancet Commission on Global Surgery (LCoGS), headed by healthcare leaders from 111 countries, gathered in Boston to research and propose strategies to improve surgery access globally. One of the committee’s goals was to bring surgeons from different socio-economic strata under one roof to facilitate collaboration and fruitful exchange of ideas. The committee also motivated the higher-income countries of North America to collaborate and shrink the existing hiatus in surgical access present in lower and middle-income countries (4). Since then, significant progress has been achieved in this regard under the leadership of North American academic institutes, neurosurgical societies, non-governmental organizations (NGOs), and even individual surgeons