What's in a Name? “Global Neurosurgery” in the 21st Century

Commonly accepted definitions of “global” include 1) “relating to the whole world”, and 2) “relating to all parts or the whole of something”.¹

A PubMed search (June 5, 2020) of articles containing “global neurosurgery” in the title or abstract yielded 75 results. All but 7 of the 75 were published after 2016: 5 in 2017, 19 in 2018, and 22 both in 2019 and in 2020 through June 5, 2020. Only 1 was published before 2011—a 1995 article by Dwight Parkinson in the Journal of Neurosurgery entitled “Early History of Neurosurgery in Manitoba: Threads in a Tapestry of World Neurosurgery”.² The second and final sentence of the abstract reads, “Highlights of global neurosurgery are spliced into the author's reminiscences to anchor the local history with that of neurosurgery as a whole.”

Was global neurosurgery virtually nonexistent before the 21st century? What is the commonly accepted meaning of global neurosurgery? What should the goals be of the global (i.e., worldwide) neurosurgical community?

“Those Who Ignore Neurosurgery's Past are Condemned to Patent Infringement!”

With apologies for perverting the famous quote by George Santayana, it is appropriate that Santayana was quite a “citizen of the world.”³ Born in Spain in 1863, he moved to Boston in 1869; following graduation from Harvard College in 1886, he spent 2 years studying in Berlin before returning to Harvard until 1896—when he went to King's College Cambridge for 1 year. He returned to Europe in 1912, living in Spain, France, and England before settling in Rome until his death in 1952.

The “father” of American neurosurgery, Harvey Cushing, also spent a formative period in international settings.⁴ For over a year (1900–1901), he visited neurosurgical centers in England, France, Switzerland, Italy, and Germany. During the century since, neurosurgeons-in-training worldwide have traveled to centers outside their home country to broaden their knowledge and surgical skills. This is certainly a form of global neurosurgery.

In the latter part of the 20th century, individual neurosurgeons from developed countries devoted themselves to improving neurosurgery in developing countries. At the risk of offending the many who are not mentioned here, the list includes David Fairholm and Merwyn Bagan, who under the auspices of the Foundation for International Education in Neurological Surgery (FIENS) established or enhanced neurosurgical training programs in Taiwan, Indonesia, and Nepal.^{5 , 6}

In the first decade of the 21st century, similar efforts by developed country neurosurgeons have improved neurosurgery in developing countries. Examples (again at the risk of offending many others) include Benjamin Warf's introduction of endoscopic third ventriculostomy for hydrocephalus and the Cure Neuro training program in Uganda, and the training of medical officers to perform neurosurgical procedures in rural Tanzania by Dilantha Ellegala.^{7 , 8} The latter project led to the development of Madaktari Africa—a program for Tanzanian health care personnel to train other Tanzanians in neurosurgery and other surgical specialties.

Other examples of global neurosurgery, begun in many cases decades ago, include the training centers of the World Federation of Neurosurgical Societies (WFNS), and numerous nongovernmental and faith-based training and care delivery programs in developing countries.^{9 , 10} A more recent trend has been “twinning” programs, which are collaborations between a training center in a developed country with 1 in a developing country.^{10 , 11}

If one wished to patent (or, more appropriately, trademark) the term “global neurosurgery” in the second decade of the 21st century, it would be denied by the United States Patent Office¹²:

“In order for an invention to be patentable it must be new as defined in the patent law, which provides that an invention cannot be patented if: …the claimed invention was patented, described in a printed publication, or in public use, on sale, or otherwise available to the public before the effective filing date of the claimed invention.”

What is novel or innovative about the recent articles resulting in the plethoric use of the term “global neurosurgery” in the past few years?

Is Global Neurosurgery Like Pornography? Do We Know It When We See It?

In 1964, U.S. Supreme Court Justice Potter Stewart, in the case Jacobellis v. Ohio (concerning whether or not a movie was obscene or “hardcore pornography”), stated¹³:

“I shall not today attempt further to define the kinds of material I understand to be embraced within that shorthand description [“hard-core pornography”]…But I know it when I see it.”

How should we describe global neurosurgery? Is there indeed something unique in the articles in the past few years that was not present previously? Is it the case “we know global neurosurgery when we see it?”

Consider the titles of the 7 articles (of the 75 articles noted earlier) published in 2020 in World Neurosurgery:

• •Pediatric Neurosurgery in East Africa: An Education and Needs-Based Survey
• •Epidemiology and Pattern of Traumatic Brain Injuries at Annapurna Neurological Institute & Allied Sciences, Kathmandu, Nepal
• •Barriers to Management of Nontraumatic Neurosurgical Diseases at 2 Cameroonian Neurosurgical Centers: Cross-Sectional Study
• •Training Neurosurgeons in Myanmar and Surrounding Countries: The Resident Perspective
• •The Impact of Work-Related Factors on Risk of Resident Burnout: A Global Neurosurgery Pilot Study
• •Review of the Highlights from the First Annual Global Neurosurgery 2019: A Practical Symposium
• •The College of Surgeons of East, Central, and Southern Africa: Successes and Challenges in Standardizing Neurosurgical Training

All but 2 of these articles concern neurosurgery at 1 or 2 centers in a single country (#2, #3), or regional neurosurgery (#1, #4, #7). Only #5 and #6 can be considered truly global neurosurgery in scope. Article #6 describes a conference held in January 2019 at a neurosurgical center in the United States, one which is representative of a host of such conferences scheduled since then. How do these conferences differ from the Congresses held by the WFNS for over 50 years? The difference appears to be their smaller scale and their focus on bringing neurosurgeons from many countries to a specific institution (rather than a convention center or similar “neutral ground”). More recently the WFNS has begun a series of International Symposia that are quite similar to Global Neurosurgery Symposia, such as the one described in #6.¹⁴

Again, we are left with the question “What makes the term ‘global neurosurgery’ a recent phenomenon?” Are we left with “If it looks like Global Neurosurgery, acts like Global Neurosurgery, and calls itself Global Neurosurgery—then it is Global Neurosurgery?”

All Neurosurgery is Local—or is It?

In the early 1980s, the Speaker of the U.S. House of Representatives Tip O'Neill is credited with coining the phrase “All politics is local.”¹⁵ He argued that success both in elections and in legislation came from focusing on local issues and the local population. Decades later—in the past 5 years—it has been argued that the trend in the United States (and likely in other countries) is toward more global issues as the key to political success.¹⁶ These issues might include conservative versus liberal views, religious and/or racial differences, economic status, nationalistic isolation versus global integration, and others.

Could this trend away from local issues and toward more general or global issues apply to neurosurgery also?

With the increasing acceptance of evidence-based medicine, the importance of large amounts of data and statistical significance has taken center-stage. Numerous articles in the past 5 years have documented the worldwide need for surgeons in general (and neurosurgeons in particular).^{17 , 18} One only needs to consider the numerous recent articles on COVID-19 to see millions over and over: millions of cases, contacts, masks, vaccines needed—but hopefully not millions of deaths globally. Big data and artificial intelligence are novel aspects of modern medicine.

Today, texting is replacing talking (with emojis replacing facial expressions) and handshake- and hug-free virtual conferences are replacing conventions. The person who invents virtual “bullshit sessions”—to replace face-to-face physical interactions over coffee or beer—will be the 21st century's Nikola Tesla (i.e., another Jack Ma or Elon Musk or Mark Zuckerberg…).

Certain aspects of neurosurgery include big data, artificial intelligence, and high-tech—not only intraoperative magnetic resonance imaging and implantable neuromodulation devices, but also statistics on all aspects of neurosurgical training and care collected worldwide. These may be considered novel inventions in global neurosurgery over the past several decades.

However, much of neurosurgery cannot be decided on a global (i.e., worldwide) scale. Whether in Tokyo or Timbuktu, the neurosurgeon and the patient must decide together what to do regarding the patient's neurosurgical condition. In this particular patient (with this particular diagnosis), at this particular time, with the particular resources available, how should the neurosurgeon and the patient proceed? Invading another person's nervous system is perhaps the most intimate interaction between 2 individuals.

It is unlikely that novel big data/AI/high-tech global neurosurgery will completely replace the one-to-one doctor-patient relationship.

“GLOBAL Neurosurgery” by any Other Name Would Smell as Sweet

This Perspective began with apologies to George Santayana and concludes with apologies to Shakespeare's Juliet. How can we define global neurosurgery in a meaningful (i.e., novel or patentable) way? Do we all know global neurosurgery when we see it? How do we avoid having global neurosurgery degenerate into a “sound bite” lacking substance?

At the heart of novel global neurosurgery (discussed earlier) are the recent high-tech advances in resources (both data and devices) that are of worldwide consequence (if not worldwide availability).

However, as seen in the 7 articles from 2020 in World Neurosurgery noted earlier, most articles are in fact of country-level or regional composition—not “global” in either of the 2 definitions cited at the beginning of this Perspective. Yet the information contained in these articles can clearly benefit neurosurgery worldwide in all its aspects, thus meeting both definitions of “global.”

Like much of neurosurgery (and politics!), the answer is not straightforward. The 3 questions posed at the beginning of this Perspective have not been answered satisfactorily. That must be a goal of future articles on neurosurgery both worldwide and in all its parts—articles on “global neurosurgery.”

Perhaps, as quoted at the outset of this Perspective, Dwight Parkinson was prescient with the first use of the term “global neurosurgery” in 1995: “…to anchor the local history with that of neurosurgery as a whole.”

We can use the term “global neurosurgery” to foster a mindset aimed at improving neurosurgery—both worldwide and in all its parts.