Global Neurosurgery: A Reflection from a Life in the Field [1st ed. 2023] 3031410483, 9783031410482

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Global Neurosurgery A Reflection from a Life in the Field Robert J. Dempsey

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Global Neurosurgery

Robert J. Dempsey

Global Neurosurgery A Reflection from a Life in the Field

Robert J. Dempsey Neurological Surgery University of Wisconsin–Madison Madison, WI, USA

ISBN 978-3-031-41048-2    ISBN 978-3-031-41049-9 (eBook) https://doi.org/10.1007/978-3-031-41049-9 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

This book is written for physicians interested in participating in global health and the general public who wish to receive a deeper understanding of the scope of global health and particularly the role of specialized surgery, like neurosurgery. It is meant to encourage physicians to participate in global health, giving them a personal playbook as to the history of this movement, what are the shortcomings, and the personal and emotional strain and lessons learned from the process. Each chapter emphasizes a particular trait or area of emphasis necessary for success in global health. These are illustrated with examples of the impact of each. This book emphasizes that we must partner, as nothing of this scale is ever done alone, that science has given us strong data justifying the investment in global specialized surgery and that “Service through Education” will leave self-sustaining programs of impact for our patients of the future. Included are lessons on the stress of operating in a strange land and the responsibility that comes with participating in a global neurosurgical effort. The goal is to give both the global health neurosurgeon and the lay person an understanding of the place of specialized surgical care in health and a roadmap for a future of self-sustaining programs to address that need. While there are specific details about the steps to establish neurosurgical care where none exists, I hope that the message is clear even to those that will never travel worldwide: that we all benefit from and can each participate in global health efforts. Additionally, truly thinking globally starts at home because such needs surround us every day. By participating in the care of others, we all benefit, because teaching is bidirectional, with us drawing inspiration from those we set out to teach. Madison, WI, USA

Robert J. Dempsey

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Acknowledgments

I want to personally thank the many patients worldwide who, by teaching us every day about courage, trust, and hope, sustain each and all of us. I want to personally thank my family, especially my wife, Diane, and children, Kara and Conor, for support, enthusiasm, participation, and adding meaning to every effort. I also thank Stephanie Schuessler for typing of the manuscript. fiens.org

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Contents

1

Introduction����������������������������������������������������������������������������������������������    1

2

Lessons Learned from Four Decades of Neurosurgical Global Health Experience ����������������������������������������������������������������������    5

3

A Life in Global Health: Preserving What Is Noble in a Profession ����   9

4

First Influences: Where Does All This Start?����������������������������������������   11

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Second Influences: Appalachia ��������������������������������������������������������������   15

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Appalachian Patients ������������������������������������������������������������������������������   19

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Appalachian Clinics ��������������������������������������������������������������������������������   23

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Seasons of the Year����������������������������������������������������������������������������������   29

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Guatemala������������������������������������������������������������������������������������������������   31

10 Chicken Buses, Dugout Canoes, Pickup Trucks, and Shoe Leather������   35 11 Applying Lessons Learned to a New Area of Neurosurgical Need������   39 12 Why Work So Hard? ������������������������������������������������������������������������������   43 13 Hold Hope ������������������������������������������������������������������������������������������������   45 14 Picking a Site for Neurosurgical Service: Ecuador������������������������������   49 15 Family��������������������������������������������������������������������������������������������������������   55 16 The Red Scrub Cap����������������������������������������������������������������������������������   57 17 First Surgeries������������������������������������������������������������������������������������������   59 18 FIENS��������������������������������������������������������������������������������������������������������   65 19 Africa��������������������������������������������������������������������������������������������������������   67 20 Operating in a Strange Land������������������������������������������������������������������   69 ix

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Contents

21 Worldwide  Partners in Global Neurosurgery: The Concept of Dyads������������������������������������������������������������������������������   73 22 OR Equipment and Establishing Neurosurgery in a New Region������   77 23 The Lancet Report 2015��������������������������������������������������������������������������   81 24 Continuing Medical Education in the Global World����������������������������   85 25 Persistence������������������������������������������������������������������������������������������������   93 26 Service Through Education��������������������������������������������������������������������   95 27 The Corners of the Day ��������������������������������������������������������������������������   99 28 Teaching Is Doctoring, Doctoring Is Teaching��������������������������������������  101 29 Why I Do Research����������������������������������������������������������������������������������  105 30 Native American Health��������������������������������������������������������������������������  109 31 Children and Family in Global Health��������������������������������������������������  113 32 Danger������������������������������������������������������������������������������������������������������  115 33 Mistakes Made and Lessons Learned����������������������������������������������������  119 34 The Magic That Makes Us a Person������������������������������������������������������  125 35 What Did We Learn from COVID-19����������������������������������������������������  129 36 On Death ��������������������������������������������������������������������������������������������������  133 37 The Way Forward������������������������������������������������������������������������������������  137 38 Epilogue����������������������������������������������������������������������������������������������������  139 References ��������������������������������������������������������������������������������������������������������  141 Index������������������������������������������������������������������������������������������������������������������  143

Abbreviations

AANS CME CNS FIENS NACHP PPE SNS WFNS WHO

American Association of Neurological Surgeons Continuing Medical Education Congress of Neurological Surgeons The Foundation for International Education in Neurological Surgery Native American Center for Health Professionals Personal Protective Equipment Society of Neurological Surgeons World Federation of Neurosurgical Societies World Health Organization

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Chapter 1

Introduction

A surgeon knows when there is trouble. It can come from expected or unexpected circumstances. It can be most frightening when it is expected, anticipated and yet uncertain as to consequence. I found myself in such a situation when I was asked to help in Mbarara in western Uganda. A young lady hoping to go to university had an enlarging brain aneurysm that had paralyzed the muscles of one eye and would likely soon take her life. The local surgeon was a friend I had helped train years before in Nairobi, and during my teaching visit, he asked me to assist. A US-trained neurosurgeon is used to an enormous array of support equipment, teams of anesthesia, nursing, and preparation; almost all was absent in this hospital. The equipment was rudimentary. There was a surgical microscope, but it was frozen and immobile, greatly hampering its utility, as you actually had to move the patient under it to see different areas rather than move the microscope over the patient. There was anesthesia, but the drugs, equipment, and even electricity were spotty, the power going on and off twice during the case. To make matters worse, I was sick fighting a fever of unknown origin and hoping to be flown home soon. Nevertheless, there was no question about what was needed: we repair her brain or likely the young student would die, so, therefore, we try. The anesthesiology started out smoothly, but the lack of equipment was almost immediate. One is used to innumerable tools, but in so many parts of the world, you have one and only one. In this case, one aneurysm clip. In the United States, I choose from hundreds of size and shapes to fit the case. In Uganda, we had no such options. It had to work. Once the standard opening was made, fortunately without bleeding, the power went off twice—each time we were thinking that surgery might have to be abandoned, but each time it would recover, as the generator coughed back to life (see Fig. 1.1). There is, of course, no air conditioning. The heat and sweat becomes intolerable on top of my fever. We are able to jerry-rig the microscope so that we would have one view and one view only, but that was all. Working in a small area behind the left eye, we are able to expose the brain, but then the next step must be meticulous microscopic dissection of the brain to avoid © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_1

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1 Introduction

Fig. 1.1  Operating under only partial light with the emergency generator, a common occurrence in global health. Neurosurgery often must be ready to be done by flashlights or hiking headlights

injury. We must literally open the brain like the leaves of a book, to allow an atraumatic approach to the aneurysm. This is routinely done in the United States with a diamond knife—literally a tiny diamond sharp enough to carefully cut the lining of the arachnoid membrane that surrounds the brain and to allow one to carefully work down the sulci as avenues of view. Of course, there were no such devices available in Mbarara. One learned quickly from the magnificent ingenuity of the people you work with in the developing world, and we fashioned a dissecting instrument from a TB syringe needle. The tiny needle one uses to give a TB test worked well to dissect the brain, but the thought of using a needle to dissect around an aneurysm is daunting, to be certain. I learned that day that with help, you can accomplish many things, including things that might not have seemed possible at first. We were able to expose the aneurysm without rupturing it, repair it with the one clip, and return the young lady to health. The team was then able to package me off with a driver for the 5 hour trip to the airport and home.

1 Introduction

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The world is full of amazing people. The doctors that taught me in medical school taught by their example of resilience, ingenuity, and perseverance, because one day a young patient would need that from her doctor. Such teaching is truly bidirectional. Although three hospitals during that trip welcomed me for my teaching, my ideas, my lectures, and my equipment, it was abundantly clear I was learning every bit as much as I was teaching. It was a trip to keep one’s eyes and ears open, to be quiet, to first listen, and then to teach. I heard and saw parents express love, pleasure, fear, and hope for their children. I saw the human emotions of people wishing better lives for themselves and their families. I saw a people’s pride in their country, its resources, its youth, and its possibilities. I learned that what may have seemed hopeless—an 18-year-old with an enlarging aneurysm in the brain behind her eye—could be a lesson of hope for the teacher.

Chapter 2

Lessons Learned from Four Decades of Neurosurgical Global Health Experience

Inspirations and need from global health to our own backyard.

How one finds themselves repairing instruments in Mbarara, Uganda, to operate on an 18-year old’s brain is a long journey that requires reflection on the lessons learned. Over this time, I have learned about the resilience of mankind and the commonality of our lives. We truly are one people. The parents who trust their child to a neurosurgeon are literally trusting you with their child’s life. They are no different in their fears, hopes, and aspirations for their children, be they in Uganda, Haiti, or the wealthiest neighborhood of the United States. Understanding these lessons can take time, however. Medical students are caught up in their studies, and young doctors buried in their work. It is quite possible to lose track of why you went into medicine in the first place. It was Hippocrates who said, “advocate for the patient in need, and strive for justice for those I care for.” These are lessons learned coming from the twisting and turning journey that is a life in neurosurgical global health. This book is meant as a teaching tool for those interested in global health. I hope it will have value to all, especially to those who will never travel worldwide but will support those efforts and understand their impact. It is told from a very personal perspective to illustrate lessons learned and to document progress made over decades, as well as hold hope for the future. While I detail some very specific advice about the steps needed to improve health from a population perspective, I hope the message is clear that we all benefit from such efforts. Global includes our own backyard and the benefit to all participants are bidirectional, inspirational, and lasting. Working in global health can teach us that all people worldwide have some basic pillars, our needs for family, faith or purpose, health, and peace. All are related and I truly believe that sincere effort in any of these areas will benefit all others. Peacemakers benefit family and health. Global health brings a purpose and supports peace and family. The importance of understanding the commonality of the desires worldwide for family, faith or purpose, health, and peace in all people makes real the possibility © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_2

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that the sincere effort to use your talents in whatever field you choose with and for others may support one of those pillars and supporting one will often benefit all four. Conversely, if one is absent, then all four may collapse. Health, peace, faith, and family are all intertwined worldwide, and if one wants to support health, they need to understand the importance of the other four. That basic concept allows one to understand that global health can really be contributed to by all people. Each may participate in their own way. You don’t have to be a neurosurgeon to do it. You can be a carpenter, a dishwasher, a politician, a financier, a doctor, a health provider or a volunteer, but when a person applies their own gift—whether that be carpentry or neurosurgery—and tries to do it very, very well, with and for others, they all add to that effort. That is a lesson learned globally: that we all are in this together and, therefore, we must all partner to succeed. We cannot have health without peace. We must partner with governments and sometimes armies. We cannot have family without health, and we cannot have purpose or faith without the other basic pillars. The question then becomes, how do we find inspiration to do such work? Who are the people that inspire us to look for what is noble, passionate, or joyful in life? This is a book about where those lessons are learned. They are learned every day from common and uncommon people that enter all of our lives. When we stop to listen and look and we see a carpenter working with joy for others, we realize we each can play a part. When we see a child with needs or a patient, be it in Wisconsin or Zimbabwe, that patient is teaching us that we all have a gift, and we use that to partner with others to serve more. We have been given the opportunity to remember a little bit of that nobility that is so common in physicians and healthcare providers when they enter this field. It should never be forgotten, because that ability to find joy and inspiration in your work is what sustains you and is what gives you the strength to continue. This is a story of how that inspiration is found in our everyday life, so applicable to global health, global neurosurgery or righting any disparity. It is remembered when we take time to thank those people every day that teach us. Sometimes it can be the courage of a patient; sometimes it can be an effort by the person who cleans the surgical instruments. There is every reason to be thankful. I hope this book shows that lessons one learns in global neurosurgery are so applicable to our work every day regardless of location, because the personal needs are always there, as are the unmatched potential for good, purpose, and joy when one is able to work very hard at their craft with and for others. It enriches the worker every bit as much as it does those they thought they came to serve. Just as global health exposes us to these basic needs or pillars of humankind, global neurosurgery for me has been a great experiential teacher, and the lessons learned from that experience translate to my everyday practice of neurosurgery and, indeed, the way each of us choose to live our lives. I hope I can convey that the key to successful global neurosurgical or global health or any medical effort to correct health disparity, whether it is with indigenous people, half a world away, or in the society that makes up your own backyard, it always seems to come down to basic principles that are very hard for a surgeon to learn, but they are, indeed, the key to success. The first is to be invited. Neurosurgeons can be very strong willed and, indeed, very bullheaded, but no project will succeed if you are viewed as an

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interloper as opposed to someone who asks permission and is invited to any task. The second major principle is to stop to look and listen. I hope to use examples from my life to show how important that is and how much one learns. There is a Native American saying: “Talking spills your power.” It was Abe Lincoln who said, “It is better to remain silent and be thought a fool, then to speak and to remove all doubt.” When one takes time to listen, one becomes a better doctor. There is so much to be learned from everyone you meet. In medicine, people will often tell you their medical complaint nonverbally—their posture, their expression, and their tone. One has to look and listen for all of these things if you do want to learn. The next principle of global health is always to partner. Bringing global neurosurgery to a world without it is an immense task. No one can do that alone, and, indeed, no one can do that if they only look at healthcare. One needs peace, one needs government, and one needs people willing to partner with you to make any healthcare program a success. Finally, service through education. The program is not about you. It is about the people being served and the culture that you are trying to bring neurosurgery to. If they can learn to take on the task, it will become self-sustaining. To make that transition, you must learn empathy and persistence. These are the lessons learned, and all of us need to learn them every day if you want to succeed in bringing global neurosurgery to a world in need or in finding nobility, joy, or purpose in an imperfect world.

Chapter 3

A Life in Global Health: Preserving What Is Noble in a Profession

Finding the people who inspire you everywhere.

To really understand global health, you must really talk about people and how you get to know people, how you get to become interested in treating people in need, and how you persevere. This is really about learning to stop, look, and listen to those around you that will teach you what inspires what is worth passion and what can bring joy in our lives. This is true in surgery, but no less so in all the other vocations if we find purpose and service in them. In my own life, one of the best ways to learn to persevere and have faith in something is to be a Cubs fan, because we only see a championship every 108 years. That may be a good start, but if I’m going to write about global health from a very personal basis, you might first learn a little bit about me. These are really lessons about what it’s like to have a life where you take two steps forward and one back, and in global health, you do that a lot. How you persevere is what you learn at every step of the way. Nobility is an ambitious title, but I really want trainees in medicine and surgery to think about what they’re doing and why they’re doing it. Often the motivations as people are starting medicine are really very pure and very noble. I feel it important to preserve that trainee attitude throughout your life. What are the key issues in global health? First, neurosurgery is finally beginning to think globally. After decades of focusing on one operation at a time, it is changing rapidly. Neurosurgery as a specialty is only 100 years old and only recently matured to understand its global impact on healthcare. The reason for this new understanding is a realization that disparities in specialty healthcare are greater than any other. When I was in medical school, I was told that I can only really do global healthcare if I did infectious disease. Fortunately, I’ve always been one to question authority. I feel that proving worldwide specialty medical care is essential because disparities between what we have here and what you’ll see in the rest of world are stark in specialty surgery. That wasn’t clear to everybody until it was scientifically studied in 2015, but it was clear to me a long time ago.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_3

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The numbers are all well known, there are 33 nations that have no neurosurgeons, and some countries that have 1 for every 8 million people. You see 1 neurosurgeon for an average of 80,000 people in the United States. We are 1% or less of the healthcare system in the United States. What does that mean to face such disparity in low- and middle-income countries? It means that if you don’t have access to a neurosurgeon, you get a maldistribution of essential services. You can’t really address diseases, which are as important as infection like trauma, congenital CNS defects in children, benign tumors, cancer, and stroke without it [1]. Without neurosurgery your trauma system collapses, as so much of trauma involves the brain and spine. I’ve given that speech to numerous ministers of health in countries around the world, so I’ve gotten pretty good at it, but it’s shocking to see what happens when you actually get out and see people. It is an opportunity not to just present your view but also to listen. The next lesson that I think you need to learn in global health is we live in a very isolated bubble and you have to get out. You have to see how other people work and live and how they solve their problems. You learn how smart and dedicated they are, and you are proud to work with them. If you stop to look and listen, you can be inspired by them. Working in global health can teach you to listen and learn all lifelong and to recognize and thank the many that teach and inspire you, each in their own very different ways. The teachers I mean are rarely professors. They are the patients, the laborer, the cook, and the frightened child you treat.

Chapter 4

First Influences: Where Does All This Start?

Service comes from all the experiences and people that form us as humans.

I was born in Chicago into an Irish Catholic family, like so many others that came about when my parents were able to put World War II behind them to chase the dream that came from growing up in the great depression and World War II. I was the second of five children and, left to my own devices, would have thought that the world started and ended with baseball. Our memories were full of being outside and of play and innumerable other children filling streets and schools. It was my family, however, that wanted something more. My parents instilled a thirst for education and reading, a work ethic and the desire to do more and to give back in a manner that would make one proud. My mother would send us off to school with the phrase, “remember, you’re a Dempsey.” They taught us to be proud of what we did and, indeed, our very name translated, “the proud tribe” from the Gaelic. We worked from an early age. On my first paper route, I was 8. We had to save for college, even though we had no concept of what that actually was, but many of us would win scholarships that would make college possible. I remember when I was 6, I was trying to read every book in the local library, a task I gave a good try, but did not accomplish. The library kept getting new books—a wonderful problem. I remember as an adult getting a library book was a way to treat oneself instead of some purchase. Indeed, one of my sisters would become a librarian. It all led to a life of inquisitiveness, understanding how things worked, and, more importantly, the why. I think the war had also changed my parents, the extent they did not feel things had to be the way they were or could not be changed. From this came a growing desire to do something in medicine. I had grown up in the middle of a polio epidemic, which swept through our neighborhood and family. I had seen cerebral palsy, stroke, cancer, and death, and I felt that medicine might well be a vocation that made sense of it all.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_4

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I didn’t think I was particularly smart in the “gift from the Gods” way people defined it when I was young. I lived in a neighborhood that didn’t really value how you were born. I lived in an area of normal people and supposed that smart people have only been born in places like Cambridge (the United States or UK) and talked with a different accent about the different things they were born to. I just wanted to read everything, complete everything, and learn something new because it was a time of possibility and change. It was a clean and simple life, and there was still time to play baseball. Then, along came standardized tests. These semi-IQ tests, which school systems seemed to revel in as a way to measure their own success, became ways of dividing classes up or telling students what they were capable of, for reasons still mysterious to me. All those times trying to figure out the why of things and reading translated strongly into success in that world. Suddenly I found myself moved to the front of the class and very quickly decided that I better build a persona as an athlete—first in baseball, later in track and field—if I did not want to be labeled, singled out, or disliked because academic success made you different. If I could combine the two, I could grow and define myself. The big part of that was a family desire to be proud of what you do. I could not control or take credit for if I was “smart,” but I could be responsible as to how hard I worked. My motto was, “Go then dreamer and change the world, or soon it will change you.” So much of this philosophy comes from my early life. Chicago is where I grew up. It is that city that Carl Sandberg called a husky, brawling city of big shoulders. If you’ve ever taken off from a plane from O’Hare, as you swing from a southern runway you’ll see massive rail yards. That rail yard is about five miles by three miles in size and the next to the south are neighborhoods of small houses. Next comes the river, canals and locks, and barges. Spread throughout are the factories. I grew up in this neighborhood. To the south of my house they made all the diesel locomotives that then pulled the trains of the world, the electromotives. To the east of me was the huge mile by mile factory of Western Electric that made every phone in the Western world. To the North was the factories for International Harvester that made the nation’s farming tractors. Down the block from my house was Alcoa, an aluminum factory, and a quarry and around it were these rail yards. These rail yards were part of the story of my father, my grandfather and my great grandfather. They were where I was expected to work and, indeed, I did. I started to work simple jobs when I was 8. I later worked on the docks that supported those rail yards. I was a teamster and a forklift driver. I was expected to join the army after high school, if I was lucky. A couple of funny things happened along the way of a predictable life. Sometimes things do not unfold as expected and sometimes it’s hard to tell why, but each and every step was an opportunity to look and learn and then join in each in our own way. I was so fortunate to be born into the family of Donald and Eileen Dempsey, who taught me and my four siblings of faith and family, but also about effort and about doing your best with the gifts you were given. Such efforts for the right causes bring purpose, joy, and passion. All my life I loved to read. At 6 I tried to read every book in the local library. Libraries played a special role. I love to teach. I found myself helping others with

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homework and I started to teach classmates in my school, which was important because effective teaching was rare in schools which in those times emphasized discipline. My brother and I attended a school where I think “Crime and Punishment” were considered career options. I only later thought of it as Russian literature. I’d actually gotten into trouble for teaching my fellow students too much. But it was that brawling era. That was my life. I loved it. My brothers, sisters, and I ran, played, taught, and helped each other and saw a world of possibilities, passions, joy, and opportunity. Where people may have aspired to college or join the army, some of my classmates aspired to join the Mafia army and did. I learned quickly that it was pretty important not to have a reputation just of a Brainiac, because that could be dangerous. So, I nurtured a reputation as an athlete, which was much safer. We all worked. As children we learned to save money for college even though we had no idea what that was. I sold newspapers and worked in a store and at a country club. One summer I was even paid to take care of Al Capone’s grave. Eventually I learned to operate equipment and drove forklifts moving grinding wheels in the warehouses near the railyards. Then, a funny thing happened in my life. They’re called scholarships, and suddenly I had a bunch of scholarships to go to phenomenally good colleges and then eventually a phenomenally good medical school. Scholarships can be for both athletics and academics, but they changed my life. When I arrived at Notre Dame, I was so thankful to find a world of opportunity, purpose, question, and passion. I came alive to that opportunity. I took every class I could. A science major, I would talk my way into classes on poetry, theology, art, business, and philosophy. I learned teamwork from my track and cross-country teams. I learned of my interest in medicine from the children at the Northern Indiana Children’s Hospital. These were opportunities other people don’t have. That was one of the lessons I learned—be thankful. These were my early teachers. Not everyone had the same chances. I also learned to take advantage of those opportunities. I know now that all this opportunity came from my family, my parents. I would never have found that library without them. I well recall each day my mother sending us children off with the wish that we would do something to be proud of: “Remember, you’re a Dempsey.” That is the very meaning of my name in Gaelic, the ancient Irish language, “The Proud Tribe.” I believe that Martin Luther King said it best, “Life’s most persistent and urgent question is ‘what are you doing for others?’”, Notre Dame was very special for me. There I made lifelong friendships and there I met Diane, who was to become my lifelong love and spouse. One of those later scholarships was to the University of Chicago for medical school. This was such a change in culture from what I had grown up with that many in my neighborhood actually did not know where the University of Chicago was! I occasionally would walk to the hospital with a Nobel laureate. It was a rarified air of scholars and ivy-covered walls, completely foreign to the world I had grown up in, and challenges came. My first day at medical school, I was very literally singled out: A full professor took me aside and said, “What are you, the token Irishman in the class?”. I got in his face and said, “Yes, I am,” and he loved my fight and became my mentor, which was

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a lucky thing for me, because I got called to the dean’s office a couple of times (once when he found out how little money I was living on), but in the end, I was different, I enjoyed it, and I learned and grew. Around this time, I began to discover the medical needs of the inner city of Chicago. A mission trip to Appalachia showed me that such needs were actually universal. It became clear to me that my life needed to be challenging, intellectual, tactile—as in surgery—and yet of broad service to people globally in need. This led directly to my training at the University of Michigan in neurosurgery. I absolutely loved my introduction to neurosurgery and still do. It is a field of immense possibility with so much that needs to be done and discovered. How does the brain function, how does it work in health and disease, what can we do to stop a tumor from growing within it, how do we keep strokes from happening, and can we literally reverse a stroke? So many questions, so much to be learned, so much to be done. It felt natural to me. When people told me the hours were ridiculous, I couldn’t imagine spending them any other way. If people felt sorry for me because of my work schedule, I felt fulfilled because it had meaning. When I became a board-­ certified neurosurgeon practicing at the University of Kentucky, I traveled regularly to rural clinics in Appalachia. I thought I went to teach; I actually learned so very much.

Chapter 5

Second Influences: Appalachia

Building Trust through empathy. Global health’s relationship to global economy—rural medicine. Recognizing global health needs include our own backyard. We are all part of global health.

Along the way as I worked to pay for education, I became interested in people that didn’t live in the city. At one point in my life, I was building houses in Appalachia. Unbeknownst to most people, I’m the second-best roller skater in Gilmer County, West Virginia. Here I saw how much you can learn if you stop to look and listen. There, I met people that broadened my outlook. One was the best carpenter I’ve ever met my life. He worked with joy and a passion to have his work help others, and he taught his skill. It was an epiphany for me. I learned what it was to be a master at something and the responsibility that comes with that. I also learned that I was better at some other important things. I was very interested, even then, in healthcare. I saw that these good people lacked healthcare immensely, and I did want to do something about that. When I became a neurosurgeon, it became one of my career goals to go back there. I spent 12 years in Appalachia. I worked at the University of Kentucky, and at that time my global health outreach was in the United States. The Appalachian area of rural Eastern Kentucky was where my clinics were located. I met coalminers and tobacco farmers. I knew of country singer’s families and the town of Hazard, as in Dukes of Hazard or Bloody Hazard if you’re a historian. I very much liked being there. I learned about people and the land. I learned of that organic connection to place and roots. I learned we’re all the same. I learn their needs were great. Their opportunities were few. I learned that I’ve been very lucky to have opportunity. So, I was interested in service there. For 12 years I would drive a little under 10,000 miles per year to visit clinics in rural eastern Kentucky. Here I found families who had been in this region since their forefathers traveled across the Cumberland gap with Daniel Boone and the © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_5

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Transylvania Land Company and settled in the valleys that reminded them of their Scotch-Irish roots. There they farmed, cut off from the rest of the world, until their timber and their coal became valuable to the industrial revolution. Major roads didn’t penetrate this area until the 1950s. Much like all other people, they were, again, no different. They all needed hope. If hope was taken from them, despair would follow. I learned that most people respond according to how they are treated. There is a very small fraction of people that are always positive. Most of the rest of us respond well if we are treated well. Only a small fraction cannot be reached. That very large majority were my patients. As I did not keep track of who could pay me and who could not, I earned a reputation of trust. I loved their language, their phrasing, often with terms like “of the mornin” which was straight from the Scotch-Irish. They would bring their medicines in a “poke,” and they would ask me about “my people.” I found my language adopting their phrases, which go far beyond the perennial favorite “y’all.” After first asking where “my people” were from, they began to dispute my Chicago roots and say, no they knew “my people,” because there had been Dempseys in the hills, including a family doctor whose reputation continued. These same people, often reviled in movies and television as hillbillies, were no different from me. They had the same needs, desires, hopes, and aspirations for themselves and their children as all. If only few succeeded, it had everything to do with a paucity of opportunity or experience, not character. For many years I ran a neurosurgical clinic in Auxier, Kentucky. This was to profoundly influence my interest in what is really “global” health. Auxier is a tiny town on US-21, on the borders of Johnson, Pike, and Martin counties deep in coal country. It also sees itself as a home of country music. Numerous country stars grew up on that route, and patients would tell stories of the music they heard at church from people who grew up to be household names. The movie “Coal Miner’s Daughter,” was set over the ridge in the next hollow. Making a living or “getting by” in this region was difficult for my patients. When their ancestors found Eastern Kentucky, having come mostly from the Scotch-Irish areas of the Northern British Isles, they found a countryside of hills, rivers, and valleys which reminded them of home. They had aspired to the fertile farmlands of the Virginias and Carolinas, but finding those full, they traveled across the mountains with teams like the Transylvania (through the forest) land company being led by people such as Daniel Boone himself, aiming for the lands of the Kentucky Blue Grass. But finding the hills they crossed to be familiar, they settled there. They found that the farming was subsistence only and only in the valleys. The forests of the hills were good for game and timber. Transportation was extraordinarily difficult, and people, once established, would spend their lifetimes in the valleys. After I had been in the clinics long enough, the people would tell me their name and I could tell what creek they were born on. While these people came to hunt and farm, later outsiders came for the resources of these hills. The first resource taken in the late nineteenth century was timber. Huge teams stripped the lands of timber. Then when it was clear cut, and the thin topsoil of the hills washed away in the rains. Massive seasonal rains of the late

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nineteenth and early twentieth century took thousands of years of topsoil, away overnight. The second resource to go was coal. A man by the name of C.C. Mayo understood geology enough that he studied the geo maps of Eastern Kentucky. He then traveled the hills and bought mineral rights. He would walk to a farm and offer a silver dollar to the lady of the house as an introduction. He then would sit and talk with husband and wife and leave with a deed for the mineral rights beneath the farm, something no farmer would ever conceive that anyone would be foolish enough to try to mine in those rugged hills. The farmers of that remote land felt no one could mine the earth beneath their farm. The mineral he was looking for was coal. As the Industrial Revolution gained momentum, it needed power. Industry needed coal and teams of lawyers, representing eastern industrialists began to develop mines, first underground and then later stripping the farms off of the coal seams. Coal became king. It did cause the industrialists to drive railroads deep into the mountains during the coal-out period. That became the first interaction for Appalachia with the outside world in large scale. During the 100 years prior, the hollows and hills had become very insular. These Appalachian people were very self-reliant, developed individual codes of conduct, became very religious, but not very churched. The emphasis was family and the farm. As the world changed around them, a need for supplemental income was created and the people went to work in the coal mines. They did in huge numbers, but the clash of culture of the twentieth century meeting this large rural population was stunning. It was not until 1951 that a major road accessed the region of Eastern Kentucky. The language and that music developed over 150  years would be unique, hence the many country music stars from Eastern Kentucky. The regional dialect would have even a tone of old English to it, retained from their ancestors who first found the region. You could hear a Scotch-Irish dialect with phrases such as “of the mornin” when a patient described when their symptoms would arise. This land was the incubator of the language, and even of music. Because many of the roots were Scotch-Irish, many of the tunes one hears in American music came directly through this route which preserved their tonal origins. I would drive weekly to different clinics in the mountains to provide neurosurgical consultation for the variety of problems, neurologic or neurosurgical, that could affect these people. Appalachia is a surprisingly densely settled area, one of the most densely settled rural areas in America and the needs were many. I saw spinal problems, related to back breaking work in the mines. Many had headaches which had to be differentiated as the diagnosis ranged from stress to brain tumors. Many suffered from stroke and vascular disease because the only profitable crop that they could grow in the hollers by the 1980s was tobacco. They used their product— smoking was pervasive—and the medical complications followed. It took me approximately two and a quarter to two and a half hours one way to go from my home in Lexington to the clinics. The roads varied widely but mostly were two-lane twisting over range after range of the Appalachians. The hills were beautiful, but river crossings between them had to be checked before I started out, because during flood season, one might well be stranded between two rivers as

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bridges washed out. Each valley crossed was unique; each micro-culture was unique. You could tell the wealth of the area by whether or not that county had coal. If it didn’t, it would retain its nineteenth century atmosphere. If it did have coal, there would be an influx of electronics, dish antennas, and, unfortunately, mobile homes, because the mobile homes deteriorated quickly. It would rain often here because the upslope of the Appalachians would catch the western moisture and drop as rain on that side of the hills. The total rainfall would be equivalent to some tropical areas. With little topsoil, mud would run down the hill, so much mud so that it would almost seem that the rain itself was muddy. The clinic was usually held in a hospital, as the regional hospitals would serve multiple rural counties. Patients would stream there regularly for my visits. They generally scheduled between 60 and 70 patients for me to see. After a two-and-a-­ half-hour drive I would have to immediately jump in and start working as rapidly as possible. The staff was one very talented lady, but there were volunteers. These delightful elderly ladies would give their time to help with the small clinic; organizing patients, bringing them into rooms—in and out—so that I could work efficiently. I was trying to see 68 patients with two rooms. They were preparing the next patient as I worked on the one in the other room. The patient’s issues were many and I had to establish ground rules. One was I did not give out narcotics, but I would try to do everything I could to care for them. The people in Eastern Kentucky are the same as people worldwide: if they are treated well, they treat you well. If they see trust and empathy, they respect that. Indeed, I would embrace the cadences of their language, which I found beautiful. There is a special grace in a phrase like, “Of the morning, I feel well.” You all (“y’all”) is probably one of the nicest phrases in English and probably one of the more revealing. It is so much better and so much more inclusive that a singular pronoun. These people would claim they knew my family. Indeed, there were Dempseys in Eastern Kentucky, even though I wasn’t aware of any direct relations. It was a wonderful way of feeling included. Their problems were many. Mining is back breaking. In lean times, they were often working in smaller and less productive seams of coal, meaning more bending. A 40-in. seam is nearly impossible to work, but the large seams of coal where a man could stand fully upright or drive equipment through were, in some places, a thing of the past. Very few miners lasted at this work past their 30 s and the spinal injuries were many. One had to make decisions about what you could help surgically, what you could help with therapy and what would relieve their pain and return their health. They were no less likely than anyone else to have brain tumors, but they were far more likely to have strokes at a premature age, primarily because of the treatable risk factors such as smoking, hypertension, and diabetes. I became very interested in preventive programs as much as trying to repair things after the stroke had happened. But mostly, I learned about people and trust and those people’s hopes and aspirations. I saw young people in mining towns aspiring for college and understood their story rang true with me. It was the same as my desire as a child to learn, use my mind, improve it, and see what I could do for others. These are people you would do everything possible to help.

Chapter 6

Appalachian Patients

Learning the values of trust and partnering.

Global neurosurgery absolutely requires slowly, carefully building trust by listening, having the empathy to observe the situation that people are placed in and bringing those lessons home to partner for the good of others. One of the most important things I did, which I think both earned understanding on my part and trust on the part of my patients, was actually go into the mines. I found it impossible to really understand the experiences that these people had without actually seeing and participating in what their work consisted of. I, of course, only entered the mines as a physician trying to understand their conditions and their risks. It was one of the more enlightening experiences in my life and left me with a deep and lifelong respect for all of my patients. I went in with their safety inspector into a deep mine, one mile into the mountain. One reads about, but is not prepared for the darkness, the danger, or the experience of mining of that time. You rode equipment deep down into the mine. If your headlight was off, you absolutely experienced total darkness, something twenty-first century people do not understand with the electronic lights pervasive even in our nights. If it rains, the mine would be in up to 18 in. of water. Heavy equipment would travel by at great speed. When we got out of our equipment and started to walk towards the coal seams, the space between the moving equipment and the rock walls would be approximately 18 in. on either side. You’d hear an enormous rumbling monster with the one eye of its bright headlight coming towards you. You’d flatten up against the wall hoping desperately they’d see your headlight and be able to navigate down the middle of the shaft without scraping you off onto the wall. As you’d walk through the water, my guide would explain, “Never straddle that cord beneath your feet because it’s attached to a machine as much as 400 yards away, and if it suddenly started that hose would snap up into you.” I asked what the cord was floating and snapping through the water. They simply responded, “thousands of volts of electricity.” As all of the equipment was electrified, you began to understand the risks that were taken. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_6

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You learned about the hierarchy of jobs in the mine. You learned that the roof bolter, the person who literally bolted the ceiling of the shaft together so that the seams of coal and shale would not separate and crash onto your head, was the most experienced and most valuable person. The shovelers and equipment operators were younger and less experienced. You realized that some of the seams were tall enough that you could walk upright, but others were not. You began to see the reason for the bent posture and the working conditions. You begin to respect these incredible people and the effort they put in to support a family under extraordinarily difficult conditions. After that I was always filled with gratitude that my chosen profession was different, but I understood that people in all professions accept risks and the best of them count their blessings and persevere. Education in the mountains varied considerably. Some schools existed only to prepare children for the mines. Some were mission-type schools, and some were quite famous for offering an opportunity for more. One program was world famous for training midwives on horseback and still existed. Although their horsepower in the 1980s may have been provided by Chevy, their roots went back to those midwives that traveled on mules through the hills. There the midwives would try to provide decent prenatal care, delivery, and postnatal care to give a mother and child a chance at health. Other schools, like Berea College, strove to improve entire families. They are inspirational people, but any difficult place has people like them. We need to find them, listen to them, and partner with them. It was the volunteer ladies that ran my clinic in the mountains that really taught me the value of trust and partnering. One day one of the elderly ladies that was volunteering to place patients in the rooms for my very crowded clinics came timidly knocking on the clinic door when I was seeing a patient. She was clearly frightened and announced that a 300-pound man was in the hallway screaming and demanding things they couldn’t understand. I was working with a patient at the time and told her that she should stay away, go to a safe place, and I would be out very quickly to deal with the angry gentleman, all the while thinking to myself, “What am I going to do?”. I was skilled at talking bullies down or diffusing situations, but this literally was someone who would be twice my size and may not be reasonable. I very quickly excused myself from my patient and I rushed out into the hallway where, to my surprise, I found complete calm and relative silence. I looked down the hallway and saw a large man, at least 400 pounds, but I realized he was wearing a badge. I walked down to the deputy and said, “Where is the angry 300-pound man?”. He smiled and said, “Oh doc, he decided to leave.” I realized that the young lady that ran the clinic and knew everyone in the mountains had recognized the problem early and then called her friend the deputy before anyone could be harmed. It was not the first time that the goodness of the people we partnered with would save me, nor would it be the last. Global health has taught me that it is based on trust. Partnerships are made—doctor with patient, physician with the rest of the team, healthcare with government, and healthcare with peacemakers. These are all vital roles that you may learn from global health, but they apply everywhere. It is very much like the fact that every day our patients teach us and make us better physicians if we stop to listen.

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Another essential lesson from global health is humility, certainly, one of the hardest things for a neurosurgeon to learn and even harder to practice. I know that lesson was taught to me by my family, parents who said, “Do the best you can with the gifts you are given” and “Much is expected of you if you are given great gifts”. At the same time, I learned the lesson from my wife and children, whose roles often in global health were far more valued by the people we served than the role of the neurosurgeon because they took time to listen compassionately and share joy and sorrow when they saw it. I am always thankful for that lesson and stunned by the appreciation that can be shown. One day while riding over the many Appalachian ridgelines that led to my largest clinic deep in the mountains, on the last downward slope, my car’s engine failed, and it limped at 20 mph into the clinic parking lot. I couldn’t figure out what was wrong, but I had 65 patients to see, so I walked into the clinic, started to work, and told my young clerk that I was stranded and maybe she could try to find a place for me to stay. She simply responded, “Dr. Dempsey, you don’t understand.” I was still learning to listen to others, but I did say, “How’s that?”, and she said, “There are no car dealers or repair in this entire county.” I said, “I know that, that is why I think I’m stranded. Could you try to find me a room?”. She said, “Dr. Dempsey, you don’t understand.” I responded, “What’s that?”. She said, “There is one in the next county over.” I said, “Yeah, that is a long way, and I don’t even know how I would get there.” She again said, “Dr. Dempsey, you don’t understand.” But this time she said, “You’ve operated on that gentleman’s wife and children.” I looked at her and said, “How did they do?”. Her answer was, “Oh very well, look out the window,” and out the window were two mechanics in the parking lot repairing my car. Again, the unbelievably talented young clerk had seen an opportunity for people to show gratitude that truly humbled me. These nice mechanics would not even take any money, and I had to go to the local butcher to buy steaks for their family as a way to repay them. Global health truly does start in our own backyard, and the lessons learned happen every day when you remember that global means everywhere in this world. I loved the work, but rural medicine was difficult. Five hours of driving, rounding back in Lexington, operating if need be, seeing that many patients, trying to be accurate and correct, and not sleeping adequately takes a toll. I began to understand that the toll could be exhaustion, but it also could be the risk of road accidents, a problem which, not surprisingly, affects too many doctors that travel on too little sleep. One early morning as the sunrise coming over the ridges would change the continuum from darkness to blinding light, I avoided a head on collision with a 20-ton coal truck by quick reflexes and blind luck. I happened to be at a rare spot with a shoulder I could steer off to. Most places on that road would have taken me off a cliff. I learned about those cliffs 1 day returning from a clinic to see ambulances and cars lined up along the road. All my life I have stopped to offer help at a crash, but this time I could see no crash, no damage, and no broken guard rail. Nevertheless, I pulled over and walked back along the guard rail. Everyone was looking over the rail, down into the gorge below. Then I realized a car had gone airborne, cleared the rail, and fell down the gorge below. Far below I could see a car in a creek stream

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with a victim half in the creek, legs in the car, and mouth just above the water. In those days I was still climbing mountains. I was able to climb down as the truckers that had stopped threw me rope and lowered the ambulance’s stretcher to me. The driver was unconscious but breathing with a pulse. I was able to work the stretcher beneath him, tie him on, and climb back up as the truckers pulled the stretcher up the gorge wall as I climbed alongside, keeping his spine in line. He survived that climb, but such events have to leave you reflecting, “what if?”. So much is so unexpected. So much of life you prepare for but cannot control when, where, or who may be there to help. In the end, you prepare, you remain open to what the world sends you, and you do your very best to be the one who comes to help. It is a funny thing—all my life crises only make me work faster, with more clarity, but after I would have to stop, analyze, think, and ask, “what if?”.

What Did I Learn of These Times? Need is everywhere. Hope is everywhere. Opportunity is everywhere. Global health is often in your own backyard. This should always be important. We can do so much if we are alert enough to listen to the needs and address them. But I also learned that I had limitations. One of these was there is only so much I can do alone. If I wished to do more, I would need to partner with likeminded people to have an impact.

Chapter 7

Appalachian Clinics

Let the patients be your teacher and learn every day and everywhere.

During my time working in medical care in Appalachia, I served multiple regional clinics. Usually, one day a week I would drive from the university hospital between 1.5 and 2.5  hours one way to a different mountain clinic. I learned many things about the land and the people, mostly by just watching. It is a beautiful country, although clear cut for lumber in the nineteenth and twentieth century, the regrowth forest is beautiful with different flowering trees each season of the spring. I remember calling my parents to say the red buds were in bloom and then on a later clinic trip that the dogwoods were in bloom. Entire mountainsides would be covered in color where different colored trees had taken root with the regrowth after the initial clearcutting. Then finally, in the later spring, the mountain-laurel would cover whole mountainsides, and deeper “hollers” would see rhododendron. It was a very populated rural area. Perhaps the most densely populated rural areas of its time in the United States. The people had been there since the first migration from Virginia and the Carolinas, across the Cumberland gap and into the mountain area which reminded them of their Scotch-Irish roots. They were intensely tied to the land—a characteristic I would learn could be seen worldwide—and the uprooting people from a land they treasure would always bring trouble. We see now in low- and middle-income countries this uprooting of the rural populations. They move to the cities hoping for jobs or a better life, and when they don’t find it, they are lost. The Appalachian area of eastern Kentucky suffered many to and fro migrations. While the first attraction to the land was for farming, it was mostly subsistence. The land was good in the hollows or valleys around the creeks where millennia of soil had come down from the hills and stayed, held in place by the forests. But when the forests were cut, first to clear land for farming and then to clear cut for timber, the next big product of the area, the soil was unprotected from the consistent heavy rains. That western slope of the Appalachians is one of the wettest parts of our country and when the big storms came, the soil washed away. Subsistent farming became © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_7

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desperate and other sources of income became the rule. When coal was needed to fuel the US industrial revolution, major banks and steel companies bought the mineral rights CC Mayo had accumulated and began to open huge mining areas. The initial effect was jobs and migration moving to the area, something that had not been seen in a hundred years. Although the contact with the outside world changed the culture, the roots of it—theology, music, speech patterns, and families—remained. They just switched to the newer occupation, because that is where money was. When one traveled to clinics in different counties of eastern Kentucky, you could tell immediately whether the coal industry was present there or whether the coal seams were present in that country by its infrastructure, jobs, and relative wealth. Unfortunately, with the income came a dependency on one economic source, making it subject to boom and bust. It was then not surprising starting in the World War II another migration took place to the north to Henry Ford’s big factories making bombers or automobiles. This great northward migration continued, but the ties to the land of these people remained. Often, workers would return on buses on weekends to be with family and then spend the week in Detroit to work. This diaspora or migration from Appalachia to other regions for jobs could continue off and on indefinitely. However, it was interrupted dramatically during the time I was working there. When the Arab oil embargo made an energy hungry country like the United States look to other energy sources besides oil, coal rapidly increased in value. The resulting excitement in coal temporarily enriched the area, resulting in the greatest reverse migration in US history. Large numbers of people moving back to the area they had left cemented their ties to the land of their family’s origin. Coal mines opened in areas deemed to be unprofitable before, because almost any small seam of coal could make money. The boom was startling and disorienting. Small family mines sprung up, and fortunes were made and lost. Workers had jobs and often spent unwisely. Mobile homes which would deteriorate in only a few years were purchased as a modern sign of wealth, along with the ubiquitous satellite antenna for TVs. Unfortunately, the mobile homes would not last, nor would the coal boom. But the people returned. They returned because they loved the area, they loved their family, they loved the soil, and they loved their independence. Unfortunately, when the coal jobs disappeared, alternate sources of income were pursued and many of them involved alcohol or drugs. Despair became part of many rural populations and, indeed, remains a worldwide scourge. Into this background, I tried to provide a small portion of healthcare that was neurosurgical care. I would travel to see clinics—consisting of huge numbers of people who the local doctors wanted to be screened for a variety of neurological abnormalities of the spine, peripheral nerve, or brain. Diagnostic tools were few and having a physician examining them who was familiar enough with the problem to screen who would get a valuable CAT scan was important. Clinics might be 60 to 70 patients. You had to work quickly but be professional and polite. If you were an outsider, you had to be accepted and you were judged by your ability to communicate. I had learned by now that most communication was nonverbal. Were you respectful? Did you look people in the eye? Did you explain things clearly and at their level of understanding? Did you listen? I learned to be efficient. It was essential to be interested in the people I

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saw. What was their occupation? What did they do? How did they live? How did they keep their house? How did they travel here to this clinic in an area with very few roads? Had their people always been there? They began to respect me and, indeed, would claim they knew my “people.” Even though I would explain no. Although I knew there were Dempsey’s in eastern Kentucky, we had probably only been related back in Ireland since my family was from Chicago. At the clinics I would find caring people, medical professionals and volunteers, who wanted their small town’s clinic to be the best. That clinic would care for their family and they would volunteer their time to help. They had organized to keep the large groups of patients in line, they would feed people, make sure they were heard, and keep order when it was unruly. They were proud of their town and I was proud to work with them. They taught me about their history of the coal worker strikes and the schism that these things caused in the community. They taught me about a place of church, music, and family in their lives, and some taught me about their aspirations for a better life. One clerk, young and very bright, was working hard to work through the community college to earn a degree. You are quickly determined to do everything possible to support such people. The patient’s conditions and concerns varied as widely as do all people. The key was to find the few who really would benefit from your help and still give comfort to all. Today, any symptom seems to get an expensive scan, but that was not true then. One had to decide how to marshal a valuable resource. You had to learn to examine and reexamine to avoid missing a clinical decline, you had to know how to look for the minute eye changes which might suggest retro-orbital pressure from a brain tumor and how to listen when a person’s complaints were a call for help. I quickly realized that I was the one who was learning. I was getting an education in people, in their hopes and desires. Moreover, I was learning that everybody was the same and had the same hopes and desire. There was no other. When you are told that some other groups are at fault or the other group is different, never believe it. We are one people. We have the same hopes and fears. We respond well when we are treated well and badly when we are not. We all want our families to succeed, and we want our children to be safe. We want to make sure there is a health clinic for those children or grandchildren, and we all aspire to be something better. These are basic to the nature of mankind. They are present everywhere. They are our source of strength, and, if abused, they are the sources of our downfall. Eastern Kentucky was a difficult place for people to live and practice medicine. The tight valleys with poor ground cover meant that torrential spring rains could wash entire farmsides away. Indeed, people routinely drowned when they tried to cross a road that was suddenly covered with water. Children, cars, and homes could be washed away in a sudden flood. Most supplemented their income by growing tobacco in the Creekside. It was a cash crop, very labor intensive, but the entire family would plant the seedlings indoor in late winter, set them in the prepared beds in early spring, cultivate them, top them to increase the leaf growth, harvest the crop individually, and hang the leaves to dry in ancient tobacco barns, hoping to sell them in auction houses in Lexington for the additional dollars to help the household to meet ends. Everyone played a role at every age; that’s what farmers do, but none

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could live off of that land alone. They had to supplement it with some other work in the coalmines or the schools or the clinics of the area. The clinics, therefore, took on an increasing importance. They were a symbol of local pride and could be very self-­ sufficient. Community surgery was done there, but not at the level of neurosurgery. There were good physicians and they worked hard. One day I received an urgent call from a very good internist from high in the mountains. It was winter, I was in Lexington, and there was a winter storm. The roads had iced over, and the governor had literally closed the roads. No helicopter could fly, and into the clinic had been brought a 41-year-old man after a road accident on the icy roads. He was deteriorating rapidly and had become unconscious before the nurse’s eyes. The internist had been called with no surgeons available as the patient deteriorated, clearly a neurologic injury. He reached me by phone and what he described had to be an epidural hematoma—a traumatic injury to the lining of the brain, which causes an expanding hematoma, or clot, to compress the brain, often with fatal results. Before he arrived, the patient had appeared normal then dazed and deteriorated quickly. With such a presentation, death is imminent. The treatment is surgical. There are medical attempts to stabilize, and I quickly talked the doctor through those but then told him he would have to do his first operation. It is frightening, but it tells you something about the quality of people. An internist used to treating blood pressure and diabetes, suddenly, is asked to be a surgeon, which he has never been trained to do. But I talked him through the procedure, and he saved that patient’s life, who went home to his wife and child. All this done only by phone, unlike the modern video capacities, which we use now to assist and consult in surgeries around the world in real time. When one takes time to help people who have little, their gratitude can be overwhelming. Food, crafts, common kindness, the latter being the most important. Medicine is an extraordinarily rewarding field. Neurosurgery is a field where the stakes are so high that people well know the possibilities of death, stroke, and neurologic injury. However, we can never underestimate the phenomenal ability to benefit, to relieve pain, to reverse a neurologic deficit, and to save a person’s brain and their very personhood, their speech, their vision, and their ability to know and interact with their children. Neurosurgery creates a visceral connection of surgeon and patient that establishes an overriding level of responsibility, trust, and partnership. If a patient does not do well, it is almost as if a little part of you dies as well. Still, it is an amazing profession like none other, and certain people chose it because they are willing to take the high risks to attempt to give people the extraordinary benefits of preserving their brain, their personality, their function, and their life. The strength of these people of the rural areas of the United States was brought home to me very vividly 1 day. I arrived in a different clinic in a different area. This region had less coal, the result being that poverty had been a way of life here. It actually was the congressional district with the highest rate of illiteracy in the nation. It had levels of what the government would call poverty, but the people living it understood that it was their life, and they did their best with what they had. They kept their clinic clean, they were grateful for the medical help, and they were good people who looked after each other.

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I arrived in this clinic in mid-day, having done morning work in Lexington and then driving down to this clinic for an afternoon of seeing patients there. I needed about an hour and a half of driving to arrive. I worked at that clinic in a portion of their emergency room. The hospital that day had but one older doctor working in the ER for what he felt was going to be a quiet day, while my clinic was filling with patients to be seen. As I started the clinic, we all heard the police scanner go off emergently. The details were unclear but then became frighteningly clear that a large coal truck—these can weigh dozens of tons—had struck a school bus. The first call had simply said that there was a school bus accident. I told a nurse this was extremely important, but school buses are large and heavy and often the accidents are lessened by the mass of the school bus protecting the children. Nevertheless, I knew full well that two of the worse school bus accidents in the nation’s history had taken place in Kentucky. One had been in eastern Kentucky 20-some years earlier, very near one of my other clinics. The report then came through that it was not a trivial accident and that the bus had been hit by a heavy coal truck. We were alone and we were in the emergency room that the victims were to be brought to. We immediately started to clear the space. I explained to the ER doctor that I had some experience with this, and while he was in charge of his ER, I could be helpful and began to set up a triage system, calling the nurses in to their responsibilities. We had no idea what was coming, but we called any resources in the region to try to converge on our ER. We soon heard the ambulance coming up the valley from some distance away. There were too many sirens. When a doctor, especially a surgeon, knows that there is trouble, they try to remain outwardly call, but the visceral autonomic responses are real. You can feel deep inside that there is trouble. You can respond in many ways, but you must respond in a way that gives confidence to the team. Your voice cannot betray your concern. Your tone does not change, but your instructions have to be clear and the people on your team want to know what to do. They can do anything they are told if you can give them that responsibility and opportunity. The first ambulance arrived as we ran to the door. It was clear that the injuries were massive. We wheeled that first child in and started working to stop bleeding, reduce fracture, and stabilize vital signs, and then 45 victims appeared. Forty-two children and three adults were unloaded from multiple ambulances, family cars, and any vehicles possible. For half an hour we ran, two physicians and the nurses to 45 simultaneous victims. Then at that half hour, every physician in several counties around had arrived, as did the helicopter from Lexington. Suddenly, we had help. The sickest were put on the helicopter, a series of other physicians, each with their own specialties—orthopedics, general surgery, and my own neurosurgery—began to triage patients to our expertise and the community came together in a crisis. Every single child made it. When it was over, nothing seemed to have been more important in a lifetime of training. These are good people who care about each other and can respond to a crisis. They are the same worldwide and they are the sort of people that we rely on everyday worldwide. It is incumbent on us to give them opportunity to shine at what they are good at and to bring out the best in them.

Chapter 8

Seasons of the Year

Recognizing career transitions: Including global health in that career.

Seasons come very differently to eastern Kentucky. While the spring is awash with wildflowers, shrubs, and trees in the hills, each season has its own rhythm. Summer can burn so hot that wildfires are feared. Spring can be so wet that floods can wash home sites away. The fall brings a riot of color, but winter has a mind of its own. Sometimes the snow is mixed with rain and mud and it literally divides color. I wrote a poem one day after such a clinic called “Dirty Rain.” It was just an unreal feeling that waters didn’t cleanse it. When snow came with ice, the roads were absolutely treacherous. There was little to remove snow in the mountains. I often told my clinic patients that the eastern Kentucky snow removal device was called April, when the warm weather would melt it. Once a school district had to close for almost 6 weeks because the school buses could not get up the roads. The seasons added a rhythm to life, which is absent in other areas, but often replaced with other rhythms. In Africa it may be religious festivals, harvest, or planting times. I think that is very important to people because it brings a sense of renewal that we see in the spring. When you work with people who touch the land like that, you understand how important such a concept of renewal is. I think in this way doctors, farmers, shepherds, and caretakers are linked. We protect, we renew, and we are at the mercy of forces we sometimes do not understand. The opportunities changed for me when people I knew from Church in Kentucky asked if I would join them to go to Guatemala for a service mission. I said yes. It changed my life. It’s all about the people. Guatemala is a land of great beauty and spectacular needs. This is the single country of the Americas where the majority of the people are indigenous. That doesn’t happen in many areas in the Western Hemisphere. Pestilence and disease that came post Columbus greatly decrease the percentage of countries of the Americas that are still indigenous, but Guatemala is mostly indigenous. So, it has very special needs, but I thoroughly enjoyed the work. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_8

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Chapter 9

Guatemala

Global health and its relationship to Indigenous Culture and Global Peace.

It was during the time in Kentucky that I grew restless, as it seems I always am, and when asked if I was willing to extend my experience beyond my safety zone and consider international global health, I agreed. I started with a church-related team, working with habitat for humanity in Guatemala during their civil war. The experience was literally life-changing. As I think back, my initial experience in Appalachia came from a time as a student when I was building houses in west Virginia and noticed the medical needs, which would later translate into my dedicated Appalachian service. This was no different. In my journey to Guatemala, I felt as if my eyes had been opened. Growing up in Chicago, I had been exposed to a wide variety of people and experiences, but these were surprisingly parochial times where one might find your experience culturally segregated by religion or ethnic background. The exposure to the Mayan culture of the highlands of Guatemala took me so far out of my comfort zone and challenged every fiber of my belief and experience. We worked in small mountain villages. Although we experienced the teaming mass of Guatemala City—a metropolis so large no one could count the millions of people who lived there—the remainder of the country was mostly spread out in tiny villages with immense needs. I first worked in the mountains of the Jaceltchal area, learning that my rudimentary Spanish was worthless in a land of ethnic languages, a jumble of tiny homes and very green mountainsides. I did basic medical clinics and saw hundreds upon hundreds of patients, providing what care and medicines I could and falling far short of addressing the real needs. This is the first time I considered that service alone was inadequate and that service through education would be needed. But even that belief was challenged. It became clearer that during the conditions of civil war, with both guerilla and military forces patrolling the hills, that education would bring danger to people who could be singled out by either side as an educated threat. It was a sobering © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_9

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realization that no person or group works in a vacuum. Without the cooperation of a growing middle class or government providing safety and order, we could not succeed. Health education is so integral to social justice and would not be possible without partnering and learning from the people you serve. My journal entry from that time reads: Dark Sweaty Valley Of massacre and children, I found a dying child and knew what to do. What if I had not come that day? What of the children of yesterday? I vividly recall learning from the Guatemalan nurses how they cared for wounds with minimal equipment. They showed me how they injected tissue to stop bleeding prior to suturing a wound—a technique I adopted. Many things learned in the developing world changed my practice in the developed one. I learned the immense kindness of strangers, hungry people offering to share their food and village people providing safety. At the end of every long day, the children would want to play soccer with us. No matter how much I was taller or faster, I could not possibly keep up with their dribbling, as they played as if born to it, and only when we would switch to basketball would I have a chance. I was truly a guest in their world, but they had invited me in and I must learn and grow even as I worked. One day working in a small mountain village, I saw a beautiful child selling fruit in the square. I asked for and received permission to photograph her and I stare at that picture daily, for she was healthy. I had cared for numerous sick people that day, but I would not be there the next—I would move onto another village. I thought, who would care for her when she becomes ill? And I truly believe that is the day I became a teacher of doctors. Over the years what I taught and who I taught changed to the rarified world of neurosurgery that I inhabit. I truly believe that medical care must be taught creatively, developed, and become self-sustaining worldwide. I thank that nameless child with the sad almond eyes, whose picture of her and her fruit sit in my office to this day because she taught me to serve through medical education. I recall exhausted mountain trips, riding in the back of a pickup truck in the hills of Guatemala and watching the sun play on the hills and the volcanic mountains. Colors of greens and gold would appear and twinkle in the evening. One evening, traveling the many miles back to our village in the sunset, we were stopped at the roadside by a man whose daughter was in labor. The scene from the golden light to the darkened hut was biblical. Fortunately, in our team was a great pediatrician. A legendary lady who taught generations of doctors worldwide. As our eyes adjusted to the darkness of their hut and she brought comfort and safety to two lives, I began to finally understand the impact a doctor can have. I really felt as if I had wandered up to a stable scene in Bethlehem and a birth 2000 years ago. Still, it was abundantly clear that all this learning was bidirectional. We were learning far more than we were teaching. That principle would forever guide my approach to both global neurosurgery and addressing the social justice needs of health disparities.

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The next day we journeyed far into the mountains to San Antonio, high in the hills of northwestern Guatemala. It overlooked the Chiapas region of Mexico, home to its own struggles. The experience here was unsettling. When we drove our little pickup truck laden with medical supplies into the village in which we were told we were expected, we found no one, no children playing, no farmers in the field, and no craftsman making their repairs. But I immediately picked up on two things: (1) an armed group without identifying insignias carrying rifles which appeared similar to the old US military M1 and (2) little tiny eyes in every window of the adobe walls surrounding the courtyard we had driven into. Equally unfortunately, no one responded to Spanish. Our local translator who guided our clinics from Jaceltchal to Spanish then to English jumped out to approach them. All I could interpret was a rising volume, an unhappy rhythm of speech, and increasing arm waving. The situation was unsettling, but there was no time to show panic. I have no idea why I did what I did, but I looked at the eyes in the windows and I very slowly stepped out of the truck, went to the equipment, opened a bag, took out three rolls of adhesive tape, and in full view of everyone in the courtyard, including the guerillas, I started to juggle. Within seconds, 40 children had surrounded me as they burst out of their homes to watch. At this point, all of the tension went out of the air, and the bemused guerrillas calculating we were either harmless or crazy left us alone. We started our clinic. Later that day as I worked, one of them stuck their rifle through the clinic window as I examined a patient. I often tell my US students how to do a focused medical exam. I can assure you that nothing focuses your neuro exam more than having a rifle aimed at you. It was not an experience I was used to at a US university hospital, but immediately the locals that had embraced us literally shooed him away, as if he was a stray to be returned to his herd. It became clear to me that a people united for a noble cause would always be the strongest of all and that I was, and always am, dependent on the kindness and protection of so many. I remember the night sky of Guatemala, exquisite stars, the kindness of the people, riding on the chicken buses. One day I needed to return to Guatemala City. The local entrepreneur, a man who owned a tiny van, into which he gathered eggs from the chickens on the hillside and drove them into Guatemala City to sell, offered to include me on his ride through the many roadblocks. That day I was the quiet new helper on the egg truck. We were waved through the soldiers who had stopped and searched our bus on the way up the mountains. That had been the first time I had seen an AK47 Russian military weapon, but now it was not pointing at me. It was a lesson of the kindness of strangers and the strength of the basic goodness of mankind, even in the face of war, terror, and cruelty. I still hoped better for people like these and, after that trip, turned my goals to a life attempting to promote those “better angels” of ourselves. Guatemala taught me several things. The first was that I was very, very, ineffective. The needs were more than I could meet. This was more about me; I was becoming fulfilled by doing medical care. I was learning much. I learned that people were crowding into the capitals, to the cities, which meant that the countryside was completely devoid of care. I learned that meant there were unique transportation

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problems. How do people get to a doctor? How does medical care get distributed? How does a healthcare system get distributed? The second thing I learned is that I couldn’t do much medically effective work in a war zone. When the clinic was disrupted by a rifle pointed through a window to intimidate me, the rifleman was literally shooed away by the nurses, because he stuck a rifle through the window of a clinic exam room and they would have none of it, civil war or no civil war. This was the middle of a civil war and I learned that the people I trained were being singled out for harm because as educated people, they were a threat to one side or the other. So that if I was going to achieve anything, I couldn’t do it alone. I had to have a stable country and had to have a stable government to avoid war. I failed to change much for these people, but I learned that there was a tremendous need that transcends medicine. I would never forget this area or these people. The next thing I learned was “service through education.” I marvel that I was taught that lesson by a child in a mountain village. Actually, I have the picture in my office, and I look at it every day. I had seen perhaps a hundred people that day in my clinic, but she was healthy, and I wasn’t coming back to that town. Who’s going to take care of her then? I realized that I had to train somebody to be there. So, that day I really began to train doctors. I began to think that “service through education” makes more sense than just service because when I’m not there nothing gets done. So, my work alone is insufficient, not sustainable. I began to relearn and think from my mistakes. I couldn’t maintain any educational system if I didn’t have peace, social stability, enough food, and basic medical care, so people I trained could stay and provide services. I couldn’t do it alone and I couldn’t stop wars alone. So, at that time, I stopped thinking of myself alone and started looking for partners and places we could provide medical education.

Chapter 10

Chicken Buses, Dugout Canoes, Pickup Trucks, and Shoe Leather

Global health, rural medicine, and transportation.

Throughout the low- and middle-income countries of the world, global health and healthcare systems are hampered by the dramatic redistribution of populations in these countries. Worldwide, a centralization of population on the capital has taken place. Many formerly rural countries have condensed all services into the capital, growing to as many as 10–20 million people, while the countryside is stripped of support services, transportation, health systems, and manufacturing. The results for the rural population of these countries are devastating. They lack markets for their crops, and they lack support services and certainly healthcare. In response to this, much of my career has been spent trying to decentralize healthcare into systems covering regions or countries which provide equivalent care in the secondary cities and designing programs where graduates can succeed in the secondary cities that serve the rural populations. Without this, the region and nation will suffer a complete collapse of their trauma system, their cancer care, and many of the other services. Those which depend on having a basic surgical program are lost, resulting in huge numbers of unnecessary deaths, disease, and suffering. Integral to this problem is transportation difficulties. Some of these countries in past centuries may have had railroads or roads which were long since abandoned, as services were concentrated at the capitol. The countryside suffers. Therefore, if one wishes to provide these services, physicians must travel these same roads and lobby for their improvement. We first discovered this in Guatemala, during their civil war; our group wished to provide basic healthcare services, including public health, shelter, food, nutrition, sanitation, and medical and surgical needs to the rural population. We targeted a region in the mountains of Huehuetenango, specifically the area of the Jaceltchal people. This is one of the many indigenous tribes, with their own specific language, customs, and traditions dating back to their Mayan roots. They inhabit the mountains in the region of northwestern Guatemala, high above the Mexican border. To © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_10

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get there one must fly into the capitol. I well remember stepping off the plane there onto the tarmac, no real terminal in those days or unloading jet bridges. I looked up and realized I was seeing my first active volcano. As someone who grew up in the Midwest of the United States, to look off from your airport and see smoke rising from a volcano not that far in the distance was stunning. It was the first of many realizations of how very different our world is, no matter how similar our people might be. The trip to the Huehuetenango area would involve, if lucky, a full day, but often multiple days of public buses. The initial ones leaving the capitol would seem modern enough and you would even be given a ticket with a seat number, although one quickly learned it was nothing more than a recommendation, rather than a reservation for a seat. The countryside was beautiful, the bus crowded, but the feeling was more normal. The difference, of course, were the military roadblocks. Travel would be totally unlike what one saw in the United States, when randomly along the way, AK-47 wielding people—some in uniform and some not—would stop the bus to check passengers. On occasions like that, our group would attract the greatest attention. We had duffel bags of supplies, we were taller, our skin was different, and our clothes were different. We carried passports and our papers were not the smudged, carefully folded Guatemalan labor passes, but American passports. The closer to the city, the more respect the American passport was given, but one of our group members had a Venezuelan passport. He was taken off the bus, and only with great persuasion, were we able to get him to rejoin our group as we argued for his need for the success of the team. As we traveled above Huehuetenango and its semblance of civilization, with its markets, church, and maintained streets, we switched to a much smaller bus. It was the first time I had ever been on the “chicken bus.” Although each country has some semblance of these crowded people carriers, it was really the first time I felt we had entered a different culture. I remember remarking that I had always thought that chickens were on the outside of the bus, but I soon learned that the chickens rode inside and many of the passengers rode on the top. Primarily, I think, they rode outside for the fresh air, although always at risk of life and limb on the perilous mountain roads. Inside the bus was literally wall to wall people. Families, babies, chickens, and children—all but us were indigenous—with their beautifully woven cloaks done on hand looms, bringing the color and spirit of their ancestors. Even in the mountains the heat was evident, and the bus took on its own odor of sweat, diapers, chickens, and home-cooked meals until we all took on the smell that I would always associate with the Guatemalan countryside. It was a remarkably evocative, even spiritual, time, as we rode past electricity above the cities to a land of a time past, when one, of necessity, became one with these people. Not all spoke Spanish so your attempts at communication, including the non-verbal communication of smile, gesture were rewarded in kind. As we ascended the mountains, the language changed to only indigenous dialects. Only by bringing particular translators would we have opportunity to converse or understand medical conditions and terms. We arrived in Jacaltanango in time to

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37

help unload the top of the bus of people, supplies, our duffel bags, and equipment. Although this would be our base, we would need transportation to the villages we hoped to establish health centers further into the mountains. We established ourselves at a small pension or boarding house. It had been recommended for its cleanliness and safety of food. Indeed, the owner’s wife and daughters carefully cared for us, boiling all their water. One of the most beautiful scenes I had ever seen was watching the young daughter prepare tortillas de maiz, patting with her hands, flipping, and cooking in a rhythm reminiscent of a young jazz performer. The family protected us, locked us in at night, and helped with contacts. We resupplied in that village. Here we saw evidence of the civil war. While weapons were evident everywhere, here they often took on an ancient look, from old rifles to farming machetes used as weapons to settle old arguments. What I remember most of the mountains is the night sky of stars, with no modern light to block the view. When you travel beyond civilization’s electricity, the stars are alive in a way the Mayans must have known. Suddenly their calendar observatories came alive with meaning. Here you understand the organic relationships of nature, history, and people. By the next day, we had arranged a small Toyota four-wheel drive pickup truck to take us further to the villages into the mountains, which were connected by rough trails beyond the roads. The pickup had journeyed from New York to Guatemala with its entrepreneur owner. That made it unique in the region. Still, it swallowed our equipment, had room in the cab for the driver and for the fantastic senior member of our group, a pediatric cardiologist renowned in every country she served. She was our medical rock. Wherever she went, she was immediately influential with the locals for her presence. Tremendously caring for their children would mean they would welcome her and all she brought with. Her skills were invaluable in a region of the world where parasites cause pediatric heart disease. The rest of us rode in the bed of the truck with the equipment for one of the great views of the mountain world of Central America. Poor transportation and the difficulties that occur when your town did not have a truck that someone had driven down from New York always beset the developing world. In Fiji I once visited a medical clinic similar to the ones we served in Guatemala. It was immaculate and well cared for but placed far beyond electricity in the central mountains of the largest island. The nurses that staffed it had a propane refrigerator to store their vaccines. They told me that the average patient would have crossed 21 streams as they hiked to them for medical care. They served an enormous region of the rural part of their country and shoe leather or sandals made of old automobile tires became the invaluable form of transportation in the developing world to achieve medical care. I learned this lesson linking transportation and healthcare acutely in the Amazon when, again, visiting a rural health provider. I arrived at the county health commissioner’s office and, fortunately, was lucky enough not to assume I knew their needs. By this time, I was beginning to understand the importance of listening first, and I asked simply what was his number one need. I thought he would talk about incubators, refrigeration, or medical equipment. His answer was immediate; he needed

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more dugout canoes to bring patients into his clinics. I had never thought of that. It was a stunning example of why my first lesson in global health is “Be quiet and listen.” These people are brilliant in working with their needs, knowledge, equipment, and education. They will teach you, if you are smart enough to listen to them. Indeed, I twice rode canoes to clinics, once in Fiji and once in the Amazon basin. As we went down river, we would see villages by the shore, families doing laundry in the headwaters of the Amazon. Then we arrived at an elevated peninsula where we could tie up and splash ashore. One of our doctors had served his internship here as part of his post graduate requirement to achieve licensure. He knew the community well and explained their needs and services. Suddenly, in a world completely foreign, the dugout canoe had brought me to something I understood about medicine and about people—that we are all the same. The needs are the same. It is the access that is different. I mentioned shoe leather. It may well be the most important part of decentralizing the healthcare system. My friend in Uganda developed a hospital in Mbale for specialized hydrocephalus care. It is a facility unique in the world. Their care is so good that the basic and clinical research done there attracted the major universities of the world. His research on types of hydrocephalus treatment and their efficacy changed the way we do hydrocephalus care in the developed world. He did it by charting the clinical course of his patients and he did that with shoe leather. He employed a series of healthcare workers to follow the patients and to encourage them to come into the clinics. Previously a family would bring their child to medical care only in dire straits, feeling they could not afford either the cost of the care or the time away from their struggle for survival. They would not return after the first treatment was done, and without follow-up care, the risks of surgery increase geometrically. The hospital employed many techniques to ensure follow-up. One was the healthcare workers who would walk up into the hills and find these people, check on them, provide that care, or bring them back to the hospital in Mbale. Another strategy was absolute brilliance. My friend developed a compound around the hospital where the mother would stay while the child had their surgery and recovery. Within that compound, his team would teach the mother skills, especially skills that may be transferable to generating income or independence when she returned to her region. One of these was a flock of chickens that the hospital kept, supplying fresh eggs for staff and patients. The team would teach the mother how to care for those chickens and how to understand that an egg business in her home village would make her independent. For that, she would need the starter chickens, which the hospital would provide if she brought the child back for follow-up care. In doing so, the hospital would change entire families and villages, along with their nutrition. Throughout history people have walked, and throughout the developing world, they continue to walk to receive their medical care, just as they continue to in rural Fiji. Solving transportation is integral to any trauma system, but also to all global medicine and surgery.

Chapter 11

Applying Lessons Learned to a New Area of Neurosurgical Need

The effort needs to start anew if you wish to effect lasting change.

The next place I went to was Ecuador. Although as a country it’s very diverse and has an indigenous population, it had oil, it had strong possibility for economic growth, and it had a middle class interested in bettering their country. Although it really turned over governments rapidly and often by coups, they were relatively nonviolent. Most importantly, people welcomed you to come. This was the first time I realized how important it is to “be invited” when doing global health. So, I went to work. We started working with their doctors and teaching one on one and we listened. Rather than assume we knew what they needed, we listened and learned they wanted education. Next, we had nurses teaching nurses and anesthesiologists teaching anesthesiologists, and I had to quickly understand the teaching of neurosurgery alone was insufficient. Education had to be horizontally spread across the health system so that it could grow and continue when you’re not there until it is self-sufficient. I learned that I could incorporate my family. At this time, my wife and children started to accompany me. It was very important. I believe that you teach by what you do; lectures don’t really suffice. People, including your children, watch what you do far more than what you say and so that’s what our family grew up doing. At a very young age, my daughter said she was really tired of going on a health mission and just lifting boxes around the storeroom. So, she taught herself Spanish and took over the recovery room. She literally would tell the doctors, “this is a sick baby,” “this one’s crying, come here,” “where is this?”, and “Where does this child go now?”. She was 8 years old, but at that size, when there was a crisis, she would run to get me. She would run into the OR, unafraid, and find a sea of tall people in scrubs and masks. She taught me that everyone contributes, everyone matters, and the impact that we all may have is magical and unpredictable. So, what did we learn from entering a new region of need? We learned that you stop, listen, and look about. What are their strengths and what’s achievable? The © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_11

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thing that became clear at that point was the educational goal to try to achieve would be a neurosurgery residency program. Only then, by training the next generation in the region of need, could we hope for a self-sustaining system of care. There were some smart neurosurgeons there, but they were vastly overwhelmed. They needed resources and they needed partners. I could be a partner on my trips, which I was doing on my vacation time when I was at the University of Kentucky. Now universities embrace such teaching as part of their global health program, but then it was done on vacation time. One lesson I remembered from Guatemala was the lack of transportation. We began to look at distribution of care. There’s two ways to solve that. You bring the patients to you or the doctors to the patients. We did both but learned that the key to the whole thing was to get the Ecuadorian doctors to take ownership of the program. That is be invited, partner to build a program, and encourage leadership in those you teach. Mostly I learned that when I partnered, I could bring to the program the invaluable addition of the following: • • • • •

Our sustained presence. Listening. Our educational efforts. Equipment and infrastructure. Family.

If you drop in, do a million shunts or cleft lips and fly out, the local doctors will hate you because they do the post-op care. You’ve depleted their resources. If you partner to help them build their program, they take it over. They will love you to come as their teacher or mentor. And that’s really what you have to do if you want the program to be self-sustaining. That’s the lesson I learned; you teach your peers at every level—the nurses taught, the doctors taught, the residents taught, and the med students taught med students. That really became important because I learned that presence is everything. Most of your communication, most of what you teach people, is nonverbal. Are you present? Do you care? Did you mop the floor? Did you clean your own instruments? And, of course, the person teaching me how to clean the instruments was my wife, Diane. Equipment is essential. Can we get them the basic equipment? Can I learn to operate without all the fancy tools that I have in the United States? Can I teach them how to maintain that equipment? That means we need infrastructure, we need biomed people, and we need more than neurosurgeons. So, we strive for modern techniques with minimal equipment, bring useful equipment, train the people, build the infrastructure, and learn from the people there. My daughter marveled at the fact that they reuse the gloves for tomorrow. COVID-19 had us doing that with our personal protective equipment or PPE. Where did we learn it? We learned it from our global health partners. There are always challenges. You might think life is just an uninterrupted story of progress. It isn’t. The two steps forward, one step back, happen all the time. The power goes out every

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day. You have to learn to be calm when the lights go off, what do you do? What’s plan A, what’s plan B? I once dropped a wall into a courtyard just to get light into the room when the backup generators failed. Lost equipment means it was stolen. What do you do? Well, I would carry it on my back and then I begin to get the local volunteers to be involved with keeping it safe. Volunteer illness, which can be fatal, civil unrest, transportation, government overthrown, and—my favorite—volcanic eruption are all the challenges you face, accept, and work through in global health. I can assure you that a volcanic eruption will slow down your operating room. It is simply not something you learn in medical school and like all challenges, you survive only because of the people you trust and partnered with and they, in turn, trust and protect you. Another time, the lights go out, you finish a case, and you find you have two body guards. You say, “Well, did the government fall today?”. They say, “No, the volcano and literally, only because the winds were blowing the other way we were able to keep working. The lava flow, fortunately, was stopped by the river.” The need is enormous. One day I finished late and looked into the corridor to find another 100 patients waiting. So, I just had to say, well, I’m going to keep going another day, next day, next day, and next day. As long as I’m here. Needs are always there in low-income countries. I can’t solve it alone if I haven’t trained people. So, we succeed when we think about care, equipment, and ownership by the people we are there to mentor. In the end, we are teachers. That is really important. The very meaning of “doctor” in Latin is “teacher.” Neurosurgery becomes teaching by what you do, not so much by what you lecture. What you do—do you come to the region of need? Are you present? Medical students would flock to the hospital because I would teach in between cases. They would bus from throughout the whole country. That became pretty special. I began to understand the need for teaching medical students to have a lasting benefit in global health. Just as I began to think teaching BioMed people was equally important.

Chapter 12

Why Work So Hard?

Finding purpose and joy in the profession you choose.

Why work so hard? Why try to wear so many hats? Why does someone try to change the world before the world changes you? My work, though very hard, is all I wish to do. It allows me challenge, fulfillment, and hope for a better future for those who lack access to healthcare. I find I can make a change worldwide in ways I never would have dreamed were possible. We all are born into a complex, unpredictable and dangerous world. It is a strange world, full of sadness and joy. Choose joy. It will help lessen someone’s sadness. I hope that can be true for so many. I have said that I think that if all of humanity shares the same basic desires for family, faith, peace, and health, then these four aspects are related. If one fails, all may. Without peace, it is very hard to maintain a system of health. Without health, family is disrupted. At the same time, building one of these pillars strengthens all the other three. We all strive to find purpose and nobility in this important work. I believe that finding that purpose, joy, and passion in life comes from doing something very well in the service of others. My sphere of influence is in healthcare. Neurosurgery is truly a profession, a self-regulating field of expertise dedicated to serving others. As a profession it is not work in the way so many define work. For that reason, I tell my students I have not worked a day in my life since I left the loading docks in Chicago so many decades ago. Others may find their efforts fit best in law, finance, teaching, theology, or carpentry. There are endless ways to make a difference. The ones that succeed do it with an infectious joy and a passion to leave their world a little better than they found it. In doing so, they are changed forever and the best of them realize with gratitude that the effort was as much of benefit to themselves as it was to those they thought they were serving. We all have so much to learn.

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Chapter 13

Hold Hope

Possible solutions to health disparity: the reasons some fail and others are sustained.

When one sees disparities in healthcare, especially specialized healthcare such as neurosurgery, I believe there are really four approaches one could take to address that disparity. I strongly believe the correct approach is to partner to provide the education in the area of need. This action empowers the people of that region to embrace and eventually take over the needed health program. I arrived at this understanding only after considering all the other time honored, but unsuccessful solutions. It is instructive to consider the history of these unsuccessful efforts to correct health disparity. The traditional first approach always was one looks at the area of need and decides to do the work for those people. This is done either by descending on that area periodically or even in some cases moving to that area for extended periods of time and setting up hospitals. These are usually called “missions.” They are usually funded by a military, religious, or political group that brings with them a desire to transform an area of need into the religious, economic, or political vision that they think the region of need should emulate. There are many dramatic examples, which are the history of colonialism. They have been transformative, but rarely lasting. The world is full of crumbled clinics and hospitals built by well-intentioned and not well-informed outsiders. These facilities and their intentions crumble or the interlopers leave and fade out or are assimilated into the local culture. That is not to say that their work was not of any value. Indeed, in many ways, improvements in nutrition, farming techniques, and medical techniques have resulted from this approach, but inherent in their structure is a tone deafness or an inability to listen to what the indigenous culture may have to offer to the problem. Or more substantly, the one that descends on the area fails to listen to what the real needs and desires are expressed by the people in the area. The results are then tragic. Understanding such a problem means that the person who wishes to assist has to learn to listen. It is the

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first principle of communication: listening. It is remarkably rewarding and enlightening. Without it, the program may quickly become resented. This is often the attitude of the local doctors. When asked about the large mission trips that descended in their region the month before, they report that such missions may consume resources, not remain to do post-opt care and, most tragically, embarrass or show up the local doctors. Such an act is implying that the local doctors’ day to day work isn’t adequate. Yet, it is easy for those that wish to help in global health to fall prey to this colonial attitude. Doctors and surgeons want to do something, they wish to do something with their own hands. However, our individual ability to care for the billions of people in need is limited, unless we in turn train the people of the region and teach them how to care for their own problems; the ones they identify as important, then allow them to take ownership of the program. The next common and unsuccessful approach is to take the brightest people from the region of need, bring them to the major educational centers of the world, and train them there. In some fields this seems to be quite successful, but in specialized surgeries, like neurosurgery, it has been remarkably unsuccessful. The simple reason is that the equipment and infrastructure necessary for that successful neurosurgical career is not present in their home country. Once trained in the techniques and reliant on the equipment of the specialized centers of New  York, London, or Madison, Wisconsin, they find it really difficult to return home. Having spent 5 to 7 years in a major center, training and getting their families to assimilate to the new culture, these trainees wish to become part of their new home country. The result is a medical diaspora with little impact on their own original area of need. A next unsuccessful approach might be to actually bring the people with the surgical problems to the major centers of the developed world and do the surgery there. We all are tempted by this, and I myself have been as well. Perhaps the lessons learned from such experiences were helpful in that they highlighted for me that I needed to find a better way. In my own life, I have learned the shortcomings of bringing people from another country to your own center for care. I’ve assisted in such programs and the lessons are many. How does one choose which child among millions of children with need should be flown to the United States for specialized surgery? These triage questions, which are always agonizing, are daily worldwide. Until we address these problems worldwide, they will continue. If one child wins the lottery of medical care, millions of others do not. Once the agency or group is able to identify such a child, the logistics and emotional toll of this approach become painfully obvious. Transporting an ill child invariably means transporting at least one family member, usually the mother, with them. When they arrive in the United States, where will they stay? My wife and I determined we would help solve that by giving part of our home. That meant our home became a pre-op and post-op care area. The effect on our children was transformative. They understood the importance, and they understood the need to help others. They responded brilliantly to the challenge of this interruption in their lives and routine. The impact on the child who is receiving the care seems quite positive. They receive healthcare, parasites are treated, clothes are purchased, nutrition is revitalized, and their eyes are open to a new culture, but

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the impacts can be jarring. My wife who would shepherd both our children and those needing care back and forth to clinics and hospital visits with benevolent friends in the medical field discovered this one day while driving our ancient Jeep Waggoneer to a clinic in Lexington. Our youngest child suddenly screamed and lunged across the back seat. Our guest, Otto, a young child from Guatemala who was being driven to the clinic appointment, unbeknownst to us, had never ridden in a car, certainly not on a paved US street. He had no concept that the world flashing by him was dangerous and that one could not simply step out of a car as it was going down the street. He had opened the door and was stepping out to explore something colorful or exciting when my youngest son grabbed him and was trying to hold him and the door shut till my wife could bring the car to a stop and explain that this was a very different world than Guatemala. The next step, of course, is trying to arrange the care. Physicians are extremely philanthropic and, especially in isolated or exceptional incidents, are more than happy to provide special care. We fail to understand the need for such care is in the billions of patients. No practice can care for billions, nor can one neglect their own patients, so care is provided during extra hours, extra time. Administrators need to feel that this is a positive thing for their program, as they are aware that resources are utilized, rooms are taken, and equipment used. Liability becomes a problem. I have been very fortunate in the outcomes of the people I’ve cared for, primarily because I am very careful about what can be done under what circumstances. Physicians in global health have tried to fly too close to the sun and find their wings melting, just as Icarus did. Historically, they tried to do a brain tumor, aneurysm, or AVM that would be difficult in their home institution and is truly impossible with the limited equipment or post-operative care in the region of need. The results then can be tragic for all, including the future of a program. Programs in developing countries have closed or been redirected after unfortunate outcomes. And what if there is a major complication for the child brought to the United States for care? The administrator may have donated the room, and the team may have donated their time. They are thinking in terms of a weekend. Your family is thinking in terms of post-op care at your house. Are you really able to provide ICU care if there is a complication? These are chilling thoughts. Usually, however, these difficult cases come up well planned, well supported, and go well. But then what? The saddest moment for our family was the realization that the mother and now healthy child may not wish to return to their home country or to the rest of their family. One thinks they are helping a child, as if a wounded bird falling from the sky and you are able to aid and release back to their element. But you discover that the world/home that they came from is not friendly and that they do not wish to go back to malnutrition, diseases, war, or societies without futures. Experiences like this taught me that we must address the entire problem. As healthcare professionals, we are not only very good at healthcare, but we are integral to a healthy society. We can encourage each and every other element of society, including politics, and are very influential in our efforts. That’s what Otto taught me on his trip to America and maybe that benefited both of us in the end. It is many a day I wonder how he is, how he is doing, because he seemed to disappear when he

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went back. To disappear into a society can be embracing or frightening for the child but it is always mysterious and unknown for those who haven’t lived it. The result of all these unsuccessful strategies to address global health disparity is my root conviction that the solution must be “service through education,” where people indigenous to the region of need are educated in their home region and take control of the program and ownership, responsibility, and pride in the program. The people of the high-income countries may, in turn, support, encourage, instruct, and re-supply the program but not direct it.

Chapter 14

Picking a Site for Neurosurgical Service: Ecuador

Finding a site of service and partnering with local doctors.

Our work went well in South America. The major difference now was (1) we were invited doctors and an active middle class wanted help for their neurosurgical patients and (2) we stopped to listen to their needs and then partnered to find solutions. When I first started working in South America, it was in the cities of Quito and Ambato, Ecuador. While Quito provided the urban care, Ambato was capable of addressing the crushing disparity in healthcare seen so often in the rural regions of low- and middle-income countries. Ambato was, in those years, a pleasant refuge in the high Andean mountains. It is a small-sized city, which provided the medical care from the Altiplano down to the Amazon basin to the east across impassable roads and waterfalls and to the west down to the coast of the Pacific. A large percentage of patients from various indigenous regions, dialects, dress, and backgrounds were represented. Some had been distinct since being placed there, like the Salasacans were by the Inca prior to the coming of Europeans. The Salasacans has originated in the region of present-day Peru but were placed in what is present day Ecuador in an attempt to unify the Inca’s holdings. Their village, Salasaca, is famous for its fantastic weavings, even to the extent of completely lining their church with their beautiful work. To this day, that tribe wears a black mourning cloak to remember the death of Atahualpa in 1534 at the hands of the Spanish. We chose Ambato to work in the public hospital. The healthcare system in Latin America is often tiered. There may be private clinics for people that can pay cash or have some rudimentary type of insurance. Next may be government sponsored hospitals or “social security” hospitals, primarily for people in particular occupations, often working for the government. Finally, would be purely public hospitals. Their hierarchy systems are unique to the country of origin. Physicians often after completing their training would be obliged to do a period of public service, which may be measured in years or parts of their work week. Often one would see surgeons and © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_14

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anesthesiologists that worked the morning in the public hospital for a small stipend and then late in the afternoon or evening at the private clinic to try to earn enough to live on. This was particularly true of specialty surgeons who after a morning of work at the public hospital would in the evening attend a private clinic which might be quite small, consisting of an OR and a recovery area in an otherwise retail part of the city. Some even set up such clinics in homes in residential areas. The public hospitals were large, primarily built in another era. In Africa, they would date back to colonial times. Sometimes the decay would be obvious to the point of walls crumbling. There would generally be no air conditioning, but in Ecuador at that altitude, even on the equator, temperatures could vary broadly from stifling hot to freezing cold in the course of hours. Altitude was, indeed, an issue, ranging between 8,000 and 11,000 ft., and the unaccustomed would become quickly hypoxic, especially if they tried to work too hard or run. I found that running was a very good way to measure my age. When I first came to Ecuador, after I finished a day in the OR, I would literally run the mountain valleys from mountain range to mountain range. Over the years, I found it hard to carry things up steps on the first days in the mountains at the high altitudes. Age will do that. The public hospitals are usually large open wards, with various types of disorders being treated. Male and female may be separated, as were medical versus surgical, adult versus children wards. ICUs may be extremely rudimentary. The hospital may have one or no ventilators. Indeed, if a surgeon could not complete an operation with an anesthesiologist bagging the patient and then have that patient extubated and be able to be cared for in a general bed, that patient would not survive. While this degree of anesthesia may be okay for a hernia repair, it was a major issue for neurosurgery. Examples of families trying to bag patients were common, in the hope that they would recover after surgery and begin to breathe on their own adequately. Much of the care was given by outstanding nurses, but in no way could they cover all the patients. Families would help in care. They would bring in meals, change linens, bathe the family member, and try to feed them in the hospital. The family unit and their care were obvious and fulfilling. I always felt most at home at the public hospital. It seemed the place and the type of work that we all went into the field of medicine for in the first place. Needless to say, the surgical conditions were as varied and as complex as mankind itself. Our travel in those times was with a complement of other physicians, anesthesiologists, general surgeons, plastic surgeons, ophthalmologists, myself as a neurosurgeon, general medicine, and pediatric care. We would each attempt to provide service, and I would gradually expand that to impress upon the group that we would not have a lasting impact, as I had learned in Guatemala, without teaching, without leaving the physicians and health system better than we had found them. The local physicians were excellent and, in many ways, far smarter than the American physicians in understanding the culture, the society and working within its limitations. They would, in turn, be able to teach us how they adapted to those limitations of material, medications, equipment, and workspace. Patients would often be cared for in the hallways and beds would be moved there. Operations though could be daunting in their complexity. Many involved trauma, but also birth

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and death, life, new babies, and obstetric complications. Many that I saw were congenital anomalies of children. Hydrocephalus and spinal dysmorphism, defects of the spine, secondary to vitamin and nutritional deficits during prenatal periods, and infection at that time were the dominant, treatable diseases. Over time, the needs would gradually change as society modernized and the risk factors of stroke, nutrition deficiency, diabetes, hypertension, and obesity became rampant. In the early period, however, our work was a battle with infection and disease. Surgical instruments were few and I would often bring them on my back in a backpack. In the days before 9/11, I would carry an entire OR set in my backpack on the plane, because I would not trust the checked luggage. On average, about half of the checked baggage would be delayed, lost, or disappear. I got used to splitting my larger equipment and disposable OR equipment into separate bags, hoping half would arrive. I would carry the precious things, shunting devices for babies, my own personal OR equipment that I had purchased and accumulated over the years, my magnifying loops, and my OR micro instruments into my backpack and carry it through the airport as if I was a tourist arriving to climb South American mountains. The airports were always difficult, an opportunity for pickpockets and customs officials looking for an opportunity to make money. I developed an almost unreasonable fear of international customs after being stopped many times. After these events, I was genuinely relived when our hosts would begin to meet us at the airport, intervene with the customs officials on our behalf, and shepherd us through. These were the middle-class people of Ambato that invited us to come. They wanted us to provide this service, and improve their charity hospital. On one occasion when I was not so escorted, I was stopped, pulled out of line, brought down to the basement of the airport with the dark corridors, barking German Shepherds and the AK-47 assault rifles, and placed in a very small cubicle. I could see in the next vestibule a very frightened man having his bags searched as they found multiple small packages wrapped in tin foil. A lot of shouting and angry language came from that area, above the barking dogs. It was meant to frighten people and it should have been effective, but by this time I was a veteran. As the soldier unpacked my duffle bag, the first thing he saw was a folded doctor’s white coat, labeled in Spanish, facing him. Next layer he found my stethoscope and next, books and medical supplies. Before he even got down to the OR instruments, he turned to me and asked in Spanish, “Who are you and what do you do?”. My simple answer in Spanish was “I operate on children’s brains for free.” A huge smile broke on his face. He understood, repacked my bag, wished me well, and rushed me back to the regular airport, apologizing for the shouts coming from the other vestibules. It became important that for us to succeed we would need that middle class to intervene. I then realized that it was most important because this needed to be their effort, not ours. We needed to be invited by a people who would take the program on as their own. They had to want to reform their health system and to improve care for the children of their community, and they had to intervene. This became the lesson learned time and time again. When instruments were lost, one of the volunteers would say “well my brother is a general, I’ll call him,” and the bags would mysteriously appear. I began to understand that the government was made of people and

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people have the same motivations that we all do. They want the best for themselves and the people they care about. It was my job to make sure they understand that these sorts of projects were something they should care about. That relationship with government, society, and donors would sustain us throughout all our efforts. The operations of those years were most difficult. With the simplest equipment I could carry, I was beginning to understand that as a fully trained US neurosurgeon, I had to relearn how to do surgery as if with a knife, fork, and spoon. I began to understand that I was learning ancient principles of hemostasis, of wound care, and of decreasing wound infections by understanding the blood supply to the region of the surgery. This was opposed to thinking an infected wound would be avoided by antibiotics, which is far from true. I became more and more meticulous in avoiding blood loss, because I had none to give if a child were to start bleeding while I was operating on their brain. I was trying to teach the local doctor my techniques while they would teach me theirs. I discovered the absolute importance of returning that patient post-op extubated, breathing freely to their family. In the United States, we have the luxury of having people ventilated in the ICU, even for days afterwards while swelling decreases. Such an event would be fatal in the developing world and had to be avoided. One had to approach the tumor without disturbing the brain and remove it without the brain swelling. One had to repair the damaged brain of trauma in such a way as to minimize post-op decline, including leaving the bone off to allow the injured brain to swell without viable brain being compressed. Working with the local doctors, like an Ambato local neurosurgeon, taught me so much. I began to understand that the first principle was to ask him what his needs were and that I needed to listen. He felt that need was to elevate the surgeries to higher levels and to do more for more people, with only slight increases in equipment. It became clear that not only would our mission be to supply that equipment but to teach how to maintain it. The modern electric tools of cautery, suction, and lights—all had to be married to an ancient electrical system in the hospital. Indeed, some days, these hospitals might not be able to have oxygen for the patient. It became clear that doctors might not be the most important in a hospital. We needed to address infrastructure. We brought a biomedical genius from southern Alabama, 6 ft. 5 in. tall, probably 135 pounds soaking wet. His accent was so thick that the locals could not understand him. He said that’s okay, as he didn’t understand Spanish either, but he knew how to show people how to repair instruments. He became the most popular person on the team. Year after year when we got off the plane and the locals met us at the airport, they’d run by the chairman of neurosurgery so that they could help the biomedical person with his bags. They understood that he could teach them to maintain the donated equipment so they could continue to use it. This allowed them to elevate their care. These are important lessons in humility taught time and time again; that the care my daughter provided, my wife provided, and the biomedical people provided were integral to the medical system and, indeed, far more lasting than the results of any one surgery. I knew that I must become interested in infrastructure if I wished any success to be lasting. In later years, one of my friends would really make a consorted effort to help a group in central Africa. This began what we call dyads, matching groups in

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the developed world with those in the developing world, returning time and time again, as we were to Ecuador, to provide that care. He showed that if he was resourceful he could, with probably approximately $20,000, convert an OR shell of a room to a neurosurgically capable OR for the developing world. With donated equipment maintained by the new biomedical people, we begin to raise that bar that had limited surgical care. We have repeated that often and need to continue long into the future. The rewards were integrative, progressive, and so reassuring. Areas that prior had no neurosurgical care began to develop broad medical care. Areas that took care of only trauma and abscesses began to take care of survivable, benign neurosurgical conditions that returned people to normal, productive life as family members, as children, and as workers. Previously they would have been dead or dependent on a society that could not support them. Reversing that was always the goal. The local medical students began to see a possibility for a future in their medical training and caught fire. The more I taught and the more I arrived not only to operate but to teach, to lecture, and to informally and formally teach them, the more the students and residents would arrive—literally traveling across the country to be there to help. That was inspiring. I gradually realized it was the people you serve who inspire you. That is probably the secret to a lifetime in medicine. I worked also in Quito in their large charity hospital, Hospital de Sul. Here I learned there are challenges one person could not overcome. I would arrive and find a ward full of young people with benign brain tumors about to die. Often these tumors were massive compared to what would be seen in the United States, 15-cm diameter tumors in young people whose heads were not much bigger than the tumor. One young lady with a massive tumor pushed us all to our limits. We started in the afternoon and soon found equipment and supplies depleted. Anesthesia became difficult and the patient was unstable with brain stem compression. The available tools just could not get that much tumor out in time. I had the nurse get me a sterile wire and created an electric cautery loop, recreating a 90-year-old design that worked. We got the young lady through and back to her family. Devising techniques for these surgeries and teaching them were immensely challenging, especially when the tools of North America were not present in these charity hospitals. Much could be done, but only by transforming the entire health system, the infrastructure, and training of the doctors that would deliver care. This first inspired us to consider an achievable goal for our work to focus on training neurosurgical residents, the doctors in training that become neurosurgical attendings. We aimed to repeatedly develop under a local champion a local neurosurgical training program. We would then credential and certify the program so that it would be a lasting contribution to a charity hospital. The educational dyad would donate and help maintain the needed equipment, raising their treatment bar, which would necessitate improving their infrastructure, anesthesia, critical care, radiology, and pathology. It worked, time and again. Neurosurgical residency programs would raise the bar for all medical treatment around an educational theme. The program would even highlight the importance of that charity hospital in its smaller city for the region, effectively decentralizing their healthcare from being present only in the capital.

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An argument I would make time and time again to minsters of health around the world was that a small investment in neurosurgical training gave lasting benefit by decentralizing their trauma system and healthcare, serving not just the capitol, but the smaller cities, like Ambato which in turn served so many people over a huge area. This model became widely successful. Another friend in Nairobi, Kenya, utilized it too by traveling to those small cities monthly to run clinics and familiarize the local hospital with neurosurgical care. When the graduates from the capitol city training program returned to these cities, this preparation helped them establish and maintain a practice in those regional cities. With proper preparation, they would be embraced and succeed. It made no sense to train people if they could not have the facilities, equipment, or infrastructure to utilize that training. The only way to do that was to train them and build the infrastructure simultaneously in the area of need. To train them in England and expect them to go back to Cameroon was magical thinking. To train them in Africa and be committed to make sure they were supplied, reinforced, continually educated, and supported by the community could become possible. My friend’s wonderful work in Kenya showed time and time again that by hosting events in the city where the new graduate was to be sited, he would raise their importance to the local officials, the local church, and the middle class that would support with pride that addition to their city. Such regional programs may serve four million people where no service existed before. This was effective, this was the goal, but it took persistence. One would find where before there was nothing, except a small room capable of lancing an abscess, now they had a modern OR, which was supported by a modern ICU. These are now capable of the surgeries of aneurysm, skull base tumor, trauma, and congenital malformation that we do in the United States. They are supplied by rudimentary microscopes, endoscopes, cautery equipment, and the beginning of a blood bank, ICU, radiology, and pathology. At this point, a 30-year journey begins to show the possibility of success.

Chapter 15

Family

Learning humility as a neurosurgeon.

I gave a great deal of thought to what the role of global health would play in my career. I was rapidly advancing as a surgeon, a medical research scientist, and a teacher. I had developed a large practice but felt there were worldwide needs I could address. It became important to me that this not be something separate from my family, but rather something we could all be proud of and embrace. Over the years, the work would bring us to most of the continents of the world, but in those early years Latin American work gave an opportunity of familiarity of customs and language, as well as the degree of safety needed to include one’s family in the work. In various ways my family has participated while working in Ecuador and Africa. While I embraced making my service one of intraoperative surgical education, teaching and trying to form residency programs, other members of my family embraced other missions. At a very young age my daughter learned Spanish so she could participate more than simply carting boxes into the storage rooms of the ORs as she and her brother, Conor, had been doing. She became an integral member of the recovery room, comforting crying babies, translating for frightened mothers, running to find doctors when they were needed. She became much appreciated. When we would land in Quito, a contingent of the citizens of Ambato would be waiting to drive us the 6 hours into the central highlands. I would step off the plane, the big deal neurosurgeon and be widely ignored, while the citizens would push past me asking, “donde esta Kara, donde esta su hija?” “Where is Kara, where is your daughter?” I would simply answer, “she is here,” to their joy. One year my wife was quietly working with the mothers of the community. As she often did, she did a good deed for a pregnant lady. I was aware of it, but only vaguely, as I was busy with my own duties. But the next year when we returned to that city, we spent our first day, as usual, at high altitude, exhausted, seeing over 100 patients, moving supplies and equipment, preparing for surgeries, lecturing, teaching, and preparing clinics. We dragged ourselves back to our $12 a night (dinner included) pension, which was the “clean, well-lighted place” of literary lore. As I opened the lobby door in the evening, I could see an entire family waiting. Multiple © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_15

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generations, including a very small baby. As they recognized my wife, Diane, the grandmama screamed in Spanish, “Diane, Diane, you were kind to our daughter. You cannot stay here.” Before my eyes, the family whisked her out the door to take her to a nicer place down the block. I forever learned my place and my lesson in humility when, at the doorway, the grandmother looked back at me standing befuddled in my scrubs and she simply said, “he can come too.” I think my family taught me humility and to value what was really important. These are difficult lessons for surgeons to learn. A surgeon’s defense mechanisms sometimes leave little place for humility. Those lessons are learned, and they stick. It became clear that this work was not about me. It was never about the members of high-income countries. It was bidirectional. We must all learn. Education is a two-way street. Progress must help all. It is never a one way or a giving. It is a partnership. That is the secret to success in global neurosurgery. From a personal standpoint, including my family, Diane, Kara, and Conor, gave the work value and reality. Ecuador taught me that the involvement of the middle class, not only physicians, but the volunteers of their society really made the efforts of global health the program of the people of that low- or middle-income country. We, from the USA, were simply assisting, perhaps offering curriculum, courses, certification, or equipment. The ownership of the program had to belong to the people there, the physicians of that country. Without that, no program could ever be self-sustaining. In the end, my “service through education” would find the local physicians, taking ownership and start to train their own.

Chapter 16

The Red Scrub Cap

Empathy.

When my children were still quite young, they began to ask hard questions about the things that were going on in the world, including the inequities in global health. As children, they participated when we twice had brought children to our home from my work in countries of need. We would care for them while they had surgeries by myself or my partners at our home hospitals. These were operations we felt we could not safely do in their homeland. I believe the experience had a profound effect on our entire family. When the entire family traveled to Ecuador to work on one such project, they all pitched in as everyone did, carrying boxes, loading equipment, and acting as a runner to bring anything from messages to water and supplies to the team. Even at a young age, my daughter wished to do more. She began to teach herself Spanish so she could communicate and comfort the children. She would gather toys or stuffed animals from her classmates and other sources and bring them and distribute them to children that had surgery. As her skills grew, so did her importance. I well remember being met at the plane in the capitol by the people of the smaller city, Ambato, that our project was sited. The locals would rush past me as I got off the plane saying, “donde esta su hija?” “where is your daughter?” I would point to her beaming to see old friends. At a very young age she began to coordinate the recovery room, calling nurses and doctors if a baby was uncomfortable, running to get supplies for them, and often, if there was trouble, running to get the doctors or nurses. She seemed fearless. She would run through an OR, which is a terrifying place to most people, but would find a sea of adults in scrub clothes. To help her find her father, I would begin to wear my red Wisconsin scrub cap in the OR, and she could find it, pick me out, and run up to get me for whatever crisis had arose. The red hat became part of me, and I wear them to this day in ORs worldwide to honor her (see Fig. 16.1). Sometimes it is difficult to understand how simple experiences can be transformative. It is abundantly clear to me that people are the same worldwide, and, while © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_16

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Fig. 16.1  The author with the red surgical scrub cap

they pay attention to what you say, they are really watching what you do. The non-­ verbal communication of being present, of having empathy, of caring, and serving are what they watch for and what they emulate. After a while, the actions of people, like my young children, teach us just as the actions of the families and patients we serve teach us, change us, and remind us what are the values, hopes, and desires that brought us to the field of medicine in the first place.

Chapter 17

First Surgeries

Taking the many steps by case-based progress to build an OR team in a disparity region.

When I first came to South America with medical groups, it was still quite early on. I worked hard to partner with local physicians and help improve their skills. I called it “teaching people to do modern techniques with limited equipment,” but I did emphasize service as well. I was often willing to do as many operations as I could to serve as many people in an area of immense need. This would become important because sometimes the local team of partners would not be able to come as planned, even on the day of a scheduled surgery. Unpredictable was the nature of their lives. Here, I would learn the value of making the project their own if I wanted it to be self-sustaining. We worked with a team in Ecuador first, both in the capitol, Quito, and in Ambato, the smaller size city that we had targeted. We chose Ambato mainly because of our local connections, its location out of the capital that served a quarter of the country, and the fact that we were invited. One of our traveling physicians had actually been born there. His relatives had developed a network of the middle-class in the city, who were very interested in improving healthcare in their charity hospital. The town was situated on the high mountain Alto Plano, a plain between two volcanic Andes mountain ranges halfway between the capital of Quito and the southern border with Peru. Although the town had private clinics and a government hospital for government employees, our focus was on the large public hospital which served all regardless of ability to pay over a massive area of the country. It was, as many of the hospitals in that region were, a complex behind gates, with small gardens, laundry hanging in the back, and multiple buildings built over the years, an OB-GYN clinic here and ER there, connected by walkways with small culverts to take the rainwater away as you ran from building to building. The main hospital building was three stories, with an elevator that rarely worked. We traveled the stairs regularly. Most things were done on the first floor: it served © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_17

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the ER, the pharmacy, the large open ward separate for male and female, and the ORs where we spent most of our time. All this was supported by clinics where working with the local doctors and volunteers we were triaging literally hundreds upon hundreds of patients, with lines that would stretch throughout the complex. The city had two neurosurgeons trained in Chile, but they could never hope to meet the need. The patient population covered a geographic quarter of the country from the Pacific to the mountain Alto Plano of the city to the Amazon basin. Because we were bringing a new service, patients had been further triaged by the local doctors over the months before. We were careful to work with our local colleagues and see which cases they were comfortable with and which they needed our assistance to learn new techniques. This worked actually quite well but had to take into account that the local doctors had practices and responsibilities of their own as well and everyone would be sacrificing time and effort for the endeavor. We tried to bring as many supplies as possible, cognizant that we did not want to deplete the local supplies, but we always miscalculated the limited supplies of the region. Usually, being Americans, we would bring too much of some supplies, then the question would be how do we dispose of the extra properly, and could we find use for them in the surrounding clinics of the local mountain villages. The patients would come from many indigenous groups, and different languages needed to be translated. Although we were working at between 9000 and 11,000 ft of altitude, depending on the clinic, it would generally become quite hot by the midday, even though we were working only in our scrubs, such is the equatorial sun. But several patients would come in from the very high mountains of the local Andes, covered in layer and layer of llama or alpaca wool. Their woven garments were hand loomed, and babies would be carefully wrapped. My family working clinic triage became used to the concept of an infant swaddled in so many layers upon layers of hand spun wool that it was an unrecognizable bundle until one would find the tiny child beneath to do the exam. Hydrocephalus was a big issue, primarily due to neonatal infections or hemorrhages at birth. We found that we could change care by providing the simple equipment that would allow that lifesaving operation to be done. Teaching doctors a surgery was important; however, these children must have follow-up care, and so training and networking, not only with the physicians but also with the wonderful nurses, families, and healthcare providers, were essential. We, therefore, would run clinics into some of the smaller farming villages, each with their own separate tribe and identity, like the Salasachans, the great weavers of the region. Other high mountain people were living at altitudes above their fertile valleys. The countryside was a patchwork of green fields and perpetual Spring. If one hit the right altitude, there would be three growing seasons in a year. Some days the Alto Plano resembled paradise. Yet, one could see on the same road snow or tropical heat, just depending on the dips and climbs of the road at altitude. If a patient was identified as someone who would benefit from surgery, then a long, well-translated discussion would take place, usually with an extended family. We tried very hard to establish a proper informed consent, which is a problem when one comes with expertise and offers free care to people who day to day lack healthcare. The power differentials are enormous. One must work hard to bring them down to

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allow patient and family to have input and understand. Nevertheless, what we provided was often lifesaving to the children and adults. We were quickly accepted by doctors, families, and patients, especially when we had brought new equipment or surgical materials which were usually inaccessible to the patients. The local health system, in those times, was extremely rudimentary for the rural patients outside of the cities. Medical care consisted of a mixture of Shamans and modern care. In the cities much of the modern healthcare was provided by a pharmacist, and drugs such as antibiotics were dispensed to those who could afford. Without the oversight of an MD, the problem of overuse of antibiotics results in resistant strains of bacteria being developed, when they are given without directions, hoping they would cure whatever it was that troubled someone. Surgical implants were essentially unknown, and if one needed a shunt, or needed an aneurysm clipped, the family would be expected to purchase the surgical equipment and bring it in to ask the physician to implant it. The possibilities that they would have purchased the correct device were miniscule and there would be a sad realization that they had spent far more than they could afford on a device that was not proper for their family member. I began on subsequent trips to anticipate these needs and bring equipment for anything I would think would be needed and to donate it. Nevertheless, for a person to get a brain aneurysm repaired in the United States, you may have literally scores of potential size, shapes, and different types of clips and coils and stents to complete the surgery. In South America or Africa, in a charity hospital, you may have one and you better figure out a way to make that one work. We quickly learned that each layer in an educational system had to work together. Anesthesiologists teach anesthesiologists, head nurses teach head nurses, and residents teach residents how to run a service, how to scrub a complicated case, and how to manage equipment and sterile technique. This education was truly bidirectional. A trainee traveling with us would learn enormous things about efficiency, hemostasis, and medical triage. Our colleagues in the country of need would teach us from the lessons they had learned of necessity over years of practice with limited resources in their country. We became quite free of our previous reliance on US technology and, of necessity, became resourceful and creative. I will well remember a tiny baby brought to me, extremely lethargic, malnourished. In distress, the parents stated it had not been able to feed, which may be all that a child that young can show you. This child was febrile. The top of its skull was bulging, clearly it had intercranial pressure, but the etiology did not seem to be simple. Hydrocephalus or water on the brain was possible. I was very concerned about a brain abscess, but how to find it? At that time, most all medical imaging was in the capitol, 8 hours by bus away, and while patients might come in with some ancient X-rays or scans when they came to our clinic, they were rarely even of the correct body part. This child needed surgery, but where and on what part of the brain, and how? In the United States, an MRI scan would have answered it immediately. That was not available for hundreds of miles. But a new CAT scanner had been brought to a private clinic in Ambato, the first in the town, and I needed that child to be imaged. The family, of course, were indigenous farmers with no income. Such scans in the United States may cost thousands of dollars. How do we provide that in a region of need? The

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physicians as a group hope to do that, but hope alone doesn’t change a society. We hit upon what was really the correct response. We worked with the middle class of the town. The people that need to take ownership for the program providing health to the region were the store owners, the larger farmers, and the volunteers who were members of the town who very much wanted the hospital to succeed. We explained the difficulty and they, in turn, explained the need to the owner of the CAT scanner—that this needed to be a resource available for all, and in turn, their scanner will be a success. The next thing I knew the town’s people had said that the scan could be provided to the baby for 25 dollars, a miraculously low price which we provided. Indeed, it was a brain abscess and, with the help of very good anesthesiologists, we were able to get this child to surgery, safely drain the infection, and provide it the long-term antibiotic care which would ensure recovery. Cases like this teach you that you do not work alone. For a neurosurgeon, a brain abscess surgery is usually not the most challenging, but to get a malnourished, dehydrated infant through a brain operation under these conditions is an anesthetic and critical care tour de force. Without that team, that child would not have made it. Without the local factory owner that knew of the new CAT scan and interceded with its owner so the child can be served, we could not have served more children after that. Nothing would have happened without the people of the city taking ownership for the health of their community. Without them, our work could not have succeeded. One learns it is not about you. It is about partnering with the people being served and finding a way to make sure it happens. I recall another case. As one is going along working, teaching, lecturing, operating, and occasionally even sleeping, a patient is brought to you. They have bled into their brain. Everything about it seems to be that of a brain aneurysm. In the United States, that’s something that I do and I teach, but under these conditions could I do such a case? Could the local doctors assist and learn from that experience? Could the patient be saved? Because of my previous experience of being prepared, I did actually bring some of the needed equipment, the clips, etc. in my supplies bag, but could we make the anesthesia, the surgery, and the post-operative care work? Fortunately, the patient was stable, meaning the damage had not been immediately fatal, and if the aneurysm could be repaired, the young patient could heal. I had a hand drill to open the skull, a local doctor had a primitive surgical microscope, and I had the clips. As a team we elected to try to save this person, and so, we needed the anesthesiologists. They did their part, and I began the much more laborious task of turning the flap, opening the skull, exposing the brain near the aneurysm without the power tools that make it so much easier in the United States. Techniques I used were taught by my teachers years ago. These were techniques from the 1940s, meticulously done with handsaws and drills, using clamps to eliminate bleeding and using anatomy to find the lesion. This was such a case where you may only have three clips; one of them better be the right size and work. But one was and we were able to clip the aneurysm, eliminating the bleeding site and allowing the brain to heal. I worked with the local doctor on this case to teach modern techniques while training with minimal equipment, as if it was a time of the past. Nearly everything

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was different than one would see in the United States. We brought bone together with silk sutures as opposed to the titanium screws we would use in the United States. The scalp was closed with simple silk sutures, which would be removed 2 weeks post-operatively. Fortunately, the patients’ recovery was swift and gratifying, requiring only brief one-to-one nursing. I’ve done many operations in my career but each one is special, just as each patient is special. Each one teaches me something, if not about technique then about what one can learn each day. Most often it is that together we could accomplish much. That may be one of the best lessons of them all. We all learn every day in global health, especially those who think they go to teach but must remain open to learn so much. I became more involved, I came to the attention of an organization, the Foundation for International Education for Neurological Surgery (FIENS). I now Chair it, but I started out like so many who wished to serve. FIENS had started over 50 years ago and they had started by service. They were on hospital ships. I gradually said, that’s great what you’re doing, but you need to think about education if you want a health program to become theirs and to be self-sustaining. The next lesson I learned is, “be careful what you wish for,” because they made me the Secretary and then the Chair of the Foundation. FIENS is an organization of partnerships. I have very little power. That’s like any Chair. They hold very little power. If they can come up with good ideas and get lots of other people to work together, then they will create something. I feel that Global neurosurgery needs education, primarily trying to develop a self-sustaining program in regions of need. My model was to start and maintain residencies, because if you have a residency, you have to have a hospital with equipment. You have to have a government buy in, you have to have the support, you have to have anesthesia. By addressing those needs, you will naturally develop health infrastructure. That may mean that they could then recreate the process in a second city, then another city, until it spread throughout country and addressed distribution of healthcare regionally. And so, we began to develop our own curriculum. We refused to dummy it down. The FIENS curriculum is based on the US curriculum because I was head of the Senior US Neurosurgical Society when we wrote the US curriculum. Equipment and aid is difficult to secure but volunteers and people to build and repair came. We began to look at certifications. If you do a curriculum and you want the people to stay in their own country, you have to get local certification and you have to have post-graduate education. That seemed to be natural and fair as it would hold the new program to worldwide standards. We began to look at this idea of “service through education” where teaching was academic service and the key to a self-sustaining program. That meant that we would get as many partners onboard to develop a training program in multiple countries, not only curriculum, materials, and drills, but we would need local champions. That meant someone in that country that had been trained in neurosurgery. Maybe they trained in England, maybe in Israel, maybe Chile. We could designate them as the program leader. Then we would find a medical school in the United States or

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Canada or in Europe that would adopt that program as a dyad. They would begin to understand what the needs were and carry it out. We went to over 20 countries. Nepal is a mountainous country in Asia. It had great challenges but great possibility for positive change. It is caught between two of the largest countries in the world, India and China. But, like all regions, it had some very bright people. In Kathmandu, a former chair of FIENS set up a dyad with his home program. He developed the first training programs there. This was repeated time and again, often by doctors giving back to their own country who trained elsewhere and went back to develop programs in their home areas of great need. These would be the champions we would build a program around.

Chapter 18

FIENS

Partnering with foundations to expand impact FIENS.org

The Foundation for International Education in Neurological Surgery (FIENS) has grown and evolved just as we hope we all do. It has been present since 1969, made up of volunteer neurosurgeons. It grew from service alone to service with education and then took on a very focused part of the huge area that we call global health by working to establish a self-sustaining neurosurgical systems in regions of need by establishing around a local champion, a series of neurosurgical training programs. The trainees of these programs would continue to train their own until more and more people are provided essential care. Decades of talking to ministers of health have allowed me to express as clearly as possible the benefits of neurosurgical care in a low-income setting health system. Neurosurgery actualizes a trauma system. A substantial component of trauma and especially of fatal and disabling trauma involves the brain, spinal cord, and peripheral nerve. Without neurosurgery, you cannot have a complete trauma system. The presence of neurosurgical care in a health system elevates critical care, anesthesia, radiology, and pathology. It allows literally millions of people to be returned to productive lives when they would otherwise have been disabled or killed by trauma, benign tumors, congenital defects, hydrocephalus, and stroke. Over the years, FIENS has looked at the components necessary to be addressed to achieve such a goal in some 28 countries. The organization has developed a neurosurgical curriculum which can be adapted to local areas. This curriculum embraces online learning and even virtual ORs where interoperative consultations become possible, just as a web-based review of radiographs and pathology slides are now possible. We developed a comprehensive curriculum based on the principles of the Society of Neurological Surgeons (SNS) of the United States. From this, milestones of achievements can allow a consistent quality of care worldwide. I had the honor of leading the SNS during part of its process of organizing this curriculum in the U.S. and those principles were shared with FIENS.  The organization has been © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_18

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helpful with certification of trainees, hospitals, and programs and has embraced continuing post-graduate education. Standards of the developed world need to be maintained in the developing world. The patients deserve no less. FIENS has been particularly helpful in developing the concept of international bootcamps. These are intense periods of study for physicians in practice and surgeons in training so that they may meet together and review the same topics and curriculum to develop a consistent standard throughout the country or region. These have been extremely successful in encouraging the local champions of the region to participate in education and to be instructed by their dyad partners from established universities worldwide. FIENS has also been involved in establishing the graduating trainees in their first position through participation in educational events which would mark the coming of the new physician to a city. The first neurosurgical program in Mombasa or Nyeri or innumerable cities throughout the world that previously had none can be celebrated in this fashion. By establishing the importance of the new program and meeting with the ministers, the press, the church, and the middle class, we are able to establish this new physician as important to their health system and supported by organizations like FIENS with a clear indication that the local society should do so as well. This has been very successful. The modern FIENS has also developed fellowships— scholarships based on philanthropy—which allow the trainees to spend short periods of time finishing techniques or educational principles at major universities of the world. FIENS also established fellowships to help pay for educational years of training, as has the World Federation of Neurosurgical Societies. As an organization, the work goes on and must be continued because healthcare is not episodic. It must grow, evolve, improve, and continue always. The future for FIENS is bright and has played a small role in partnering to improve care in Asia, the Americas, and Africa. These programs will continue and emphasize not just establishing the program but also maintaining the graduates in their post-graduate education and introduction into their first practices. Care is distributed throughout the area of need, not only in the major capital. Important areas still need to be addressed. It is our sincere hope that the future will bring more partnering and care to sub-Saharan West Africa and to the Central Asian regions where so much still needs to be done. The benefits are many, however, and one of the those is that as we train excellent young neurosurgeons, they become our next volunteers. Neurosurgeons are philanthropic all over the world, and those that remember the excitement and passion that brought them into neurosurgery in the first place remember that they succeeded by partnering. They, therefore, make our best volunteers for future programs. This is a generation that grew up with electronic communication and education offerings that are rapidly bringing modern neurosurgical care to areas where it was unimagined even a decade ago. This is the benefit of working very hard at something you do well with and for others and then partnering to make it happen. You first listen to the needs in an area and then educate in a way to elevate those around you.

Chapter 19

Africa

Applying global neurosurgery to a continent.

In the early 2000s, after working mostly in South America and Central America, FIENS was invited to sub-Sahara East Africa. That was a region of enormous need. By this time, our Ecuadorian program really already had a training program. Could we export those lessons elsewhere? We started in sub-Saharan East Africa, a region of four hundred million people, with at that time nobody being trained in neurosurgery. This, of course, meant no effective trauma system and no complete care for cancer, stroke, pain treatments, benign brain tumors, or repair of congenital defects in children. One quickly realizes this list of disorders effects most of us individually. It also effects all families worldwide. To change that, we must be willing to be bold. In this case it meant building a training program of and for Africans in their own land as the key step to a self-sustaining system of care. We started to work to develop a program in Kenya. That meant you had to be present. You had to go, you had to listen, you had to make mistakes, and you had to correct them. We had local support, and we were invited. There were eight neurosurgeons in this country of 37 million. They would be the program director and the major teachers that we would build a program around. We spoke to the Ministry of Health of the need to change the trauma program and to train doctors in Kenya. If the ministry would fund the residents and pay their salary, we could aid in the education and equipment. In 2007, the Kenyan ministry of health said they would allow the residency program. Then it was pretty unique, because the program spanned multiple sites in multiple countries. A trainee could get a good peds surgery experience here, an adult surgery experience there, and trauma experience at another site. Lessons were learned about transportation and disruption of care. The neurosurgical health system, like many services, had collapsed onto the capital in Nairobi, at one hospital, with three thousand beds and five thousand patients. Then neurosurgical care could only be done maybe one day a week. Patients would wait under the © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_19

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Jacaranda trees, hoping they would be seen. If you’re in Mombasa and you have a benign brain tumor causing seizures or hemiparesis, you’re going to close your shop or your farm and travel to Nairobi, and your family loses everything. You may get surgery or die waiting for it. Under such conditions, Mombasa itself never would develop a complete system of care. There would be no complete trauma system anywhere. That was my speech to the minister of health. What could be done? The Nairobi neurosurgeons set up clinics in the major cities: Meru, Kisumu, and Mombasa, once a month to operate there and get the nurses trained. The goal was for the graduates of the Nairobi program to be sited to these cities and develop their own programs. That meant we had to be looking at infrastructure. That meant we had to be thinking, how do you set up a program? That, of course, is what the academic societies did in the United States. We could import those lessons. So, the outreach clinics were started. That meant infrastructure. You can’t be effective in neurosurgery without neuropathology. It took me awhile to realize that. Neuroradiology, equipment, supplies, and ICUs are all needed. So, everything had to grow at once, but if we could get excitement among those doctors and some minimal equipment donated, they would build it. They were very, very, resourceful and very bright; soon it became clear it wasn’t our program. It was theirs. We would help supply the curriculum and build the confidence of the government. Those doctors and their patients were hoping we would help out, really helping out. I learned how little you need for an operating room. When one teaches neurosurgical operations with minimal equipment, you become very focused in your OR back home and you never underestimate the quality of doctors in low- and middle-income countries. Neuropathology in East Africa taught me the importance of infrastructure. Without pathology the tumor program made no sense. Any neurosurgical program must partner with anesthesia, pathology, neuroradiology, and critical care. What seems impossible is done when it is a common good. Healthcare providers of all types are basically philanthropic. Given the opportunity, they will amaze you with skill, teamwork, and vision with and for others. That’s because we build teams. That’s the way it started. It was based on stopping to listen and then building teams of partners to solve the issues. That set an example. Sometimes the joy and passion of a good idea is contagious and multiple organizations sprang up. Hundreds of doctors, nurses, bio med, and administrators began to volunteer, building their own programs, and governments became involved as the programs spread throughout sub-Saharan Africa, Ethiopia, Uganda, Tanzania, Zimbabwe, Zanzibar, Asia, and the Americas.

Chapter 20

Operating in a Strange Land

The details of surgical procedures in areas of need. Making surgical plans and following them.

Going to surgery in the best of circumstances in your home hospital, with all your equipment and teams about you, is still a leap of faith. This magic that allows someone to trust you to open their skull, to fix something in their brain, to put everything back, and to return them better than when you found them to their family is a phenomenal leap of faith. The more experienced you get, the more the surgeon realizes there’s a leap of faith on their part as well. Having seen everything that can go wrong, equipment failures, drug reactions, allergies, unexpected bleeding, seizures, and knowing that even in the most careful of circumstances something unforeseen may happen, requires a leap of faith every day in neurosurgery. In the developing world, everything is magnified. You come to a place, you establish a relationship, you find them a champion, and you try to bring them along to where they could teach others—that means you must operate with them. You bring with you basic equipment, large neurosurgical tools to open bone, and delicate ones to manipulate fine structures. Some are disposables and most you sterilize and reuse. You try to anticipate the needs you will encounter, but you are never complete because each place is a new world to you. I have made over 45 such trips and each is different. You meet patients in hectic clinics, which may number up to 120 patients. You try to triage who can be helped, who is beyond helping, and what could be helped in your home country, but not here. You must work hard, and you must train and build their health system if you really want to have more impact than that the very small percentage of the need that you can directly touch. You ask yourself: which patient can physically survive neurosurgery under the conditions you find, as you tour the hospital? You see a primitive microscope. It may be frozen in one spot or does not work at all. You ask about blood transfusion and there is little or none. You question the cleanliness and worry. You are able to obtain some films or scans on the patients that come to you, usually done in the capitol, carried by hand by the patient or family. Back home you would say these are inadequate and you’ll just repeat them at the cost of thousands of dollars. Here you have © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_20

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to figure out how to read and understand them, what details do they hide with their poor resolution? In some, you can only feel that the brain is being compressed by a tumor or damaged by an aneurysm or infection, and so you make a plan. Discussing with your local surgical colleague, the one you hope to become the champion you build a training program around, you wonder if your combined language skills are good enough and that you’re getting everything across. Your knowledge of their language is rudimentary and theirs of yours, but surgery is a separate language known worldwide to surgeons. Sometimes that common skill is your language, and you go forward. You find a medical student that translates beautifully, but you still try to use their language as best you can, because it’s the right thing to do (see Fig. 20.1). The two surgeons meet the patient’s family, and they mistake you for a demigod because you are from a place unknown. You have been represented as an authority. The patient and the family were never certain they would win this human lottery and that they would be chosen to have surgery as so many are not so offered. To be considered the reason their loved ones have been given a chance at life places an enormous responsibility on you. In one hospital I found a ward full of people with huge benign tumors and said to my Ecuadorian colleague, “Ok, now we’re going to teach how to do benign brain tumors in young people who are about to die and need not.” And that’s what we did for a week, just teaching that over and over again. And you’d take a young, beautiful teenager with a massive tumor that needs not to die and return them to their family with hope for a future. The concept of benign brain tumor is sometimes misunderstood. Benign means it is not cancer, and it does not grow in a malignant fashion, but just because it is not cancer, it may still kill them just by the tumor’s size, mass, and growth. The tumor may not metastasize to the lungs but can still kill by its impact on the brain alone. And so, you persist. You have help with anesthesia, but they are concerned. There’s no blood in this hospital. The whole family is trying to arrange some from

Fig. 20.1 Education continues at every level and at all times

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donors. There’s limited anesthetic help and the OR equipment compared to what you have back home seems to approximate a knife, fork, and spoon, but it is sufficient. You learn over years that so many of the tools we use in the developed world are superfluous. That’s not to say they aren’t helpful. The base surgical tools can be adequate, but you must exercise far greater caution and care. The process will make you a better surgeon when you go home, as you will never underestimate the importance of not losing blood. You will always know the tissue planes, you will always know the blood supply, you will stop the blood supply to the tumor and protect the brain, and you will plan carefully for even the most seemingly straightforward case. The OR in these lands is always late. The time you actually get to start can actually be predicted by adding an expected delay to the predicted time. There is a rhythm to life in these lands. It predicts exactly how long before all staff are assembled, the patient is brought, and the team is happy to proceed. The nurses will need to follow their preparation and you must respect them. In one hospital, the delay was “shoe covers.” These are the thin paper or cloth covers they demand even over surgical shoes, but if that’s what was needed to let the operation start, then that’s what you do. Finally, it starts, and you start working your way through the scalp, muscle, bone, and dura. No power drills, you open by hand as your neurosurgical ancestors did so many decades ago. Fortunately, I was taught these techniques long ago and it goes well. The brain, however, is diffusely swollen. We brought osmotic agents to help relax the swollen brain. We had planned for that because we expected it from long experience. The tumor blood supply must be found and stopped. Tools we use in the United States for hemostasis may not be feasible. Cautery might be ancient. Hemostatic drugs are far too expensive for this land. You simply must find the source and stop it. The tension is huge, but you must decrease it or the team will lose hope. You teach, you tell stories, and you acknowledge the several technicians whose help you need so much because you want them focused and calmer than you feel. You must actually work faster because of the concern of prolonged anesthesia and the limits of post-op care. Inevitably, the power will go out some time that day. When that happens, you have to have a backup plan. You learn this and you take that planning home with you for the rest of your career. Every case has a Plan B and a Plan C. What if this? What if that? When the power goes out, the technician then brings in a camera light and shines it in, and you keep working. If the oxygen goes out, the risk is immense. Do you have a backup? On one occasion, a fire broke out and we had to evacuate an OR with the patient. All survived. In these days, the common camping and hiking headlights, with their great lumens of power, have changed our cases. We now actually use those lights in ORs as our backup. If you find yourself in an unexpected spot, you may have to devise an instrument. Once, when I was faced in Ecuador with a very firm tumor I could not easily remove, I remembered reading about something from the 1920s and made a loop cautery, whereas I may have used some very expensive tissue emulsifier in the United States. Thankfully, the devised tool works. When you restore that young lady to her family, you know that your goal was to teach the local doctors and teams how to do this. We teach them and they teach us

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how to respond to the crises which are inevitable. You are very satisfied that both of us have learned again, and again, and they will soon become independent. But the impact of that young lady, returning to her family, is immense. It reminds us why we do this in the first place. You round on that patient, you follow her to the simple ward, and you see the immense caring of the nurses. The head nurse, called “sister,” has pride in her team. They direct care, but some is delivered by the family, who may feed and bathe the patient themselves. If you were not there, they’d have to pay for the very suture that you brought to use on that case. You learn a lot about people when you work to fix their brain and you learn that they’re all worth the effort. Not only in the big picture of training a team to do this for many but actually the everyday impact on the person in front of you today. Service and education become one.

Chapter 21

Worldwide Partners in Global Neurosurgery: The Concept of Dyads

Pairing training programs for low- and middle-income countries with established programs in high-income countries.

From the beginning, we began to develop dyads where we’d link Kenya and UW, Uganda and Duke, Harvard and Uganda, Henry Ford and Myanmar, UAB and Vietnam, and on and on. As partners, they would listen to each other’s needs and solve mutual problems. We can donate that equipment. We can establish the site of training. We begin to teach. In doing so, we began to link dyads online thanks to people smarter than me about electronics. When low-income countries have access to WIFI, you don’t have to bring books, you just need passwords. The education was bi-directional. They began to begin to correspond with US doctors and US universities and teach us. Every time I went to a dyad, I learned. Then the governments began to get involved. One day, the president of Tanzania promised us he’d put 15% of his national budget into healthcare if we help organize it broadly, because neurosurgery was part of an overall health system. He bought the latest in equipment for their hospital in Dar es Salaam. I had the honor to set it up. From this, you learn. You learn things everywhere, every day. The very active idea of a dyad program meant that we all would learn. The Duke team discovered and then published that we raised the quality of critical care, anesthesia, and general surgery by building neurosurgery. It was completely the opposite of what people had taught me, where global health had to start with primary care. And that was really wonderful, because I’ve been arguing for years that we aim high for the best of care worldwide and suddenly it was beginning to make sense. The Duke program really developed in Uganda. The Ecuador program became self-sufficient, maintaining their own programs. Real care came from nothing to something that was self-sustaining. That’s tangible. Over the years, FIENS has touched 28 countries in the low- and middle-income areas of the world. Slowly it became clear that a few dedicated teachers could change much, even whole health systems effecting millions. To expand it more, we needed more partners. One excellent partner is the World Federation of Neurosurgical Societies (WFNS). The WFNS links societies of neurosurgery worldwide giving it access to some brilliant people, some with great political connections and some that are just very, very, thoughtful teachers. They had © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_21

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been teaching for years, but now directed efforts to areas like Kenya, Southeast Asia, often addressing practical problems of neurosurgery in low-income countries. Education was changing in scope and direction. We partnered with many other programs. NED out of Spain works in Zanzibar. This program built a neurosurgical hospital center in Zanzibar, where they previously had no care whatsoever. They staff and train it so a Tanzanian graduate can be sited there. As we sited educational courses there, we brought people worldwide to partner. The bidirectional learning taught us to be practical and efficient and work with limited resources. As programs grew, so did the electronics, WIFI, and equipment. MRI brain scans came to Africa during this time. We started with the occasional CAT scan, and now we can get an MRI at least in every capital. Next, the teaching went to Asia. Not only is there need in Southeast Asia but also enormous possibility and resources. In Korea and Turkey, we found that several of our trainees were now professors. They are very grateful for the training that they received and more than happy to be involved and donate time, equipment, and resources. They taught me it’s not about us; it’s about how we can best get neurosurgical care out to people. Nothing about this is easy, but some sites are more difficult, usually because of a lack of peace or government support. Zimbabwe is one of the more troubled countries in the world. But when their educated expatriate young people said, “We’re going back, would you bring your education program?”. We said we would try. So, we’re trying to start programs there. It’s very difficult because of the lack of stability in that country. We start by rebuilding infrastructure. We work out of a well-built but old hospital from the British colonial times. That’s the available structural resources, but their true resource is really quality people. The hardest project is Haiti. Haiti has suffered from remarkably poor stability. Natural disasters of hurricanes and earthquakes only made things worse. The US response was not very well thought through. What we did was pour aid and service onto this country without enough emphasis on education. It has been slow to build infrastructure or a middle class to support a training program. What does that mean? We poured so much food into Haiti that their farmers went out of business. They couldn’t compete, because they couldn’t sell their food. We made them a dependent country, not a self-sufficient country. The problems with medical education were worse. Sometimes struggling governments would say if people are flying in to do the medical care, then the government did not need a training program for their own people or its cost. My friends from the University of Miami have worked there for decades providing service but could not get a training program approved, so I said, “I have a lot of titles. Let me go and help and then meet with the ministers.” Because I was the head of this FIENS foundation and then was International Coordinator for the WFNS, I could meet with the minister. I said, “If you want to have a trauma system, if you want to have regional health care, you need a training program,” and it was approved. This is a very rudimentary training program, but the need is still enormous and often interrupted when conditions are not safe. One day, I found the sign, “ventilator stops working abruptly” in the ICU. Another day, I found eight people to a hospital bunk

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bed. That is four patients and four mothers to a bunk bed. So, I learned that the needs are great. You cannot let them overwhelm you, but it’s going to take a long time and a lot of steps forward and steps back to solve them. No one can solve them alone. We need to get buy in by local people and we need them to take ownership. And then we can build something.

Chapter 22

OR Equipment and Establishing Neurosurgery in a New Region

Understanding the limits of equipment. The benefit and limitations of key equipment in Global Neurosurgery.

OR equipment can be extremely variable. When I first started this kind of global effort, I found craniotomies being done with 70-year-old tools, hand drills to open the skull, small spatulas to try to explore brain tissue, and extremely inadequate ways to stop bleeding based on inventions from the 1910s in Boston. This caused FIENS to stop and think what was essential and which of the tools used in the United States were non-essential for the basic care of the trauma, benign tumors, and congenital defects we wish to address in the developing world. One of my colleagues and friends working in Uganda discovered that many of the expensive hydrocephalus shunts being used in the United States could be replaced by a reusable endoscope and a cautery and revising an old technique of internal diversion of CSF within the brain. His work and research in Uganda changed the way we practice care of hydrocephalus worldwide and won a MacArthur “Genesis” award. We also found that simple shunting devices may be better in a world where less maintenance is possible and more infection risks exist. Organizations such as the World Federation of Neurosurgical Societies (WFNS) have devised low-cost basic neurosurgical tools in collaboration with major manufacturing companies. Simpler microscopes, endoscopes, and micro instruments have been devised, allowing the new biomedical trainees in the developing world to focus on those instruments and their maintenance. We can now convert a standard OR into one for neurosurgical use with philanthropic input for costs that are possible in low- and middle-income countries. These same principles in supplying intensive care units are essential. One cannot expect a fully trained neurosurgeon to remain in a place that does not have the basic instruments needed to practice. The amount of equipment needed can be surprising. Most people think that neurosurgery requires the multimillion dollar machines that dominate ORs in the United States and Europe. In fact, converting a standard OR for neurosurgical trauma—tumor and basic vascular work—can be done if you emphasize two keypowered instruments, one for coagulation and one for drilling bone, along with © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_22

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Fig. 22.1  An example of the small amount of equipment that can completely change a hospital’s ability to provide neurosurgical care, in this case allowing it to take place at the public hospital in Guinea

basic surgical sets (see Fig. 22.1). These can often be obtained as surplus or donations and can be carried by individuals flying to teach. The next step is a surgical microscope, which can be more difficult, but often is part of partnering to obtain equipment from the local government. All of this becomes part of establishing a new neurosurgery graduate in a new city, which prior had no such care. New equipment can be purchased, and if the local government is appropriately dedicated to their success, they will succeed. A rather brilliant strategy of establishing the new graduates in a region without a history of neurosurgical care was pioneered by another friend and colleague in Nairobi. Graduates would be introduced on returning to their city of origin because my friend had generated a monthly clinic there for years prior, training nurses, bringing equipment and doing simple surgeries in place. Then when the graduate was prepared, an international team would hold a conference in that new city to showcase the work that was possible and the importance of the new trainee to the local hospitals, government, and religious groups that would need to embrace the new graduate. This introduction allowed this new center of neurosurgical care to be highlighted by being part of the continental post-graduate training program, bringing graduates from countries around. The impact is sincerely appreciated by local officials, who see growth and service in a sustainable fashion. All of these efforts changed profoundly for the better in 2015 when the Lancet Commission released its report on essential surgery. We are dedicated to the principle that basic surgical care is a fundamental right, as is access to food, nutrition, antibiotics, and freedom from war. That basic surgical care is the care to deliver surgery when needed to people who can be saved and returned to a productive life by straightforward procedures. The Lancet Commission determined that basic right was absent from five billion people in the world. The cost in lives unnecessarily lost may be as high as 47 million, which dwarfs the lives lost in the major pandemics of our times and yet goes on year after year. The World Bank noted the loss to the economies of the world was measured in trillions of dollars.

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These reports caused a compelling argument to be made that surgical training had to be done and had to be done in the nations of need if we wanted the trainees to remain and work there. The World Health Organization (WHO), including all the ministers of health of the world, endorsed such a program. With that endorsement came the stunning embracing of a concept of “service through education,” developing training programs through multiple organizations worldwide, but focusing their work on training rather than service alone if one was to develop a self-sustaining system of care. My own experience was an almost immediate contact with the World Health Organization and their commission on global surgical training. At the same time, I argued strongly that WHO had to embrace the mission of stroke prevention, treatment, and recovery, as stroke would surpass infection in the coming decade in its impact on death and disability in low- and middle-income countries. I was extremely satisfied to see the result, which was the organization of the Lancet Commission on Stroke in the Developing World on which I serve. Equipment came; it was often donated. We talked to a lot of equipment companies in the United States and they helped with needs to be donated, shipped, and maintained. As programs grew, so did the complexity of the cases done. I taught surgeons to do their first brain aneurysm cases in many cities and a few countries. Now, they’re widespread and being treated throughout the world and not just in high-income countries. Graduates in such places as Nyeri, Kenya, show such complex cases are quite possible. And it is a level of care that was unheard of before. Nyeri is one of those satellite cities that had nothing before and because of the teaching program is the start of a new world of possibilities. Soon such programs were spreading to Zanzibar, Uganda, Bolivia, Haiti, Myanmar, and Vietnam in an awakening of education and surgical care. Sometimes a good idea can spread like wildfire when you give good people an opportunity to channel their desire to help others.

Chapter 23

The Lancet Report 2015

Scientific study of the global surgical need. A sea change for global neurosurgery as governments and ministers of health recognize surgical training as a health priority.

For years I had been proposing “Service through Education” in the Foundation for International Education in Neurosurgery (FIENS). That is a plan to try to change global health slowly, incrementally, but permanently. We are using education to develop self-sustaining programs of training in neurosurgery, in the countries of need. These programs are run under the leadership of the doctors of that country, until they, the neurosurgical champions of that country, would take the program into a self-sustaining system that aids the entire health system. To do that, we needed to get governmental approval of residencies and a method to pay for those trainees, teachers, equipment, and supplies. We needed certification for the graduate and sites that they could establish their new practice. They need an ability to sustain themselves and their families. All of these issues were problematic, and all faced individual hurdles unique to their country or region. It was clear to me that we could best achieve these goals by forging partnerships or collaborations with government and medical societies, both international and in the regions of need. We need those partners for certification bodies in the regions of need and as a source of volunteers, philanthropy, educational information, and systems of care. We needed to rely heavily on the academic programs of the high-­ income countries and their neurosurgical societies, each of which I knew had a philanthropic aim mentioned in their charter. We wished to be their avenue to fulfil that aim. This went slowly but gave me decades of experience talking to ministers of health and medical societies, building momentum until 2015. In 2015, the Lancet commission systematically looked at the impact of not having essential surgical care in low- and middle-income countries and the effect of that deficit on global health. The results were dramatic. They realized that five to six billion people in the world lacked that access to basic surgical care. Simple lifesaving surgery could be the difference between death, disability, and dependence or a return to a productive life. If that surgical care would be considered a basic right of man, much like access to antibiotics, clean water, food, or freedom from war, the © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_23

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impact is stunning. Dozens of millions of lives need not be lost annually. Trillions of dollars in economic impact could result for these strained countries worldwide [2]. The World Bank confirmed these figures and the unsustainable cost of not addressing this surgical need. The World Health Organization pledged unanimously, something extraordinarily rare for an international organization, to attempt to address this short fall. But how? Colonial medical systems had failed. Episodic medical missions were non-sustained, and taking the brightest students to train in other countries did not give them a health system to return to. The only way, I urged, was to train surgeons in the region of need and, in doing so, establish the infrastructure that would sustain the new surgeons in their low- and middle-income countries. The impact on me was immediate. I had been espousing training in developing countries. The World Health Organization embraced the concept that education had to be close to the need if one wished surgical supply, infrastructure, and systems of care to be developed and last. The best way, I felt, was to train them where the need was. That would compel the trainers in a dyad to become involved in the infrastructure of the area of need. They must be involved in developing anesthesia, critical care, general surgery, nursing, radiology, and pathology, in unison with neurosurgery. This model worked best if you partnered in a dyad or by twinning, a program from a high-income, usually a university-based source with the nascent program in the country of need. The nascent program needed a local champion you could support and build around. Educational courses would be organized and then a curriculum developed. The result was the recruitment of top-notch neurosurgical trainees from the region of need. FIENS would work with curriculum, equipment, teachers, and local certification in partner with the governmental and medical society groups in that home region. The emphasis always was on getting the local teachers to take charge of the program. That is, make it their own. Education with COVID-19 became virtual, but initially it had always been hands-on and in person. The future will be a combination of both. Equipment was donated or purchased locally. Ideally partnerships with governments emphasized both salaries and equipment for the trainees. The Lancet commission and WHO resolutions changed everything about developing partnerships. With that continued support, soon multiple major national and international societies became involved, supplying the curriculum, the internet expertise, the volunteers, and sometimes funding. However, mostly that funding remained philanthropic from a growing public perception of the possibility of channeling “Service through Education.” It was my goal at that time to take these efforts truly global. Needs exist due to disparities in healthcare distribution. These exist not only in sub-Saharan Africa. Certainly, they are seen throughout large areas of Asia, Latin America, and, indeed, even in my own country, in my own state. Systems of healthcare have traditionally forgotten large groups of people. These disparities may be geographically, economically, or politically isolated. Health disparities are everywhere. It is wrong to think of this as an us-them issue. I would argue that in healthcare, there is no “other.” I have spent my entire career studying stroke and its risk factors. If you consider

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stroke, you discover the number one group in the United States for risk factors for stroke are Native Americans, who are a proud part of the heritage of my home state of Wisconsin. It led to listening to the Elders of a Wisconsin Native American tribe, until that Nation declared their interest to seek help to decrease their risk factors for stroke and delayed cognitive decline. Both were so important to the health of the most important resource for the culture of this tribe, their elders. These elders are the keepers of their language, culture, and heritage. The impact of this Lancet Commission report could not be underestimated. What I had seen, listened to, and observed over decades was suddenly placed before the world. No one could do that alone. When the WHO resolved to attack the shortage of surgical care and the concept of global health, it was natural that I would argue for stroke care as well. Stroke care is something that neurosurgeons should, and must be, strongly involved in. We are the therapeutic arm of treatment for both ischemic and hemorrhagic stroke. These are devastating diseases affecting far more than is apparent in those that are rendered hemiplegic, mute, blind, and aphasic by obvious strokes. Smaller, debilitating, and progressive TIAs and silent strokes rob cognition from literally millions in a premature fashion and may well trigger the devastation of Alzheimer’s at an earlier time than may occur in patients without stroke risk factors. The Lancet Commission was a huge lesson in the power of careful study, observation and putting the facts before an interested world. It was to be the model of much to come and should be part of the solution to any health challenge, be it pandemic or disparity. It not only brought science to the issue, but it outlined a cooperative and collaborative effort to solve it. Indeed, the Covid-19 crisis illustrated the faults of not following such a course. When science is refuted by leadership and collaboration becomes isolation and nationalism, then disparity, disease, and death result. The concept of “the other” would lead only to self-destruction. One cannot contain a pandemic without collaboration and empathy for those about you locally and throughout the globe. Just as the problems of stroke are not unique to the developing world, all diseases come home to your own backyard. A pandemic is as local as it is global and must be attacked on both fronts with observation, science, and collaboration. The lessons learned from global health apply every day to every patient we see. And, indeed, this lack of care, especially in stroke, will surpass infection in the developing world. So suddenly people began to have scientific data about what we’ve been saying and everything changed. The World Bank said this is costing the world economy seventeen trillion dollars, and this lack of care has to be addressed. The World Health Organization, which is part of the UN, said surgery must be made a priority. The vote was made unanimously, which rarely happens. Every minister of health in the world agreed. It became clear; we must train surgeons and must train them in their own country. Because otherwise if we take trainees to England and make them a neurosurgeon, they’re going to stay in England because there’s no infrastructure back home. WHO asked who trains surgeons in countries of need? The next thing I know, I’m flying to Geneva. And everything took off. I found

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myself visiting five continents a year, trying to set up programs. You don’t do that alone. We would think of the people we could partner with. We developed a web-­ based computer curriculum based on the US criteria for training. We received grants and training scholarships from philanthropists, web learning from American Association of Neurological Surgeons (AANS), curriculum from Congress of Neurological Surgeons (CNS), the milestones, and the boot camps from the SNS. My question always was if this was the standard of training in our country, why not do the same in low-income countries? Such plans need ministry support in each country. So that’s what we did, and things took off. We then added post-graduate education in the countries served, and we began to highlight standards of training and patient care.

Chapter 24

Continuing Medical Education in the Global World

The role of bootcamps, milestones and establishing a new surgeon in an area of need.

As new graduates began to be developed from numerous training programs in the low- and middle-income countries of the world, it became clear that we had an obligation, not only to educate them initially but to continue the education. Continuing Medical Education (CME) is an absolutely essential part of medicine. Further, we needed to standardize education to a consistent level of quality worldwide. In modern medicine, CME or post graduate education after your initial training is essential. A field like neurosurgery will quickly pass by a surgeon who does not keep his education up. New things are constantly being developed, new standards of excellence and expectations, as both neurosurgery and its aligned fields—anesthesia, imaging, critical care, and prevention—evolve, change, and improve. To really grasp the importance of CME, we harness both lessons learned from the high-income countries, as well as those from the low- and middle-income countries. In the high-income countries, two concepts, milestones and bootcamps, became essential. For low- and middle-income countries, the idea of personal contact and establishing a program as essential in the eyes of the local people, the government, and the secular and religious leaders was key. The Society of Neurological Surgeons (SNS) in the United States pioneered the concept of bootcamps in the early part of the twenty-first century. I served at that time as an officer and eventually president of that society. As the complexity of neurosurgery increased, the concept was to bring trainees at a particular level together nationally. All were to get intense training to bring them all to the same level. This could include standardizing the way to address a trauma situation, standardizing different surgical techniques, learning safe ways to handle instruments, and learning the basic principles of surgical care appropriate to the trainee’s level and experience. This caught on rapidly in the United States, until it became an expectation that every trainee in a given year would go through this same national training. The other thing that became important was that the teachers of these © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_24

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bootcamps were the bright young faculty throughout the country. They embraced this idea and gave up their time, often on weekends and evenings, in an already full schedule so that they could participate in the training of the next generation. It was also abundantly clear that the trainers learned from the experience and they made contact with each other and this next generation of their field. The lessons learned were truly bidirectional, that is to say the teachers learned as much as the students. After seeing the early success of this “Bootcamp” program in the United States, FIENS decided to support its launch in the developing world. The first was done in 2015 in South America. A program in Bolivia was held with the support of multiple organizations, curriculum from the SNS, teachers from the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS), and local on-site preparation from the philanthropic organization, Solidarity Bridge, resulted in a program which drew both teachers and trainees from five South American countries, with an emphasis on those with less complete neurosurgical systems of care, Bolivia, Paraguay, Peru, and Ecuador. It became readily apparent that there was a tremendous thirst for this training model as dozens of students appeared from these countries, far more than had even been expected or registered. The interactions were bilingual, bidirectional, fulfilling, and revealing. These were very bright people with very practical knowledge that they wished to improve and expand. The most important lesson, however, was the impact on the faculty. We purposely devised a course so that one half of the faculty were experienced teachers from the boot camps of the United States and the other half were from the targeted countries of South America. We taught side by side. One could see the sudden realization in the faculty from the low- and middle-income countries that they could do this. They became confident of their teaching skills. Most importantly, they learned the invaluable lesson that working with other neurosurgeons, many whom they may have felt as rivals before, was actually the best solution. At the completion of the course, they resolved to and did carry out the formation of a new regional educational institute for neurosurgery in Central South America. I would see this new cooperation time and time again, as we began to unveil bootcamps in other continents. We next went to Africa in 2016, the year after that to Southeast Asia, then returning to South America and Africa in subsequent years. Each time, the teachers were learning as much as the students. The students were energized with the quality and their possibilities. They began to understand things such as checklists, time outs, professionalism, and accountability. These courses were not simply how to do mechanical techniques. They were far more lessons of becoming a complete doctor. This was always our goal. It became an easy way to be in contact with the graduates and to impact whole regions and to leave an attitude of teaching, curriculum, and standardization of expectations, which would be the foundation of milestones. Milestones were the concept from the SNS in the United States that each year we would expect a trainee to hit a certain level of ability and if they did not, they would continue at that level until they had, so training would not go by total number of years, but by total accomplishments or milestones. Milestones were standardization of trainees where one was expected to achieve certain skills and a knowledge base to progress to the next level of training.

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This replaced advancing by time spent on the job with advancing by lessons learned and skills mastered. The experience was most rewarding. After years of working with the young people of Africa, we helped host its first bootcamp. When the first bootcamp was put on in South Africa, so many traveled to it from up to 20 African countries that the impact was great. Trainees would offer thanks. The people from South African countries would ask me, “Who are you and why do they know you?”. I would say, “That young attending was our resident in another country,” and “That resident was a student that we had worked with.” This happens time and again. Then the new teachers we had picked from the countries would come and say a group they felt was their traditional rival had amazed them with their teaching ability. They would say, “They are really quite good,” and I would say, “Yes, you should work more with them.” Then later in the same afternoon, the other formerly rival group would come to me and say, “That other group can really teach.” My response, “Yes, you should work together.” This concept of bootcamps was probably one of the best educational advances of the period after 2015 because it embraced the basic principle of showing the local teachers what they were good at and allowing them to take control of the project. It must be said that this could not have been done without the help of many medical supply companies. These knew that as low- and middle-income country’s health systems were modernized and trained, that whole health system would need to be supported by companies like them. Their help was invaluable in these training sessions. The next goal was to establish the trainees in their new positions. If we were to take someone from Cameroon and take them to a regional neurosurgery program and train them, we must then re-establish them as graduates in Cameroon. If we had someone trained in the capitol of a country and then wished them to be the first neurosurgeon in a large second city of that same country, we had to have an introduction program. The solution was very much pioneered by the work of my friend in Nairobi, who reasoned correctly that the trainees would need the support of their new city, its middle-class, and its hospital to succeed. What he pioneered was a program that when a graduate was ready to be reintroduced to their home area, he could organize an international educational program in the target city. This event would be staffed by major neurosurgeons from throughout the world who would come teach, meet the local officials, and demonstrate surgery with the new graduate. The international leaders would also meet with the health minister, local leaders, and hospital officials until they understood that this graduate was a person of importance, bringing a neurosurgical program of value to their city. As the international teachers, we would assure continued support for the new graduate, and we would express our hope that the new region would do the same. The results were outstanding, as time after time local officials would partner when presented with this as a win-win situation for the people of their community. In Mombassa and Nyeri, such Kenyan programs excelled. Nyeri in the highlands surrounding Mount Kenya was an eye opener. Working at the catholic hospital, the trainee developed trust and understanding with the city. We only reinforced this and, in doing so, he established an outstanding program. He

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operates at a very high level of neurosurgery, doing brain aneurysms, spinal fusions, and complex tumors with a high level of skill in a city where there had been no such care. It was exactly what we had always hoped for and now it was happening time and time again. Further bootcamps would draw as many as 100 trainees from throughout Africa, and the overall training experience would, again and again, establish new members in the neurosurgical community. It became clear that life was changing. The difference between having no neurosurgical care and having a program is lifesaving for many. It began to give hope for a cancer program, a trauma program, and for care of congenital anomalies of children. Establishing the graduate in new cities and regions of need made sense of what we had been trying to do all along. Some ideas just seem to catch fire. When we standardized education at modern levels, whole countries rose to meet that standard. Teaching grew in Zimbabwe, South Africa, Chile, Bolivia, China, Kenya, Vietnam, Nepal, and Afghanistan. In each site we met inspirational people willing to train in neurosurgery against all odds. They were brave even in areas of conflict and inspirational in their desire, passion, and joy of a profession of service. One day, I had just given a lecture in Africa about credentialing, curriculum, and standards. In the audience was a Chinese official. She said, “We have 1.3 billion people. We have some of the best hospitals in the world, but not a standard for the others. Would you come?”. I said “Yes,” and found myself addressing the Chinese Congress of Neurological Surgeons. I spoke about revolutionizing the teaching of neurosurgery and setting national standards, and I learned another valuable lesson. I learned to be careful what you wish for, because the next thing I know I was the honorary cohead of neurosurgical resident education in China. We began to roll the educational platform out. We did the first boot camp outside of the United States in South America. We learned that if we have half of the teachers to be from those countries of need, they learn they can teach. They learn that they could be the champions we could build a training program around. Bolivian neurosurgeons who had fought with each other as rivals would come up to me and say, “Why that person can teach better than they thought.” I said, “Yes, yes, you should work together.” The result has become that they built a teaching Institute for Neurosurgery in Bolivia. Such was never heard of before. It wasn’t just for Bolivia; it was for the five low- and middle-income countries which surround that area. We used simple tools to teach. Ventriculostomy models were handmade. When we returned 2 years later for the next course, they had 3D printed a beautiful teaching model of 3D microscopic anatomy. We brought these concepts to Africa. We brought it to Southeast Asia and back to South America and it grew and grew. And as it grew, it became an international objective for teaching societies from Japan, from Saudi Arabia, from Congo, from India, and from Pakistan. It was an idea, once expressed, that took on a life of its own (see Fig. 24.1). That is always the idea. Such work is not about us. It’s not about America. It’s really about the countries that invite us and when can they take ownership. The Uganda program began to decentralize. My friend had built a neurosurgical hospital in the eastern part of Uganda teaching exclusively pediatric neurosurgery. In the

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Fig. 24.1 Continuing education emphasizes a thirst for knowledge in those we partner with worldwide

western part of Uganda, a university medical school would become the third neurosurgical center in that country. I would travel there to teach vascular brain aneurysm surgery. A bootcamp in Myanmar would spread that education concept to Vietnam. In Chile, one doctor really wanted to train people throughout South America. He built the brain dissection models with a 3D printer with drillable model skulls and dissectible plastic vessels for microscopic teaching. When we did a training camp there, we taught five countries. It was fantastic and got the countries of need involved so that they were doing half of the teaching. Nyeri, Kenya, is an area of about four million people which previously had no care whatsoever. Based on this need, the training program at Nairobi sited one of the new graduates there. We didn’t just send them and leave them alone. We marked the event with a large educational course. We brought people from worldwide. We told the local ministry of health this is important. This is bringing new surgery to your people. You need to be supplying this hospital and we will continue to work with them. The results are amazing. In the first year, the new neurosurgeon had done dozens upon dozens of difficult cases and hundreds of small ones. He has solved the trauma problem for the local systems, but he’s working alone. We next need to train a partner and to really make the program grow. He has over one million people to care for. So, one surgeon is just a start, but it’s a really significant one. The buy in from the local hospitals, governments, and churches is enormous there. That is very, very, important to success. Great problems remain, everywhere, poverty, war, and the pandemic. Such challenges affect everything. During a pandemic I couldn’t travel anymore. I had to think about infrastructure. The new program still needs sterilizers, linens, and nurses. That’s what we must do. The trainees are going to need equipment, and they’re going to need unity and the local certifying bodies to accept them. They must have a sustainable practice and be able to support their own family or they cannot stay in the new site. Each new surgeon needs some sort of income from their government or a combined private practice and charity practice. The models are different in every part of

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the world, and we need to listen and adapt to these local customs if we wish to succeed in placing new graduates. Surgeons need continuing education. So, FIENS provides that by partnering. Finishing graduates, such as one who’s gone back to his home in Cameroon to found the first academic program in West Cameroon, need philanthropists like the FIENS Foundations to fund his extra training. That extra training, or fellowship, including time at the University of Wisconsin for 3–12 months, was for working with simulators, working with the dissection lab, and observing in our ORs. Such an experience puts a gold star on these graduates back home. Their local officials see that. They’ve had extra training and the teaching on how to be an academic, and, with help, they might be able to run a training program. There are many ways to change things. Equipment might be very simple. Partners can supply the base neurosurgical set and often the base microscope. We can take a simple OR in East Africa and change it into a neurosurgical OR with a lot of help from companies and from philanthropists for as little as 26,000 US dollars. This equipment gets them started. They will always want a state-of-the-art microscope, but we can get them a small one and can make it work. Dyads between established academic centers and the new programs became essential by listening, recognizing a need, and partnering to meet those needs. Without the dyads, we don’t get this done. Dyads are adopting programs in Kenya, in Bolivia, and in Asia. The local government has to be supportive and maintain safety. I’ve never been successful setting up a long training program in a war area. I need somebody in the ministry that understands the benefit of education for their people. There are many good people in the world, some are in government and some in community leadership. All can be very helpful in global neurosurgical education. We must get a certifying body if we wish the new graduate to be accepted. In East Africa we used the certifying body for general surgeons and taught them to certify neurosurgeons. When we placed a graduate in Mombasa, we brought people from Japan and Spain, North Africa, Prague, India, Pakistan, and Kenya for an educational program to celebrate. This event said, this person is important, and this program is important to your city. The two people that got us started, the two neurosurgeon champions in Kenya, are now the real leaders of the program in Kenya, and they in turn have trained young graduates, who now provide neurosurgical care for four million people in Eastern Kenya out of Mombasa. Next, we have to see that the doctors can sustain themselves. Without that possibility, they cannot stay or keep their family in the new city. Our most successful has been in Kenya where government healthcare pays enough that a neurosurgeon can live as a doctor, have a family, and support it. That has been the best example of a government as a partner in the infrastructure needed for such a program. In other more difficult sites, inspiring young female doctors train in neurosurgery in cultures where factions restrict female education. We only succeed when they do and they are training their next generation. Continuing education is our key to sustaining any program. We site these courses where the graduates are, so that they may be recognized by their community and attract other neurosurgeons to join them. When like graduates interact, they are

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never left alone. Courses go on throughout the world, and, with this, we begin to develop new dyads and new partners. It’s amazing to look back over the years. We began to train nurses, we began to train students and the students become our residents, and the residents become our faculty. It’s very intriguing. When we put them together, it overcomes traditional borders. When we did the bootcamp in South Africa, we learned that traditional boundaries that separate whole people can come down when they teach together and look and listen to the qualities of skill and compassion that even traditional rivals have. Education happens when you break down barriers. People working very hard with their special skills with and for others to build the pillars of health, peace, purpose, and family are the basis of global neurosurgery.

Chapter 25

Persistence

How to maintain motivation and passion in your profession.

Being involved in global health is constantly a matter of being enthusiastic, committed, persistent, and realistic. Everything is two steps forward and one back. Work you may have done with the best of intentions may be gone in an election when the new president wants nothing that may remind them of North Americans. Dempsey’s first rule is that “change is often good, but it is always hard.” One realizes that in most parts of the world things work slowly, but if there is a constant vision, a goal, and unifying principles, it will persist and it will be transferrable from good people to good people. The source of this is always the youth. Students who persist come back as residents; the residents come back as junior faculty now training their residents. It is a stunning realization; if one persists, your students succeed, and their gratitude is unending. If I gave a lecture in Dar es Salaam, I would look up and find two residents that had traveled by bus across three countries of central Africa to be there for that teaching. This is what inspiration is. Education became the structure that allowed persistence. Without education, service would not be lasting. It would only last as long as you were there. No one, I had learned sadly, can operate on everyone in a country, but education could transfer that role to the new surgeons trained if the program had unifying principles. These principles meant: First, you need to be invited. No one accepts a program forced on them. Second, you must listen. The most important part of communication is listening. Learn the people’s needs, desires, and resources. Third, bring together a program that addresses those needs. Fourth, the program is a partnership designed to be taken over by the local doctors. You are there to help. The ownership of the program is theirs. Too many highincome countries try to impose “their” program on a region of need. When the people of the region in need take ownership of what truly must be “their” program, it can be self-sustaining as they train their own. My contribution is to improve peoples lives in the way I know how. This is through neurosurgery. It is a small part of healthcare, but it is a key capstone. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_25

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Without it, the arch of healthcare does not stand. Without neurosurgery, trauma doesn’t stand, cancer care doesn’t stand, and congenital CNS care doesn’t stand. Infection, tumor, trauma, and degeneration of the central nervous system dominate the end of life. All of these conditions may be addressed by neurosurgery if it is present, delivered, and sustained. To deliver that, one must understand the roles, needs, and achievable goals. Five billion people with need cannot be supported by any small group. Solutions must be through education developing a system that is self-sustaining and grows as the need grows. That education system must be under the ownership of the people of need. The people champion their own. They know their needs, they know their world, and they must navigate it with our help, not in spite of our efforts. Therefore, one must bring in the middle class, the government, and sometimes the military as collaborators. One must explain to the government the common good for all if we raise neurosurgery in their land. In turn we must raise the other areas of medicine, anesthesia, critical care, diagnostic radiography, therapeutic oncology, infectious disease, and pathology to achieve wide ranging benefit for all. The final principle is that the motivation for such a program is not about you at all. It always must be about the people that are being served. Then the compatriots who were inspired to go into medicine are trained to take ownership of their healthcare system. These are the principles that are lasting. These allow success. What I am really saying is that basic surgical healthcare is a principle of life and it is a principle of social justice. Good people worldwide desire faith, peace, health, and family. When you restore health, you do much to restore faith, peace, and family. Unrest in the world is ongoing, consistent, and repeatable but always has to do with disparities. Correcting that disparity in healthcare is social justice. It is a key basis of change for the better in society. The motivations for people to go to this profession are many. Altruism may be based on religion, personal moral codes, family tradition, or things your mother taught you. So many people come to healthcare for these very altruistic reasons. Our job is to remind people of why they started in healthcare in the first place, to give them an opportunity to practice, to achieve those altruistic goals, and to show them the progress that is present. That is what I hope FIENS can do.

Chapter 26

Service Through Education

The teacher becomes the student.

Although I hold many titles, department chair, neuroscience researcher, director of a basic science laboratory and a clinical research unit, teacher, clinician, and administrator, my primary role is that of a neurosurgeon. It has defined my adult life and has provided the challenges, experiences, successes, and failures that define me. When I saw my role in the developing world as “service through education,” it was clear to me that this had to be in neurosurgery. Such a belief ran completely counter to the statements of my early teachers, who felt that the only contributions in lowand middle-income countries for healthcare could be in infectious disease, sanitation, or other extremely worthwhile and well-known areas. But I felt differently. Over decades I have explained to ministers of health that without neurosurgeons, they could not have a true trauma system; without neurosurgeons, they could not provide complete care for stroke or cancer; and without neurosurgeons to care for congenital defects of the central nervous system in children, their prenatal programs were incomplete at best. I was able to demonstrate time and again that; by training a handful of neurosurgeons, we could revise their entire national trauma systems. In many low-income countries, the population has collapsed on the capital, literally millions of people overwhelming health systems, but the effects on their rural systems are more devastating, and usually the rural areas lack any effective medical system. If a person has significant trauma to the head or neck, their life would be lost. Yet, we know that timely intervention can return many to useful and productive lives. If a family member suffers from a benign brain tumor, something easily treatable in US cities, the family would uproot, lose their shop or farm, move to the capital, and wait under the jacaranda trees in Nairobi, hoping that they would be the lucky person picked to have the rare neurosurgery at the government hospital. The odds of that happening and being successful would literally equal those of the odds of you winning the power ball by stopping on your way home tonight and buying one lottery ticket. However, if we could redistribute graduates of a training program, trained in the capital, but returning to their individual regions of need, we could establish a national trauma system, cancer care, and stroke programs. All of these © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_26

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diseases without intervention will devastate these areas of the world in the decades to come. Stroke and cardiovascular disease, for example, will become the number one cause of death and disability in the developing world as it surpasses infectious disease as risk factors soar. When one teaches neurosurgery in the United States, you become very used to the modern trappings of a university hospital. The ORs are exquisite, computerized with 3D localization to find minute tumors in the brain and minimize damage to surrounding structures. Microscopes, endoscopes, and catheters routinely allow us to minimally invasively repair the injured or ill brain. Anesthesia is exquisite. Safety, even during my career, has advanced in leaps and bounds. The situation in the rest of the world, however, is extraordinarily variable. Often, one would find in the government hospitals conditions approaching those of the mid-twentieth century in the United States. Essentials as simple as suture, drugs, and clamps may be in short supply or may need to be provided by the family of the patient undergoing surgery. In Africa, unless you bring the clips needed to repair a brain vessel aneurysm, the family may need to go out and buy one and hope it fits and can be sterilized. That is not to say that most regions of the world don’t have access to some modern equipment, but rarely do all of the people of that region have access to those centers. Their hospitals are often the public training hospitals. The dilemma then with limited equipment became, “Can surgeons be trained in their country of origin?”. For decades I argued that they must be. The old traditional system of bringing trainees to England, Germany, or New  York for specialized training failed their countries of origin because they did not return. They had been trained in techniques and equipment which were not available in their own country, and they would not know what to do if they returned. Conversely, doctors like me flying to their country for brief periods of missions could treat hundreds, but the impact on the millions in need would be imperceptible. The 2015 Lancet Commission states that five to six billion people in the world do not have access to basic surgical care. This is the type of basic care for conditions that could take their life, yet they are easily treated in our country and would return them to productive activity. It became my mission to develop ways that surgical training, and with it the basics of essential surgical care, would be present in the country of need. While I was working on such a plan in Ecuador, I was recruited to the over 50-year-old volunteer organization, the Foundation for International Education in Neurological Surgery (FIENS). Founded in 1969, it started as a service organization of philanthropic neurosurgeons traveling throughout areas of need to deliver essential healthcare. As it also embraced education, I joined and argued that it should move strongly toward developing residency training, certifying it, and completing it within the countries of need. Over the years, it went from one of many organizations that I was involved in, to be the one that I felt I would focus the most energy, and in 2012 I was asked to chair that foundation. FIENS principles are straightforward. Philanthropic neurosurgeons throughout the world are working as partners with local champions. These champions are neurosurgeons, perhaps the first neurosurgeon in a country, who trained elsewhere. They would return and struggle, yet they could be the champion of which a program

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could be built around. Next, we used dyads or twinning of established programs in the developed world such as Valencia, North Carolina, New  York, Wisconsin, or California, which we paired with programs of need in the developing world. The visits of dyad partners would be focused on developing an education program. The equipment, rather than being random surplus, would be focused on the specific needs of the area, as identified in partnership by both sides of the dyad. The influence of the developed country was often essential in running interference with certification and developing local support. Our presence would often ensure the local involvement of the middle class and the government, which would be needed to certify the trainees. Working internationally, with multiple organizations, basic equipment can be procured, although we quickly learned the most important thing about equipment is that be maintained. This started FIENS looking at the total infrastructure, the biomedical people, the nursing, the critical care, the anesthesia, the neuroradiology, and the neuropathology. Without each of these components, a complete program is not possible. Yet, when you strive to develop each of these infrastructure components, you are by definition, not dumbing down the care being given, not simply training first aid people to do neurosurgery, but rather you are saying that the people of those developing countries deserve the same level of care worldwide, a complete health system. I feel very strongly about this. It is a basic principle of social justice, and it is the way in which healthcare and social justice are intimately related. I learned this lesson most vividly in Nairobi. This was one of many times I learned to strive to develop empathy and about the need to be quiet and listen. I had spent the week teaching the difficult surgical topic of brain tumors in children and it seemed a very successful week. The patients had done well, the tumors removed, the trainees were more confident, more enlightened, and the teams were better trained. That evening, we were invited to the children’s cancer ward, where our patients and the others of the ward thanked us in the way they chose. They sang a Swahili chant and response song. It was absolutely beautiful. Tears filled our eyes with gratitude as we thought we had made a difference. Then during the song, the very wise head nurse leaned over to me and said, “It is unfortunate they will all die.” I was shocked. I said, “what, what, why is that!?” She said, “You don’t understand.” They were the exact words I had heard so long ago in Eastern Kentucky. I repeated, “What, what?” and she repeated, “You don’t understand. We have no chemotherapy program to follow-up the cancers and to stop reoccurrence of those that had been removed.” I was outraged. I said, “Well I am an American, I will get you chemotherapy.” Again, she simply said, “You don’t understand.” This key phrase I’ve heard before, because when we speak quickly and think we know something about another culture, we often don’t understand. This time I stopped to listen. She said, “We have no chemotherapy program because we have no idea what tumor you removed. There is no neuropathologist in sub-Saharan Africa.” I was stunned. I had never thought of that. That I had never thought of that, meant that I had not stopped to listen well enough to the needs of the local doctors. I finally learned that most important lesson.

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As I reflected, I walked down the hall to the pathology department and asked, “Do you have a young assistant professor who doesn’t mind traveling and would like to learn?”. Although the difficulties of bringing someone to another country for surgical training are immense and such trainees in the United States may not be allowed to touch patients, neuropathology could be taught in a twinning fashion with extensive electronic communication and short periods of in person instruction. And so, this program was started, and now sub-Saharan Africa has neuropathology and neurochemotherapy. For me it was a lesson in empathy. It was a lesson in listening. It was a lesson in the strength of people, and it came during that song, one of the most beautiful I have ever heard, because it was from the heart and soul of these children and, yes, they were my teachers.

Chapter 27

The Corners of the Day

Guate – Ecuador – Africa. The commonalities that unite a world.

A surgeon sees a lot of sunrises and sunsets. Many are out of the hospital windows, but in a profession that rises before the sun and returns after it sets, one begins to cherish that hour of sunlight that they may see. It is highly unlikely you’ll be at your window in the middle of the day when surgeries and clinics are usually scheduled, but sunrise and sunset you may see on occasion and, in that case, you cherish it. There is a glow, an affirmation of life. You feel you can see the chlorophyll in the leaves and vegetation. In a world that is often black and white, that influx of golds and reds, especially if reflected on water, is a spectacular acknowledgement that there is something more than the obvious to life. I often think of the sunset in Guatemala, riding on the back of a pickup truck trying to get back to our pensión in Jacaltenango before darkness made the trails impossible. The mountains would glow. Miles and miles away you could see the smoke from the village, a small refuge in a sea of golds and greens. I remember a sunrise on the Indian Ocean when we were establishing a program in Mombasa. It is a time only for workers. The only people you see up are farmers, fisherman, or people scurrying to open their tiendas, their stores, for the morning rush. One particular day, a magical gold reflected on the ancient fishing boats tied in the harbor. Another morning, you could see the water taxi, nothing more than a dugout canoe with an outboard motor and the sun outlining the dozen or so workmen crossing north to their worksite by water. I have always tried to step outside to see the sunrise. Certain times of the year, the sunrise will greet my entrance to the hospital. There is something life-affirming in sunrise that is needed to support a person whose job literally is life and death. A neurosurgeon finds very simple ways to affirm life and to maintain their confidence, their hopes, and aspirations. Teaching global neurosurgery has taken me throughout the world, often teaching or operating in five continents in one year, but one would be a fool if one did not © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_27

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stop to listen and look, during what may seem a feverish pace of work. All throughout you is a world of immense beauty, both human and natural, and the interaction between is magic. I’ve come upon people that live by waterfalls, rainforests, arid plateaus, and bustling cities. The cities have a color, a smell, a music, and a dance all their own. Traffic—foot, bicycle, pickup truck, bus—roars along, a cacophony, no, an orchestra really, if one is tuned to listen to it. At night, young lovers court in their city square and light floods the cathedral. Music plays and families cook and prepare meals in the open air. There is dancing, there is music, and there is life. The impact on someone who spent hours holding death at bay in a primitive operating room can be overwhelming. There’s a poetry in this world. To watch the population of Quito flow from the mountainside into the city at daybreak, running to find work, feed their family. A human river flowing around the hospital. It is the corners of the day that attract me. Perhaps I see more of starlight than others because the hours are so long in the OR and when I emerge one blinks at the brightness and noise of life, as someone emerging from a cave. Planets and stars are my friends. I chart them and see them worldwide. It was Galileo who said, “I have loved the stars too fondly to be fearful of the night.” Surgeries are needed at night as well as day. People are born; people get sick throughout the day. Sometimes, it is the corners of the day that the surgeon seems to hold and possess. The sunrises and the sunsets and the first star give an attachment to life, without which a neurosurgeon would be only a technician, soulless, and mechanical. Without that empathy for the person you treat, the person before you, the ability to appreciate the nature in life that they appreciate, and the desire to return them to that so they may know the joy of a child or grandchild, you would only be a soulless technician. Sometimes one has to look at stars to realize one’s place. The small impacts that we have, and yet understand that if we can return people to appreciate that, we’ve accomplished something. So many of the things we do in neurosurgery impact one’s ability to think, to see, to appreciate, and to love. To return that faculty to a patient is a gift. To appreciate the value of it is the bigger gift, because when we do, that patient restores our humanity. That can be lost if one works too hard, runs too fast, and is overwhelmed by the need. Sometimes the corners of the day teach us that. Some people call it faith, some people call it nature. Most don’t understand it, maybe that’s why it is called faith, but all of us must question and appreciate it. It is not about us. What we do can help others and that’s a beautiful thing. For me, this very difficult field of neurosurgery became easier when I realized it was a far easier way for me to help people. My work could be part of service and that if my service was education, the impact would be magnified thousands of thousands of times over. I can only treat some thousands of patients. The people we impact, those we teach to teach others in a self-sustaining fashion, will treat millions and approach those billions that presently lack care. More importantly, they will treat the people that aren’t here yet. They, and their trainees, will impact people we will never meet or imagine, and, yes, some of them may go on to change the world. That’s an impactful thing that I think people only understand when they take the time to appreciate the colors of the corners of the day.

Chapter 28

Teaching Is Doctoring, Doctoring Is Teaching

The Definition of “Doctor”. The roles of teaching and empathy: the need to first listen and then partner.

Many people ask about the importance I place on teaching in medical care when I talk about a philosophy of “service through education.” That is, using education as our primary way to deliver our service to the patients and trainees we care for. My obvious goal there is to magnify the impact of what you do through the people you teach, who will touch patients far off, or far-flung, in time and place than you ever could. Indeed, a teacher affects patients that aren’t even born yet through the people they teach. The answer really comes back to what it is to be a doctor. I, like many medical students, worked tremendously to obtain a degree as a doctor, without ever really knowing what that meant. Medical students do feel, not incorrectly, that being a doctor is a service and is a caring. It is a profession that brings its skills, as all professions do to an area of knowledge which is self-regulated, involves technical and intellectual skills, and provides an expertise or a service to others. But, there’s more. In Latin, the root for doctor, “doctore,” is “teacher.” When I realized that, so many things began to make sense. A great teacher does not have their students memorize and regurgitate lists of facts. Indeed, when I see that going on I know that nothing is being learned. Too often, medical students initially seem to succeed by their remarkable memories. In this age of instant information with online computers in everyone’s hand or pocket, we will find memorization may be a thing of the past. Learning to think is very different. A great teacher figures out ways to allow their students to understand and to take ownership for their own education. A great teacher teaches people how to learn and then expects them to go ahead and do it lifelong. In medicine and especially in neurosurgery, one must not only teach surgeons. We must teach our patients as well. Neurosurgery is rightfully frightening to a patient. A good surgeon must take the time to teach that patient about their disease and the plan of action. If they truly understand, they will take an active role in their care and recovery and invariably do better than an uninformed patient taking a passive role.

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Building a Partnership with Patients Empathy: Listen, Teach, and Partner I often wonder what is the magic that conjures up a relationship in minutes, to be so deep as the one between a surgeon and a patient, whether it’s in your own hospital in a modern world, or in a rural facility in a low-income country. A very frightened patient, knowing only that they have something terribly wrong with their brain, meets a surgeon for the first time. In the space of minutes, a bond must be forged that allows that patient to put their entire life in your hands. I tell students to think from the viewpoint of the patient, who is literally entering an unknown world. The patient probably doesn’t frequently enter a hospital, and they’ve never met a neurosurgeon. They think of brain surgery as something that’s mythical or otherworldly. Yet, here comes this person who seems to be saying, “Trust me, I’m going to open your skull, take your brain, magically fix it, return everything where I found it – there are risks, but you’ll probably be fine.” Everything about that seems foreign to any patient’s experience. They have to be frightened; they have to be lost. What is the magic that allows that fear to be overcome and surgeon and patient partner in the effort? It becomes a very visceral bond between two former strangers that makes a life in neurosurgery so special. I think there are many parts to forging this bond. The first must be understanding. The physician’s first job is to listen. Indeed, that’s the first part of every successful conversation and listening means so much more than attention to words. Always remember most communication is nonverbal, the way they walk, the way their eyes move, and the way they sit. Do they have confidence or fear? What is it they really want to know or say? Can you anticipate those questions? I tell students that my average patient probably has 11 questions I must answer. They range from “What is a brain tumor?” to “Will I die?” to “do you know what you’re doing? Have you done this before?” to mundane things like “Will I look the same?” But they are really asking, “Will I be the same person? Can I ever be healthy again?” If the physician doesn’t answer those, the patient will never be able to participate in their care. This second point in this personal bond is probably the most important. You must show them that you understand that it is their medical problem. It is their doctor’s visit. It is their trip to the healthcare professional. It’s important to give them ownership. I knock when I enter the room, I’m asking permission by that act. I ask, “Is this a good time to discuss?” I’m trying to have them understand that they cannot be passive about their illness. Just as the first part of the physician-patient relationship is the physician listening, the second part is a partnership. With very active participation by the patient in their health and recovery, I’ll often assign them a role. They’re in charge of their pre-op preparation, and they’re in charge of their post-op, avoiding pneumonia or blood clots. How much I need them to walk, how much I need them to be active, and what they need to do. Most are reassured by this. They are able to exert some control in providing input. In turn, the physician must explain

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their own level of confidence and their own level of competence and their experience. We must teach what the patient can expect and, indeed, what could go wrong. In all this, the surgeon must give the patient hope, just as we are giving them the right and responsibility to be active in their care and management. It is a mistake to think that because a patient does go to sleep for a large brain operation, that they take a passive role. They do not. If they truly understand what’s happening, what’s possible, and what they must do to recover, things invariably go better. The physician’s role is to make sure they do understand by listening, partnering, and communicating, often, even answering questions before they’re asked. This is what great teaching really requires. The surgeon must say: “My experience with this problem is thus. The possible outcomes are this. The risks are real, but the benefits are real and they far more outweigh those risks.” If, indeed, the explanation makes sense to you, then it probably will to the patient as well. An informed patient may confidently become a partner in their own care. This is, of course, the basis of all of medicine. If doctor is to mean teacher, then teacher does not simply spew out information, but the teacher strives to obtain understanding in others. Such understanding comes from the physician asking themselves, “What would I need to know if I were in my patient’s situation?” and then answering those questions. That degree of empathy is communicated to the patients and is a major part of earning their trust, their partnership, and their role in their own recovery. It still seems miraculous, the degree of trust, which seems necessary to navigate the fears and uncertainty there are in any medical condition. I believe this is true of all branches of medicine. The major difference is that the nature of neurosurgery magnifies the possible risks, benefits and consequences of all such actions. All doctors should be no different in their teaching roles. The role of a doctor is to teach their patients enough about their health and disease that they may take ownership for their own health. If it’s a stroke patient, the patient must understand the risk factors and that they can manage to greatly decrease their own risk of another stroke. That will only come if you educate them. If you simply give them orders—lose weight, stop smoking—it will never happen. You help them to understand the relationship of diet, weight and diabetes, smoking, and atherosclerosis. If presented in terms that they understand, they may take ownership of their own health. That’s a teacher’s goal. This relationship of needed trust I may have learned in global neurosurgery, but it is an example of the many things that, once learned, effect all of our practice and life. This relationship need be no different in neurosurgery. Neurosurgery is extremely complex, and no patient feels that they understand it. The average patient comes to my clinic with a stroke, aneurysm, or brain tumor terrified; they know nothing of neurosurgery. They have innumerable questions, many of which they can’t even articulate: What is neurosurgery? What’s a brain tumor? Am I going to die? Will I be myself? Will my personhood be changed by this tumor or the surgery to correct it? A doctor must be the teacher who helps resolve these questions. The surgeon must anticipate them and address even the unspoken questions until the patient has an understanding of their process, their aneurysm, their tumor, and their outcome. If they can participate and take that degree of ownership in their care and

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decision making, the doctor and patient become a team in that effect. That’s what a great doctor does, they teach. Great teachers don’t impart knowledge as a bucket, scooped with a ladle, but rather allow understanding that gives purpose and confidence to their patients and patients. The poet WB Yeats described teaching as “lighting a fire,” rather than “filling a bucket.” So, I believe that doctors are educators. It happens every day, with every patient, if done properly. On a global scale, when global needs and health disparities are worldwide, to me that means you must teach to address that need. You teach the middle class to take ownership of their health program in Ambato, Ecuador. You teach the physicians in sub-Saharan Africa that they can do the surgeries that they read about online. You show them that they can become teachers of their next generation of neurosurgeons in their own country. You teach politicians that transforming healthcare includes transforming surgical care and that can change the welfare of the population they swore they would serve. You teach the worldwide societies, and you teach the organizations. Sometimes, well-intentioned organizations, like the World Health Organization or medical societies, need to be shown the way. I presented to WHO the importance that stroke will play in global health. In the next decade, stroke is projected to surpass infection as the number one cause of death and disability in the developing world. This makes sense as risk factor profiles change worldwide. The scourges of modern life, from poor nutrition, obesity, smoking, unchecked hypertension to diabetes, increasingly affect low- and middle-income countries and result in stroke, heart attack, and renal failure. I feel education is the key to what a doctor really does. When one sees a need, such as global health disparity, one tries to meet it through service and by teaching what you know. For me that was teaching neurosurgical skills. I found that niche I know to be of service and the results continue to grow through the people you have trained.

Chapter 29

Why I Do Research

Remembering the integrity or completeness of the neurosurgical mission requires a desire to continually improve.

People are often surprised at the amount of scientific research I do. When one wears many occupational hats, I find that the world likes to categorize you as only doing one thing. Some think that I am primarily a clinical neurosurgeon, some think primarily a department chair, and some think primarily a teacher and some think primarily a researcher. I truly believe that I am all and none. I don’t believe anyone is defined so simply. It only makes sense when they all come together. I do not think I could just play only one role in my life. At one point, my wife made me categorize all the jobs I was doing and write them down. When I got to seventeen, she said, “Okay, put them in order of importance to you.” It was a fascinating exercise. It highlighted the danger of being spread too thin but also made clear to me that I only made sense as a person when all the roles worked synergistically for the same good. Research is actually extremely difficult for a physician to incorporate into their lives. So many medical students think they will do research. They will most all tell the residency director that they will when they apply for a training program, knowing full well the residency director wants a program that has more research in it. However, the physical and mental demands of training, of doctoring, and of continuing that work tend to make people triage their time down to one thing or another. For most, that’s patient care and patient care only. I was always troubled, personally, by that. I knew that patient care, learning, and providing neurosurgery are what define me. It is, indeed, primary. That interaction with patients, that tactile, intellectual compassion, and contact mean so very much in defining myself, and I know that. But I had to understand how dissatisfied I would be, if that’s all I did. The reason is simple: I am in a field called neurosurgery and I am providing the very best care in the world. I trained in some of the great schools in the world. I trained hard. My patients do very well with difficult diagnoses of brain disorders. Yet, I was not satisfied, because nothing we did, and nothing we do today, is still good enough for the sick patient in front of you. The best care in the world for stroke, brain tumor, pain, and congenital anomalies of children’s brains is simply not good enough yet

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and must be improved. To me, that means you have to do research, because that’s the only way we will improve the care we provide. Research is an interesting thing. It can take place in a formal laboratory, such as a PhD’s test tubes, western blots and genetic studies. It could take place in an operating room or a clinic, where we study which treatment is best. It can take place in your clinic. It can take place on a Native American reservation. And I argue it must take place in all of the above. This is because every aspect of care: how we deliver it, what we deliver, and how we harness the power of our advances in understanding the genome, immunology, cell division, pharmacology, hemostasis, or surgical technique—all can be improved by scientific investigation, which is then published and spoken about, and suddenly you realize that is teaching. So really, patient care, research, and teaching, for me, were, in the end, one thing all one. It all came back to the patient and your desire to do the very best for them now and in the future. I learned that very early on. In medical school, I worked on diseases of the nervous system that are still not treated, still not cured, to this day. But our treatments have improved, which gives me hope. That’s what we’re supposed to do for our patients. We strive to improve their lives and give them hope for the future. For me, that requires research. I started such research in the 1970s and since the 1980s on have had continuous grant funding for that research. That itself is an accomplishment. But I’m most proud that the work has impact for patient benefit. I work on the basics of atherosclerosis and stroke and of identifying who’s at greatest risk and who might benefit from interventions. If I can lay the scientific groundwork to identify the risk factors of stroke and work on the distribution of healthcare and health disparity, I can teach patients to take charge of their health and, when they are well-educated, take ownership for their recovery. When the 2015 Lancet Commission spoke on the need to educate surgeons to meet the massive shortage of basic surgical care in the world, I was asked to consult about what I did for neurosurgical education in low- and middle-income countries. I said yes, but I argued that at the same time we must have the World Health Organization (WHO) address stroke as well, because our work has shown that this would be the scourge of the developing world in the coming decade. I am proud that they have responded and have started the Lancet Commission on stroke in the low- and middle-income countries to address this. Things like that come from years of study, years of research. I cannot separate time for patients from time for research. I would argue the reason why I do research is because it is integral to my everyday patient care. If I’m doing it well, when I go to the clinic, patients ask me “Doc, how is your research coming?” Because they know I’m working on their problem. I cannot simply go away from patients and work in the lab. I have to make it integral to my every day. I designed our neurosurgical offices at the University of Wisconsin so that many of the surgeons need to walk through, or around, their labs to get to the OR. It becomes part of their every day to be talking to the scientists and the scientists to them. The scientists need the clinical issues to actualize their science, just as the physician needs the sciences to address the patient clinical need. The study of genomics is worthless unless someone can translate it to health and disease. Clinician scientists can and must do that.

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A surgeon-­scientist can speak both languages and translate surgical science to the public, to the patients, and, indeed, to the politicians. We are responsible to redirect the debate until healthcare becomes an individual priority, a national priority, and, at the same time, truly a global health priority. When the Lancet Commission was established for stroke in the developing world, I saw an opportunity to bring the stroke work home as well. If, indeed, medical research needs to take place in Africa, it needs to take place in Wisconsin just as well. Our university had been working with Native American tribes in our state for years. In a conversation with the elder council of one of the more prominent tribes in our state, they raised twofold concerns. One, they were concerned about stroke in their elders, and they were concerned about the premature loss of cognitive function, decision-making, and mental awareness, which is such a fear of our elders everywhere. I could truthfully say that was something I had been studying for years. Working with them, we developed a partnership on the problem at their invitation. This led to the partnership between the University of Wisconsin Comprehensive Stroke Program, which I co-lead, and the tribal Health Council to develop the project, “Stroke Prevention in the Native American Population.” Is it service? Yes. Is it research? Yes. Is it common sense? Yes. But, it’s an excellent example of being invited to a question by people with a need and developing a partnership in a preventive health program which we wish the tribe to have ownership. We simply partner to help. It’s a model developed over years of global health work and it’s gratifying to see it come home, to my own state.

Chapter 30

Native American Health

Health disparity needs are truly global and include our own backyards.

A medical career can be so busy, so chaotic that one can fall into habits and patterns to try to get through the day. I found that I needed to stop and reflect and reassess, maybe reinvent, many times in my career. It is a renewal that we all need that if one wishes to contribute, one needs to maintain a creativity, a vision based on experience if one wishes to impact positively the health of others in society. There are several threads in my life. When my wife told me to list my many fulltime jobs, VA doctoring, university doctor, teacher, researcher, etc., she had made her point. It was time to prioritize them. It was abundantly clear that I loved caring for patients with difficult problems and trying to change them. It was clear that I loved science and the scientific approach to the problem, my research. I loved to teach, to try to leave something after me so that people smarter than I would carry on the work, champion the patients, and do it in an innovative way. I clearly had a passion for disparity or underserved populations, low-middle income countries, trying to figure out ways to solve their problems, working with individuals while trying to influence societies and systems. I had for 40  years researched stroke and its devastation on life and society. Scientists estimate as many as 11 million people per year suffer at least silent strokes in the United States; perhaps one million are the more obvious ones leading to paralysis, blindness, and loss of speech or life, but the insidious ones are silent strokes, which we see on imaging. These seem to devastate society’s elders by loss of their cognition, their creativity, their judgement, and their decision-making in a premature fashion. It is a pre-Alzheimer’s state based on small vessel disease, small strokes as it were. Indeed, in some ways, the people that have had a warning sign, a motor weakness or loss of vision, just transient, may be fortunate enough to go and receive care for their risk factors: their hypertension, their diabetes, etc., before the big stroke or cognitive decline. These are lessons I learned over years of working

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with patients, and my research showed it time and time and again. I worked on ways to repair stroke, but mainly I tried to prevent it. It was in this background that I realized that my practice in Madison, though fulfilling, wasn’t diverse enough. As is always the case, when you feel something is missing, you look to your peers. Within this university are groups that work with minorities, and one particularly interacted with me on questions of population health. This was our Native American Center for Health Professionals (NACHP), which worked with our more than 11 Native American tribal nations in this region to distribute health information and models of care. I knew one important thing about Native Americans; as a group they possess the highest distribution of those risk factors leading to stroke of any group in the United States, fully a third more prevalence of risk factors than in all other racial and ethnic groups in the United States. Once that groundwork was done, things began to happen rapidly. After decades of emphasis on global health work, I reflected on my earlier work in Appalachia, Central and South America, and Africa. Remembering that the needs are everywhere—even in your own back yard—it made sense to look at Wisconsin. By this time, I was well known both for global health and for stroke research in prevention, acute intervention, and repair of the injured brain. I determined that I wanted to aim my research in as effective a way as possible by focusing on the disorders of greatest impact on the people I served. As I thought about my desire to serve the needs of the people around me, if one researched the number one US population for risk factors for stroke, it turned out not to be the groups you expected in the United States regarding ethnic or urban population, but rather it is rural Native Americans. Wisconsin has multiple such tribal nations. Knowing that, I looked into the stroke situation in Wisconsin, and, true to principles, this time, first I listened. By this time, I had learned to listen, and I listened to a particularly wonderful group, the elders of a Native American nation of northern Wisconsin. Within this tribe, as is true of many Native Americans, their respect for elders was culturally profound. Elders are a treasure and resource of the nation, a repository of the tribe’s history, language, and wisdom. As I spoke with them, they expressed their needs, including a tremendous concern about stroke and its risk factors, diabetes, and hypertension. But then they expressed their further concern about premature cognitive decline or dementia in these cherished elders. It became clear that this request was a summation of my medical interests and my prior research and clinical work. We talked for some time over years. We traveled to the reservation, listened, and met with the tribal leaders. We proposed, with them, a partnership of their health council and the Comprehensive Stroke Program of the University of Wisconsin, which I co-­ founded and co-lead. The loss of cognitive function in their elders was not just a personal loss. The elders are the tribal nation’s keepers of its language, traditions, principles, and history. Stroke and cognitive decline were exactly what I had been long researching. I was intrigued and went and listed some more. It became obvious that the tribe was interested and that they had invested time, money, and leadership in their health council. This was a superb group of people supporting the tribe’s health, including their clinic sited on the reservation, where 12,000 of the 18,000 tribal members received all of their healthcare. As we talked, I asked if they would

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be interested in a partnered program to decrease stroke. And indeed, they are. That was the start of the program, “Stroke Prevention in the Wisconsin Native American Population.” Together we worked out a culturally sensitive program in partnership to understand the unique risk factors for stroke in the tribe, to work to decrease them, and to scientifically study what interventions actually worked to decrease those risk factors. If doctors think that just telling a person to lose weight or watch their sugar intake is effective in the United States, then they aren’t looking at the people around us. Obesity and the toll it takes in diabetes and stroke continue to soar in the United States. With the elders, we decided to teach all ages of the tribe and to study intensively a select group of elders at risk for stroke. We developed health fairs with tribal activities where members could learn of stroke risks. Through a stroke scale, the high-risk patients could easily be identified. We’d ask if they wished to participate in intensive coaching by tribal members, we would train to try to modify their lifestyle risk factors. We would also devise programs for children to help to influence their elders to stop smoking, to exercise, and to have the children recognize the signs of stroke because often they are cared for by their elders and may be the one to identify a stroke or TIA and call for help. The ideas were clear. Could we identify the risk factors within the tribe, including specific or unique risk factors? Could we develop a program to change those risk factors for the entire tribe at every age? If one wishes to change diabetes, obesity, and smoking, you start with children. Not only do you develop healthy lifetime habits, but they influence their elders. In this world, the elders may often be babysitting the children. The children, in turn, may be more effective than I could be in getting the elders to stop smoking or address their risk factors for stroke. These children, if aware of the signs of stroke, may be the ones to call 9-1-1. The more we talked, the more ideas came. Native American physicians and Native American medical students asked to join. They would grill me mercilessly to try to see if I came as an interloper or a listener. Their enthusiastic embrace of the program suggests that they were satisfied and that this plan had value. The University of Wisconsin scientists wanted to join on because the project translated their science to services addressing medical needs. They could adapt their science to stroke prevention. One group works with the physics of blood flow and can non-invasively look at blood flow to the brain and see the flow patterns which suggest high risk of stroke. They can identify patients developing premature atherosclerosis and who would benefit best from stroke reduction strategies. Others looked at unique blood born proteins, which may signal past or even future strokes. The Tribal Health Council piggybacked this new science on their wonderful holistic programs for exercise, diabetes, and healthy nutrition and we went to work. During the process of developing the program, I learned so much. I learned that my basic principle that communication starts by listening was even more true here. When you meet people, they want to know your story. I’ve learned this with the Maori people of New Zealand, of wanting to know your story. There they would ask, “in what canoe did your family come to the island?” When I met with the Wisconsin tribal council, it was clear that I wanted to know their story, what hopes did the leaders have, and what they wished to show me of the tribe. If I would take

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some time to learn about their crops, their history, their connection to the land, their hopes for education, and their hopes to protect the youth and elders from the modern scourges of health, perhaps I could be trusted. I learned that all people are similar. They wish the best in the basic things that they value: family, health, peace, and faith. They respond to how they are treated. They respect others’ privacy. They not only want to be helped; they want to help. They want to participate. I don’t know if we’ll be able to change stroke incidences in an entire tribe, but I know I will try and I feel we will succeed. We are succeeding slowly. We wish to do more and, to do that, we must do it together.

Chapter 31

Children and Family in Global Health

Humanizing influences in medicine.

People ask what it’s like to involve your family in global health work. They ask about risks, and they ask about adventure, but I think they don’t realize the power of embracing a meaningful endeavor together. I always felt that I had that family support, whether they traveled with me or not, as all support each other in their own way. Indeed, some of the best support was from those that did not travel. They help prepare, they cared, they reassured, and they just were part of the family. When family did travel, they became an incredibly important link, a component that was important for our work to for succeed. What they did was humanize me as they involved the people of the area we thought we were going to help. It gradually dawned on me that the important thing was that we were invited and that the people of the region—be they the physicians, the patients, the wealthy, the poor, the volunteers, and the families—needed to be involved. We needed them to take ownership of the program of healthcare in their own land. In many ways my family were the eyes and ears of this process, the ones that would involve the middle class and encourage ownership by the locals. Many times, my wife, my daughter, and my son would simply work with the hospital volunteers in Ambato. They would welcome them when they recognized my wife’s gentle ability to have empathy with people that seemed very different but were really very much the same. Our hosts picked up on this immediately and welcomed us, where my more quiet and very focused ways would take some time for them to get used to. This is why my wife would quietly work to help a pregnant lady one year, and their family would come back to honor her a year later and have her meet the baby. My children were like that as well. Their incredibly infectious enthusiasm for everything in life would be embraced by every age of the people who we work with in South America and Africa. For my daughter, it did not matter if it was the professors in Africa, who she as an adult would interview for her work on the distribution of healthcare and the barriers to it in sub-Saharan Africa, or the children that she as © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_31

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a child would comfort in South America in the recovery room —all were included. Her ability to see and address the common needs of people made my work on the medical needs synergistic. I came to realize that nothing happens in a vacuum. The more this health project becomes part of the fabric of the region, with the people looking after each other through medical care, the more we would all learn and succeed. My wife and children saw culture through ways that no one could ever imagine as a tourist. To be invited to a traditional wedding is a gift outright. To see a low-­ income family’s pride in sharing a meal with you is something that came to me through my family. They interacted so easily with the culture we were immersed in. I truly believe it became much easier to involve the local doctors and healthcare workers because of Diane and the children’s humanizing presence. I also know when there came trouble, the local people would rally to our defense and safety, far more because of their presence. When an insurrection took place and I had to smuggle my family out, the locals took charge and found the driver with the ability to chart a course around roadblocks. When our children were young, trusted locals would say it is time for you to see our zoo or our waterfall or meet their children. My son one day met me at the hospital to report that he had seen a condor with a local family. This is a cultural experience that no tourist can ever have. Families are something universal; they are a way that we link people together. Families remind us of the universal experience of wanting the best for our children, be it in education, experience, health, nutrition, or safety. We all want our children to be fulfilled and have opportunity. That’s the invaluable lesson that a family can teach if you stop to listen.

Chapter 32

Danger

Responsibilities in global neurosurgery.

People ask what I fear on a global health trip. What do I fear about global health in general? In general is the easier question. We all fear failure. So many attempts have been tried over the years to assist others in global health. They often fail because their motivations aren’t direct. Many go to provide healthcare in an attempt to gain political advantage for their political state. Others provide healthcare to advance their religious beliefs, and some provide care to fill an emptiness inside themselves. I truly believe global health only succeeds when your work is invited, partnered, and developed in such a way that it may become a self-sustaining part of the culture of the region served. This is only possible when it is consistent with the cultural beliefs, hopes, and desires of the region served. In the end, the great teacher is surpassed by those they train. The teacher is forgotten, but a part of them lives on in the work of those they trained. Personal danger is a much more difficult question, because it embraces the ones you are responsible for, the family or volunteers who join you, the people you may educate in the region you serve, the patients, and their families. The lessons here are so many and they are learned slowly over time. I once was taken aside by a nurse in her rural Guatemalan village because I had provided too many dressing materials for one injured patient to take home. They warned me I would single the patient out for robbery and that it would be better to have him to return repeatedly to have the dressings done at the hospital. Things that I would never have conceived. I did not initially understand that in some areas if I trained healthcare providers, they could be perceived as a threat to the local guerillas or political factions because the trainee had assumed a leadership role in that society. That danger could come to those I trained was a chilling reminder that we needed relative peace to change health for the better. My consistent concerns, however, were always illness and transportation dangers. You expect and accept this risk in yourself, but you cannot tolerate it in your © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_32

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family and your volunteer team. To find volunteers you work with or family members sick is crushing. I have had to evacuate older volunteers who, at altitude, could not tolerate trivial viral infections. The commonness of dysenteric diseases throughout the world makes absolute precautions essential. In one episode, 18 volunteers simultaneously fell violently ill. The healthy ones of us had to finish operations where the primary surgeons fell ill. I would then run from room to room to nurse the sick volunteers. The tragic stories of all too common road accidents on mountainous washed-out roads mean I have to know who’s driving. Are they reliable, responsible? Who recommended the driver? A hospital fire due to poor wiring caused us to evacuate all and the next trip we brought two engineers to address wiring. The worst incident happened one clear, cool, mountainous day where an insurrection suddenly closed the roads. Transportation was stopped by roadblocks and the mountains were on fire as safety shut down. Unfortunately, my daughter and I were working at a small village clinic high in the mountains, hours removed from my wife at the main hospital in the blockaded city. All this was unknown to us, so when we were returning in the near sunset, we came upon the first simple roadblock, more peripheral from the trouble. We explained we were a medical team returning to the major hospital and we were passed by. It was a mistake. We soon learned we were trapped between roadblocks as far more violent factions emerged. At the second and third roadblock, angry men carrying machetes and frighteningly primitive weapons of wood with huge metal stakes pounded through them charged at our vehicle, which was stopped by barriers they had erected. The driver and I had nothing to protect ourselves or my daughter with, other than persuasion and presence. It is a strange thing. In emergencies sometimes, time slows down for a surgeon. This is no time for screaming. You work fast and decisively. You see one thing and the one thing in front of you, whether it’s to stop the bleeding or control the airway. A human brain is phenomenally vascular. A person can die from a major vessel bleeding in literally seconds. In the OR you rapidly work to gain proximal control of the bleeding or rapidly work through options of resuscitation. When someone charges your family with a machete, you can panic, or you can slow time and work fast. That day, the thing in front of me I had to concentrate on was their weapons and put myself between them and my daughter. A machete is a farm instrument, but a board with a spike through it is purposed built only to harm people. That’s the person you have to stop. Fortunately, we were still in surgical scrubs, including my daughter, and I stated firmly in their language that I was a North American surgeon that had to get to the main hospital. Seeing my daughter, laying in the back, stopped and confused them. We could not take a pleading tone, and we had to act quickly, calmly, and as if we belonged. I purposely said, “North American.” Certain factions, in certain times, in certain years, favored different countries because of the politics of the world. I had to make the urgency of the situation be medical and not political. They stopped, argued among themselves, and then pulled the barriers back and we passed. All were safe that day, including the patients at the clinics and the hospital, but such incidents change our lives forever. Sometimes for the better, sometimes for the worse, but they definitely do change us. I can never think of father and children

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without knowing the awesome responsibility that life’s unexpected incidences make for all. I can never think of those men without realizing that violence can never be our response. We can only pray to be the better person by living and dealing with the difficult truths that life brings us every day.

Chapter 33

Mistakes Made and Lessons Learned

Global neurosurgery lessons that apply every day and everywhere.

Life’s experiences should lead to constant learning. Unfortunately, one of the best teachers is always our mistakes, as long as we understand and correct them. I tell people there are four major lessons I’ve learned from decades of trying to work in global neurosurgery. They are as follows: My goal for global neurosurgery is self-sustaining care. The key idea is that throughout life not only must you be persistent, but you must be learning. I have learned a lot by mistakes. In my surgical career, the reason I pay attention to everyone’s cases is I don’t want to go through life without learning new things. I want to see what works; I want to go to our conferences and see what didn’t work. If you go into volunteerism, there are such stages when you learn far more than you serve. First, you’re overwhelmed because you try to do it all yourself. Next, you try in vain to fix everything. Then, in the final stage, education, you leave something that’s lasting that is not about you. It is their program. Everybody that goes into global health has these similar lofty goals, but nothing is lasting without something like education to give it permanence [3]. These stages of global health participation led to lessons learned. The first lesson I learned is that service alone is not sustained. The developing world is full of random clinics that were built and staffed and abandoned, because it wasn’t building infrastructure, education, or training. Well-intentioned surgeons flew in, did some surgeries, and left. The people left behind were worse by knowing what they were missing. The opposite example is a friend of mine from Kentucky. He was my partner years ago. I went to South America; he went to Africa. He built a neurosurgical hospital in Eastern Uganda. With it he built an educational program of and for Ugandans. It is a lasting, sustaining program, which is theirs. They become the mentors of the program which had trained them. That’s lasting. Now in sub-Saharan East Africa where previously no one was training in neurosurgery, we have hundreds that are training to be neurosurgeons or starting their practice.

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The low- and middle-income countries of the world are littered with failed health clinics, usually set up by different political factions for purposes tangential to healthcare or well-intentioned people trying to fill an emptiness of self. When a person wishes to justify their life by providing service, they have to understand that service is admirable and they have helped some dozens, hundred, or even thousands of people, but the need is in billions and the need will continue when your service is done. Episodic service trips to developing regions to provide healthcare cannot last. That provider will age, sicken, die, or lose interest. The need will always be tremendous. So, in my case, it had to be coupled with education and, gradually, an education program that could be self-sustaining and taken over by the local doctors, nurses, and health providers. To do it alone does not last. You must train the ones that will come after you, who will care for the people who are not even born yet and will still have needs. We who came to help become peripheral. We will become forgotten and that’s what should happen to the teacher; their trainees should surpass them. That’s the challenge, to understand that global health is not about yourself; it is about the people you serve and you making them into leaders. The second lesson I learned is never assume you know more than the people around you, because you don’t. I call it, “shut up and listen.” When someone appears saying, “I know what you need.” They never actually know. What you really find when you stop to listen is these local doctors are brilliant. They teach you how to work with few resources and how to work with challenges and how to overcome them. You just partner and help. I met a young nurse who lives and works in Haiti. She brought a child down from the mountains to our hospital in Port-au-Prince with obstructed hydrocephalus. She was tapping the child’s brain, daily for a month, and brought the child in on a bus for our help. The child had no fontanelle, meaning she had been pushing a needle through the skull daily to drain fluid and keep the child alive. I have always been both shocked and amazed by what good people in a difficult situation can do, how they would care for each other and how much I learned from them. I learned that lesson again in Ecuador when I made the mistake of thinking I knew what healthcare the Amazonas region needed. I was talking to their local health official. I said, “What’s your biggest need?”. I thought it was going to be ventilators and medication, but he said, “No, it’s dugout canoes. I need them to bring the patients in from down the Amazon.” Fortunately, I had been quiet because if you don’t shut up and listen when you are with dedicated people that know their world well, you’re going to look like a fool. Empathy is the key to understanding that you need to be invited. This is based on communication, and most important of all, the first part of communication is to listen. Time and time again, people, including myself early on, think they know what the needs of the people they serve are. They’ve read about it, they’ve seen videos, and they’ve made vacation trips to the region. In truth, the people who actually know the needs and have trialed the solutions and need your help carrying them through are the local people, the people you serve. This was made clear to me by the

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Amazonian healthcare workers. Then you provide that need and you begin to listen and plan as partners. A doctor who does not first listen to their patient will always miss symptoms. They will always miss signs and will never satisfy that patient’s needs. It is the same with any group, organization, or health system. First listen to the people you hope to partner with. They’re brilliant at what they do and brilliant in how they provide their care with minimal supplies. You will learn so much. You will learn techniques to not lose blood during a surgery. You will learn how few instruments you actually need in the OR. You will learn that issues that you felt were important may actually be trivial in their world and you learn that what is trivial to you is lifesaving there. You only learn those things by listening. The next lesson I learned is very little education takes place in a war zone. As a matter of fact, in a war zone, the people you educate are a threat to the wrong factions. They are ostracized or become refugees. I met a lady training to be the first female neurosurgeon in Mali. As before, I asked, “What was her biggest threat?”. I thought it was supplies and equipment, but she simply said, “It’s ‘Boko Haram.’” Boko haram forbids such education. She is an educated female in Mali. I came back and told our residents, “You have no problems. I have no problems. We’re going to support this person.” That’s what I love about listening and being inspired by brave people. They give a gift for which I am always thankful. You cannot provide a comprehensive education program in a warzone. You need a stable middle class, and you need a supportive government or one that wishes to achieve stability. In a warzone, medical care becomes episodic and temporary. Stabilize and evacuate is a very necessary part of medical care, but it does not provide a long-term healthcare solution. So, you must partner with government, you must partner with the middle class. You can use healthcare as an element of stability, equity, and peace. Even in a warzone, you can work in that fashion toward education and change, but you need to embrace peace, fairness, and safety as essential parts of healthcare if you wish to succeed. Fourth rule: you have obligations. You learn you may have to think on your feet. I once was working in a war zone, got out of the pickup truck and found nothing but rifles. I literally put on a juggling act for the children in that village until the guerillas decided I was either harmless or stupid and let me go. But sometimes you must learn to juggle more than rolls of tape. You juggle emotions; you juggle decisions. Sometimes you have to think on your feet and sometimes you have no answers at all. We all are responsible for our actions. In healthcare, you are also responsible for your patients, their families, your team, and your volunteers. You are responsible for those people that you came to listen to and you’re responsible that your trainees are able to achieve a position of respect within their society, which will allow them to continue to work. You hope to maintain the integrity or wholeness of what you do through the work of so many. Real progress comes in partnerships. If the army is protective and if the government helps organize the healthcare, you can have success. You’re responsible for the people you train, who may be ostracized or helped. You’re responsible for the

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volunteers you take with, the families, your own, and the patients’ families. They are your partners, and you can accomplish nothing without them. These are all hard lessons which came from decades of attempts and failures, of two steps forward and one step back, but they brought us to where we are today. Now we have organizations dedicated to education, invited to countries of need, partnering with the governments, people, patients, and physicians of that area. It must be a thoughtful program of growth, with a goal of becoming self-sustaining under the direction of the people of that country. There are many threats in the rocky road that is global neurosurgery: illness, transportation, civil unrest, and violence. Illness is real. Dysentery, not Ebola, is my major concern when working anywhere in low- and middle-income countries. I once had 18 volunteers fall sick at the same time, literally fell to the ground during their cases because they had not been careful with what they ate. I never drink or eat anything that I don’t know is clean and/or freshly cooked when I travel, so I was healthy. The next time I brought (a) strict food and drink criteria and (b) a doctor to take care of them. I did not want to be irresponsible in an area of need and have our group deplete the local resources for medical care. What’s the effect of COVID-19 on this kind of work? All international travel programs were postponed. In the first month of COVID-19, I postponed five continents of programs and that hurts. The need will be even greater when COVID-19 is in the past. Until then we have to continue the lessons taught. We work online and trust the work that we did to setup the systems of care will help the areas of need get through the COVID-19 crisis until we can be back and directly address the major health needs. But sometimes challenges can be inspirational. I thought that COVID-19 would shut teaching down, but it was our trainees worldwide who knew internet communication better than we did and soon hundreds of online courses developed into a bidirectional learning process. We developed virtual visiting professors and used technology to see into an OR half a world away and teach intraoperatively. Transportation is both a problem and a threat. My school had a group of medical students in South Africa studying medicine whose bus was hit by a train. On any travel I always want to know who’s driving. How do I make it safer? Natural disasters happen, but they’re not my major concern. Civil unrest is my biggest safety concern. FIENS has pulled whole programs out of countries near their election time. If a government is unstable, I’m concerned because the threat of violence is real. To have your co-workers, your family placed in jeopardy changes your life forever. In sum: First rule, service with education. Second rule, shut up and listen. That’s worldwide and that should be every day. Third rule, education requires stability. You can’t do it alone. You partner. You partner with government, the middle class, with anesthesia, and with critical care surgery. You don’t fight each other, you join, and your actions make you responsible for many.

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Fourth rule, you have obligations. The obligations to the patients you take care of are worldwide, but what you learn from global neurosurgery benefits all of us well into the future. That’s how you make it part of your everyday practice. What you learned in Africa comes home as well here. What you learned in medical school you never let go of. When you remember the nobility of your desire to be a doctor, it only makes sense if you spend every day making a world that is better for your patients, the ones in front of you now and the ones of the future, because you’re training the people to take care of them. These are lessons learned. They should be learned everywhere and applied every day with passion, purpose, and gratitude. The lessons learned in 28 countries apply to the US as well. This modern concept of centralization of the population is destroying rural areas. It’s so very obvious in Latin America, but of course, it’s happening here also. It’s very hard to get good health care in rural United States, because the geography is so huge. Throughout our country are great regions of need. Be it inner city Chicago or on a tribal land, these lessons apply every bit as much at home as in East Africa. Never lose sight of that. That’s why we started the stroke program on the Native American reservation. It’s right under our nose. They have the worst stroke risk in the United States and deserve to have that addressed as well.

Chapter 34

The Magic That Makes Us a Person

Aspects that separate neurosurgery from other branches of medicine but draw us closer to our patients.

A good surgeon knows when to be afraid; a good neurosurgeon knows why. When one is dealing with the very essence of a person’s self—their happiness, their memories, and their laughter— it is literally in your hands, and you always question if you can do enough. Can you do it cleanly? Can you do it well? To cut, repair, and heal the very soul of a person is what you’re called to do every day, the essence of wakefulness, personality, self, and love. How do you work on this and leave it better than you found it? That’s the challenge, and that challenge is always there, and it is an unrelenting foe. I always try to know the patient’s family, if at all possible, pre-operatively. I know that in an uncertain world post-operatively, I may save the patient, but it may be the family I’m talking to. A person can be rendered aphasic by a tumor, a stroke, an aneurysm, or the surgery to correct those. Descartes felt the seat of the soul, the human soul, resided in the depth of the brain in its center—a small gland called the pineal. He may not have been very far off. This mystery, what makes us unique, what makes us ourselves, is centered in this brain that challenges a neurosurgeon every day. You come home from the OR, or you meet people who talk about the challenges of their work or their office, and you reflect that you have been working in the middle of someone’s brainstem and trying to fix it. You say nothing, because the process, the risks, and the potential for good or harm are overwhelming and rarely spoken of. I work in a world where a patient’s life may be saved, but sometimes not the self of the person—their thoughts, their brilliance, and their cognitive skills. Those are the things that define them that are prized by your patient. That’s the challenge. It may be as simple as you operate on a person, and you spare their brainstem and their life but lose hearing from one ear or a function that they felt defined them. Or worse, they may never awaken from such a surgery. Each day you strive to provide the best surgical care in the world, and always you must not be satisfied. In a world of brain cancers, stroke, pain and congenital malformations of © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_34

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children’s brains, you cannot be satisfied with today’s best possible care, because none of it is good enough if you actually care about your patients. The brain cancer comes back. The stroke is stopped, but the damage remains. This is why one does research. This is why I push neurosurgery towards the field of regenerative neurosurgery. That is the study of the repair of the injured brain. It starts with the understanding of the proteases, genes, and connectomes that made the brain in the first place. If you understand that, can one recapitulate those processes to repair the brain? That’s what I study in my lab, because I start to wonder how can we help people heal? I feel strongly it will be done by harnessing the brain’s own processes, the ones that made the brain in the fetus remain in the adult brain and in its genes. We will try to re-harness them for future repair. It’s interesting to be in a profession where one tries to find “what is self,” what defines our identity or consciousness and our abilities. To a philosopher, these are theoretical questions. To a neurosurgeon, they are real and every day. To see the brain fog lift when you relieve pressure on an injured brain, to see families say that their matriarch is “back,” to see a tribal elder be restored, or to simply awaken someone whose consciousness had been lost by a bleed, a clot, a tumor, or a stroke is magic. People ask, “how do you do it?” Surgeons always defer that question with some deflection of an answer, minimizing the magic, but the truth is, we really don’t know how we do it. There’s nothing in our schooling, or preparation, that prepares you to take these risks every day, except you have to really care about the people that come to you. Today, two families in Madison, Wisconsin, tried to thank me and, embarrassed, I tried to deflect it. One talked of getting her life back when she was suddenly freed of the mysterious, suicidal pain of trigeminal neuralgia and the incredible fog of the medications that had unsuccessfully tried to control it. Suddenly the pain was gone by a surgery at the brainstem, correcting the cause. The other family spoke of getting their father back when his tumor, with its swelling and brain distortion, was relieved. Both of them were thankful to the person of their surgeon, which is something we can deflect as we talk about the team that supports us. We’re just doing our job. But both of them implied something more profound that there were forces we do not understand or control. One said, “I don’t know if you believe in God, but...” The other simply implied such things. There are forces we don’t control that make our life mysterious and sometimes allow people to do things they truly don’t think they’re capable of. All of us have a life story, whether they be surgeon or patient. All of us worked hard to develop that person that we are, and all of us know that some of it was not under our control. And so, you try, and you try every day, and you try to improve every day. And if you get good at it, you try to spread that knowledge. You try to care for people worldwide and you try to teach it worldwide, because you realize you can care for relatively few, but those you train may change the lives of many. So, you go on and sometimes you are afraid, and most of the time you never show it and all the times you are amazed, because, when one sees the living brain, one has to marvel at it—its capability, its beauty, its potential, and its mystery. I am known as a multitasker. I balance multiple laboratories, clinics, rounds, teaching, research, and administrative care, but the OR is the different place for me.

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It is the one place where I focus on one person, one responsibility, and one job. I prepare for it carefully. I prepare alternative plans if the unexpected happens, I work through them, and I never lose sight of the patient or the person in front of me. For a multitasker, the ability to focus on one thing brings out the best in me and brings a reassurance that all the work makes sense that all of it has a particular resolution or goal, even if it is only a resolution for one patient before you. That occupies everything and you find yourself in a situation some call “flow.” Time disappears, focus is present, and you think of steps and steps ahead until you solve the problem before you. When the patient awakes it is magical and you know you’ve done something that made all the work worthwhile. If you can return them to their family whole or better than they were, you know that for a short period of time the mysteries made sense. I often try to make marveling at the mystery and magic of the brain sound humorous. During a posterior fossa operation, the brainstem shows us its cranial nerve functions. These are an incredibly complex, unimaginably successful strategy to give and receive information to and from the vital part of the brain that controls wakefulness, vision, smell, hearing, breathing, and heartbeat. I show it to the students and describe it as “God’s greatest creation” and then trying to insert some humor say, “followed closely by Yosemite Valley.” But it is that brain that is our window to the beauty of life and who we are. It is an awesome responsibility to know you are trusted with that care. You can approach that one of two ways: you can be overwhelmed, or you can be grateful for the opportunity to serve. And if so, you do it to the very best of your ability and you then try to do it better because your patients need you to.

Chapter 35

What Did We Learn from COVID-19

Global health comes to our everyday lives with the COVID-19 pandemic.

The year 2020 brought a shocking reality to a complacent world. COVID-19 showed that this novel coronavirus could defeat armies, economies, world leaders, and unprepared, everyday people. What had been only a rumor in the background in late 2019 exploded upon the world in the late winter and spring of 2020. Historically, major infectious outbreaks in Africa, South America, and Asia, such as Malaria, Zika, AIDS, and then Ebola had been far in the background of the average American’s consciousness. Even when something like AIDS came to the United States, the vast majority of people felt it was not a problem for them but rather a lifestyle problem for others. COVID-19 changed that in ways that hadn’t been seen since the middle part of the twentieth century. Historically, major outbreaks—leprosy, polio, tuberculosis, bubonic plague, and cholera—had swept through civilized and uncivilized regions, indiscriminately. The wealthy would try to flee the larger cities, not knowing but sensing that isolating themselves from infected people would somehow be important. 2020 had brought a smugness to high-income countries, like the United States, that such diseases were either of the past or of nations and regions of the world that were still living like it was the past. When the pandemic overwhelmed the extremely modern hospitals of New  York City, the reaction was chaotic. Many health systems, including my own, essentially tried to close their doors and to do only essential services with really skeleton crews. Tremendous burdens fell upon the providers, nurses, staff, and physicians, who remained in ER, respiratory, critical care, and emergency surgery. When those providers, too, fell sick, a type of slow panic ensued. As economies closed and as restaurants, business, factories, theaters, and preventive medicine clinics closed, the economy cratered, and the health system suffered a self-inflicted wound. The major scourges of the twenty-first century in our society—hypertension, diabetes, and obesity—require preventive care and checkups. Absent that, the diseases they cause—cardiac infarction, renal failure, strokes, and intracranial © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_35

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hemorrhages—soared. Screening for cancer risk were cut back, meaning that numerous people missed the opportunity to find their breast cancer, or other diseases, early and in more treatable stages. Healthcare learned slowly that a crisis does not mean that we abandon our base job. In healthcare, we must take care of the entire patient, the entire society, and all of the diseases. It’s true that sometimes you must emphasize one over the other, but not forget the other, because while the pandemic may kill millions, cancer, heart disease, hypertension, and diabetes can kill more. Unchecked, such diseases surge and a society’s health plummets. The lessons were equally stark in global health. Our traditional models of global health were hands on. Doctors traveled to a region to teach; trainees traveled to centers to learn. Travel was curtailed by the pandemic and its fears. Schedules such as mine, which in the year prior may have included five continents of teaching, had to stop for fear of becoming a super spreader. It took a while, but we learned to use the tools of our time, which were electronic, virtual, and computer based. We developed self-teaching websites for hypertension, diabetes control, stroke avoidance, and stroke risk factors. We embraced technology from industry, and virtual reality platforms allowed us to use “green screen,” connecting a doctor in their operating room in a low- or middle-income country to a mentor in the United States so that anatomy could be explained and discussed in real time. Surgical questions could be asked and answered. We all became very good at online meetings and used shared video and audio for education. It became our new platform and our major avenue of education. The impact was not as deep or thorough as being there in person, but it was broader and many more were impacted. Resources then are needed to bring people in the low- and middle-income countries online. Today, hardware, software, and WIFI connectivity allow such education. Surgical equipment is still needed and could be shipped, but instruction then had to be virtual. We learned that we could regroup, report, and emphasize our core principles. We could serve through education, even when it was not in person. We modified fellowships to make them virtual, with one-on-one coaching by senior faculty from FIENS and other groups with the fellows in training. We learned that we could connect more often, in many ways making up for the lack of the in-person connectivity. None of this solves the problems of global health, none of this solves COVID-19. But the principles of global health—partnering with sanitation, transportation, and public health—are also the basic keys to controlling any pandemic. So those educational principles we stood for from the beginning would hold in good stead those areas we worked to develop. Certainly, during COVID-19, neurosurgeons were repurposed to pulmonary care in some centers, but the neurosurgical need was actually increased by the pandemic. Brain tumors often presented quite late and critically ill. COVID-19 renders patients hypercoagulable, and we believe it causes an inflammatory vasculopathy, which greatly increases the risk of heart attack and stroke. COVID-19 isolates high-risk patients who fear to travel for fear of catching the disease, but when they do not travel, they do not see their doctor, they do not renew their medicines, they do not have their blood pressure or diabetic A1C checked, and they suffer the multi-organ consequences of untreated risk factors.

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Finally, we learned a lot about ourselves. The great capability of a healthcare provider is to inspire in a time of fear or crisis. All of us remember the terrible terrorist bombings of the Boston Marathon. Sequential bombs went off. Police were sure that there would be more. Indeed, the bombers did have more, but the thing I remember most was that as those bombs went off, the nurses, doctors, and EMTs at the finish line ran into the danger to help. That’s what doctors and nurses do in a crisis and after an initial period of COVID-19 chaos and fear, doctors, nurses, and healthcare professionals reorganized and attacked the COVID-19 problem. They did it with strength, compassion, intellect, and selfless wisdom. What I learned from COVID-19 was that I am very proud to be a doctor. I’m very proud of the people I associate with. I’m very proud of the fact that we are all in this together, and we are one people who all have something to give to help each other, whether it’s computer skills, medical skills, compassion, or teams of quilt makers sewing masks for homes for disabled and special need patients. There is inspiration in good people’s response to a crisis. That’s what I learned from COVID-19.

Chapter 36

On Death

The true impact of the lack of access to essential surgery for the majority of the world.

Surgeons are faced with death every day. The prospect that something could go horribly wrong during a surgery is coupled with the certainty that we deal with diseases which sometimes are not curable. We see death both acutely, perhaps in the emergency room after a massive trauma, and chronically. Some patients have genetic conditions which cause them to recurrently develop brain tumors. You may treat for decades, removing literally dozens of tumors until the cumulative total of the tumors becomes untreatable. These are people who had become family to you. They are known to everyone in your clinic; every nurse, every staff person, and every medical assistant know them, and they are cherished. Yet, they still sicken and may die in spite of your efforts. The situation is no different worldwide. You’re teaching in Africa and a family comes to you. They are desperation and hope combined. Somehow, they’ve won life’s mysterious lottery, and they and their sick loved one find themselves in that waiting room when you are there. Your presence allows the local doctors to consider doing a needed operative procedure they usually would not. The surgery would be extremely difficult under ideal conditions, and the conditions you find in this hospital are not ideal. The family speaks the universal language that requires no translation. It is hope. It is fear. It is prayer. It is desperation. It is an appeal to deity. It is great fear of the unknown. Surgeons have seen that so many times that they know the unspoken language and, in truth, they share the very same fears. While all doctors understand the ephemeral nature of life and fear to question their own health, medical students assume they have every disease they read about. Good doctors have to control that personal fear and put it out of mind, but good surgeons never forget their patients. It is so difficult to explain to somebody that they are going to die. It is so difficult to go out to a waiting room and tell the family that no matter how well the surgery went, the diagnosis discovered is not curable, at least not in our present time. While such moments stimulate your absolute desire to do research, © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_36

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to try to find a better way, you still have to deal with today. The world is full of ways to deal with such things: research, philosophy, avoidance, and faith. No one really knows the best path, but each of us develops our own ways to cope and still be productive, still be solid, and still be useful to others. There are still surgeries to do that need you to continue to be focused, skilled, complete, safe, and effective for the next patient. I once worked upon a tiny child in South America who came to us seizing with failure to thrive. She had not been able to feed or maintain her weight. She was a tiny infant, 6 months in age. This was a condition which usually would go undiagnosed and be rapidly fatal. The question was, could I do anything? The answer was, I did not know. My experience and the physical examination I did told me this had to be a structural brain mass. In those days, the charity hospital had no way to study the brain. The only MRI scanners were 8 hours away in the capitol, but a CAT scanner had been purchased by a private group of radiologists in this city. The cost, of course, was impossible for this family to bear. But all of the volunteers and supporters rallied and appealed to the owners of this scanner who they knew. This showed me the importance of a middle class in a country that would take ownership for their country’s health needs. This scan was provided with some financial support from those of us who could. It showed that the child had a massive abscess, but that could be treated, often successfully in our country. The question was, could it be done there? The alternative is certain death. So, we put the team together. Fortunately, we were traveling with a very good pediatric anesthesiologist, the most important part of this surgery. I’ve done such surgery often under ideal conditions, but the less-­ than-­ideal conditions are concerning. Anesthesia was magnificent and the child survived. The diagnosis was made, the abscess removed, and then a whole team of people organized, and we supported the antibiotic care that the child would need to completely recover. Tremendous modern resources were mobilized to save one life. In a world where death can be so common, life may seem cheapened. These decisions about the value of life, about the meaning of death, are for all men and women to make. The neurosurgeon only knows that they are at the front lines of the battle and have to decide their own moral compass. They have to do what is best, and they have to soldier on and hope that our society will keep pace. Conversely, a neurosurgeon must know when it’s time to realize that all we can give is comfort. Sometimes we do that by a needed surgery, sometimes in our presence, and sometimes in our calmness. There are so many things we cannot fix, but then we palliate. If that give comforts, then we have done our job well. These are lessons learned, indeed. The preamble about life and death and the value of one life brings us to the Lancet Report of 2015. If 47 million deaths over the next few years are unnecessary in our world and could be prevented by timely surgery, then the lesson learned from fighting so hard to save one life makes it sensible to try to save millions. I cannot do 47 million surgeries. At one time I blindly went about just doing as many as I could, as fast as I could. But now I understand success will come by partnering with a society that recognizes this need. My job is to train neurosurgeons and mobilize the billions of people who together will solve these problems. We need take the lessons

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learned globally and provide the modern surgical health service not just in the Capitol cities of the world, but into the secondary cities and beyond wherever the patients are. By carefully improving care for trauma, salvageable tumors, infection, congenital anomalies, and stroke, we can do so much better. Only then will we see progress. We may never fully understand the value of life and death, but our daily experiences teach us the battles before us and that the comfort we give to patient and family make that battle worth fighting.

Chapter 37

The Way Forward

Each helps in their own way with their own talents.

A neurosurgical procedure in some ways follows the cycle of a lifetime. Planning and preparation are followed by a beginning. There are immense challenges, successes, and even failures along the way. The finish can be rushed, but it is usually quiet and reflective as to what has come before. Cases can be quite long, as lifetime can be and, therefore, both are subject to reflection, learning, and change. The lives we all lead are each unique, yet also so very similar. We all face immense challenges, endless successes, and failures and somehow manage to regroup and try another day. It is never possible to succeed if we forget the lessons learned along the way. A good surgeon who learns and improves from each surgery also finds lessons learned to chart a better path or better surgeries or better care into the future. The similarities to the world today are many. We see so much need; we have successes, awards, and small victories; and yet, we see overwhelming diseases, senseless wars, manmade disasters, and a world that naturally can throw unexpected challenges our way. How do we keep going? How do we keep caring? We have to learn each day, each surgery, each person, each patient, and each challenge, no matter what our career is. I have traveled worldwide, I have seen great needs, and I have seen very good people try to right them and I know they need help and they need partners. I know that healthcare and, indeed, specialized surgical healthcare must play a part in that. So many times, you see people who hope for health, peace, safety, food, water, and shelter. I believe that people all striving for faith, peace, health, and family understand that if one of those pillars fails, all may fail. If we all in our own way do something to support one pillar, it may strengthen all of them. I am not a civil engineer; those people do such wonderous things to bring clean water to places where there was none. I am not a diplomat, those people who, if properly motivated, can preserve peace and provide justice. But I am a neurosurgeon and I am a teacher, and I believe those tools can help provide health in a world where concern for others © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_37

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must be made victorious, overcoming a world where the other is considered different and, therefore, an enemy to be vanquished. There is no other. We are all one people and my small component—my small gift—could be to provide better healthcare, which I believe is as essential as clean water, nutrition, shelter, and safety for the good of our fellow people. I truly believe that good health and healthcare can be the basis of peace. It requires cooperation of all, it requires concern for the other, and in the practice, it makes us all better. In the end, that has been my way forward. Help provide for each other by trying to do well what I know best. That is neurosurgical healthcare; it is teaching. Because through teaching the benefits can be not only immediate in my own patients, but ongoing in the patients that are cared for by those that I have taught. When we have enough empathy to realize that care for others improves all, including ourselves, then we see the way forward to a better world.

Chapter 38

Epilogue

The future is here, and it is of and for people.

I have just returned from Vietnam. There I met people who were not consumed by past wars or grievances or historic loss, rather they were like all people worldwide: wanting a better life and better health for their family and for their children. I met a young mother who feared that her child wouldn’t be able to walk, I met family after family grateful for medical care, and I met young students innumerable, hoping for a better life, some from very poor villages and rural areas who had shown the intelligence and desire needed to treat people in medicine and have been enrolled in a medical school because it was available to them. The course we taught was to bring people interested in neurosurgery up to an international standard of education. This course we taught first in the United States and then throughout the world. We always teach with a cadre of teachers from famous international neurosurgical programs working side by side with an even larger group of teachers from the area being served. Working side by side, we appreciate their skills and we each realize that we are equal worldwide. More importantly, the young faculty doctors in the low- and middle-income countries realize that they can teach, they can collaborate, and they can have input to education and change their world. I think that all of us have that good—to change the world. It is a crazy world. There is war. Throughout my entire life, there has been war. The site may change and the grievance may change, but it is really the same war. Interestingly enough, it rarely involves that everyday person you meet when you work in the hospital. There are the good people that care for their families. Their leaders may be misguided and war, conflict, poverty, and corruption result, but the people, they are the best, and this is reinforced worldwide again and again. I make lasting friends, and their gratitude is the same as my gratitude for meeting them, because I learned, and I know that all of us want to be an instrument of peace. For me, I have decided that there are many ways to do that, diplomacy, food production, education, and security, but for me it is healthcare. Where good healthcare is © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9_38

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provided, peace is possible. The two are interlocked. Where good healthcare is provided, optimism comes to the future because families begin to feel there is a future for their children, not one of dysentery, avoidable deaths and missed surgical diseases which afflicts so many millions worldwide. These can be prevented. That is my lifelong hope that I can contribute to peace through providing healthcare and education, to magnify that provision through the people I teach. I believe that has a strong impact. I’ve seen it in Africa, I’ve seen it in Asia, I’ve seen it in Central and South America, and I’ve seen it in the United States. This month I got to see it in Vietnam, where historic rivals become today’s colleagues, and we come to understand the family of man is richer for each of our very individual contributions. Each trying in their own way to do something—be it carpentry, teaching, dishwashing, or neurosurgery—makes a contribution if they do it with and for others. So, we celebrate these contributions because we are one people. When we highlight our commonalities, our hopes, aspirations, beliefs, and not our differences, we no longer see people as the other, but as our brothers and sisters in a world of possibility.

References

1. Mukhopadhyay S, Punchak M, Rattani A, Hung YC, Dahm J, Faruque S, Park KB, et  al. The global neurosurgical workforce: a mixed-methods assessment of density and growth. J Neurosurg. 2019;130(4):1142–8. 2. Meara JG, Greenberg SL.  The lancet commission on global surgery global surgery 2030: evidence and solutions for achieving health, welfare and economic development. Surgery. 2015;157(5):834–5. 3. Dempsey KE, Qureshi MM, Ondoma SM, Dempsey RJ.  Effect of geopolitical forces on ­neurosurgical training in sub-Saharan Africa. World Neurosurg. 2017;101:196–202.

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9

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Index

A Africa, 29, 50, 52, 54, 55, 61, 67, 68, 74, 86, 88, 96, 99, 100, 107, 113, 123, 133, 140 Acquired immunodeficiency syndrome (AIDS), 129 Altruism, 94 America, 26, 29, 47, 68, 129, 140 American Association of Neurological Surgeons (AANS), 86 Anesthesia, 1, 50, 53, 70, 96, 134 Antibiotics, 52, 61 Arachnoid membrane, 2 Asia, 64, 68, 74, 140 Aspirations, 25 Atherosclerosis, 106 B Benign brain tumor, 53, 68, 70, 95 Bidirectional, 5, 32, 61, 73, 74 Blood pressure, 26 Blood transfusion, 69 Bootcamp, 85–88 Brain abscess surgery, 62 Brain aneurysm, 1, 3, 61, 62 Brain cancer/tumor, 18, 47, 126 Brainstem, 127 C Cancer, 11, 35 Cardiovascular disease, 96 Career transitions, 29 CAT scan, 24, 61, 62, 74

Central Asia, 66 Central nervous system, 95 Centralization, 123 Cerebral palsy, 11 Cerebrospinal fluid (CSF), 77 Certification bodies, 81 Coagulation, 77 Coal, 17, 24, 25 Colonialism, 45 Commonality, 5 Communication, 46 Community surgery, 26 Congenital malformation, 54 Congress of Neurological Surgeons (CNS), 86 Continuing medical education (CME), 85 COVID-19, 40, 82, 83, 122, 129–131 “Crime and Punishment”, 13 Culture, 13, 114 D Danger, 115–117 Death, 133–135 Degree of safety, 55 Dementia, 110 Diabetes, 18, 26, 51, 109 “Dirty Rain”, 29 Doctoring, 101–105 Dysenteric diseases, 116 E Economic growth, 39 Education, 39 Education offering, 66

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 R. J. Dempsey, Global Neurosurgery, https://doi.org/10.1007/978-3-031-41049-9

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144 Educational system, 61 Electronic communication, 66 Emergency room, 27 Empathy, 57, 58, 101–104, 113, 120, 138 Epidural hematoma, 26 Epilogue, 139, 140 Essential surgery, 52, 78, 133–135 F Family support, 113 Follow-up care, 38, 60 Foundation for International Education for Neurological Surgery (FIENS), 63–66, 73, 74, 77, 81, 82, 86, 90, 94, 96 G Genetics, 133 Genomics, 106 Global economy, 15–18 Global health, 5–7, 9, 10, 15, 16, 20–22, 29, 31–41, 46–48, 56, 57, 63, 65, 73, 81, 93, 104, 107, 110, 115, 119, 120, 129–131 children and family, 113, 114 Global medicine, 38 Global neurosurgery, 6, 7, 19, 32, 56, 63, 67, 68, 73–75, 77–79, 81–84, 91, 99, 103, 119 benefits, 123 constant learning, 119–123 responsibilities in, 115–117 rocky road, 122 Global peace, 31–34 Good health, 123, 138 Guatemala, 29 Guerilla and military forces, 31 H Head nurse, 72 Health care quality, 65 Health care system, 74 Health disparity, 6, 32, 45–49, 82, 94, 104, 106, 109–112 Health education, 32 Healthcare program, 7 Healthcare system, 10, 35, 38, 43, 49, 51, 53, 54, 69, 81, 82, 97, 129, 130, 138, 139

Index Hemorrhages, 60 Hemostasis, 52, 61, 71 Hierarchy systems, 49 Hippocrates, 5 Humanity, 31, 43, 100 Humility, 21, 52, 55, 56 Hydrocephalus, 38, 51, 60, 61, 77, 120 Hypertension, 18, 51, 109 I ICU care, 47 Indigenous culture, 31–34, 45 Infection, 51, 70 Informed consent, 60 Inspiration, 6 Integrity, 105–107, 121 Interaction, 86 International customs, 51 International standard of education, 139 Intraoperative surgical education, 55 Ischemic and hemorrhagic stroke, 83 L 2015 Lancet Commission, 81–84, 96, 106 Latin America, 49, 55 Liability, 47 Lincoln, A., 7 Low-and middle-income countries (LMIC), 49, 73–75, 77, 79, 81, 85–88, 95, 104, 106, 109, 120, 122, 130, 139 M Magnetic resonance imaging (MRI), 61, 74, 134 Mayan culture, 31 Medical care, 23, 32, 33, 37, 38, 61 Medical complication, 17 Medical diaspora, 46 Medical education, 32, 34, 45, 46, 53, 74, 85–91 Medical needs, 14 Mentor, 40, 41 Micro culture, 18 Milestones, 85, 86 Mining, 18 Missions, 45, 46 Mobile homes, 18, 24 Motivation, 93, 94

Index N Native America, 109–112 Native American Center for Health Professionals (NACHP), 110 Natural disaster, 74 Neonatal infections, 60 Neurologic deficit, 26 Neuropathology, 98 Neurosurgery, 6, 9, 14, 26, 27, 32, 39–41, 43, 45, 46, 49–54, 63, 65, 67, 69, 73, 74, 77–79, 85, 88, 90, 93–96, 100, 101, 103, 105, 119, 125–127, 139, 140 planning and preparation, 137 Neurosurgical training program, 53 Nobility, 6, 9 North America, 53 Northern Indiana Children’s Hospital, 13 Nutrition deficiency, 51 O Obesity, 51, 111 Operative equipment, 13 Orthopedics, 27 P Parasites, 46 Passion, 93, 94 Paucity, 16 Pediatric heart disease, 37 Persistence, 93, 94 Personal protective equipment (PPE), 40 Pestilence, 29 Philanthropy, 47, 66 Pineal, 125 Postnatal care, 20 Post-operative care, 46, 47, 71 Poverty, 26 Prenatal care, 20 Pre-op care, 46 Program and encourage leadership, 40 Public hospital, 59 Public service, 49 Q Quality of care, 73 R Regional programs, 54

145 Retroorbital pressure, 25 Rhythm to life, 71 Rural medicine, 21, 35–38 S Scholarships, 13 Scientific investigation, 106 Self-sustaining program, 63, 73, 93, 94 Self-sustaining system, 40, 65, 67, 79 Semi-IQ tests, 12 Service through education, 31, 34, 48, 56, 63, 65, 79, 81, 95–98, 101 Service-learning, 7 Silk sutures, 63 “Social security”, 49 Society of neurological surgeons (SNS), 65, 85 South America, 49, 59, 61, 113, 134 Spinal dysmorphism, 51 Spine defect, 51 Stroke, 11, 14, 17, 18, 51, 79, 83, 96, 106, 109–111 “Stroke Prevention in the Wisconsin Native American Population”, 111 Sub-Saharan Africa, 104 Sub-Saharan West Africa, 66 Surgery, 1, 69–72, 87, 96, 100, 104, 125, 133, 134, 137 Surgical microscope, 78 T Talent, 137, 138 Teams of lawyers, 17 Transportation, 16, 35–38, 40, 116, 122 Traumatic brain injury, 26, 52 Trigeminal neuralgia, 126 Truckers, 22 U United States, 2, 5, 23, 36, 56, 77, 140 U.S. Neurosurgical Society, 63 V Vascular disease, 17 Ventriculostomy, 88 Vitamin and nutritional deficits, 51 Volcanic eruption, 41 Volunteer illness, 41

146 W World Bank, 78, 82, 83 World Federation of Neurosurgical Societies (WFNS), 73, 74, 77 World Health Organization (WHO), 79, 82, 83, 104, 106

Index Worldwide specialty medical care, 9 X X-rays, 61