Street vendors sell caskets along the road that leads to the hospital in Mwanza, Tanzania. It’s a stark reality, this expectation of death distilled into an image, then seared into memory. Reid Thompson, MD, can’t forget what he saw, and he doesn’t want to forget.
“When you walk out of the hospital and come down the hill, lined up on the street are all these people selling caskets,” said Thompson, the William F. Meacham Professor of Neurological Surgery and chair of the Department of Neurological Surgery at Vanderbilt University Medical Center. “There is a thriving casket business right outside the hospital. That’s because people go to the hospital to die.”
They die from many diseases, but they especially die from head injuries, brain tumors, infections and hydrocephalus that could be survivable if Tanzania had more neurosurgeons.
Tanzania is one of several low- to middle-income nations with a scarcity of neurosurgeons. The Vanderbilt University Medical Center International Neurosurgery Program is helping medical personnel in some of these nations improve care. It’s a new program that operates on a shoestring budget with VUMC staff using vacation time and sometimes paying their own airfare.
“One of the real challenges for us is how do we do that in a sustainable way — sustainable in a sense that it does not just become us going over and doing a few surgical cases — but develop an opportunity to be involved in educating neurosurgeons in those areas.”
Thompson traveled to Tanzania last summer along with two VUMC colleagues, neurosurgeon Christopher Bonfield, MD, and E. Haley Vance, DNP, APRN, a pediatric nurse practitioner with expertise in neurological surgery. Between stops in Mwanza and Zanzibar, they performed 19 surgeries.
Colleagues went to other countries to share their expertise. Michael Dewan, MD, MSCI, worked in Uganda last year, while Ahilan Sivaganesan, MD, traveled to Sri Lanka.
The physicians, who plan return trips, say they learn as much as they teach.
“They don’t have the same tools that we have here so we can be doing a case that I would think is fairly simple here, but it turns into something much more complex over there,” said Bonfield, director of the International Neurosurgery Program. “They teach me how to open up skulls and repair spina bifida in patients, among other things, with instruments that I wouldn’t have thought of or used in that way before. There have been a few times in the operating room here that I needed to do something else — that maybe something wasn’t working — then I thought back and remembered I had seen people do it a different way. It’s still safe. It’s just different.”
He said the work also hones his patient analysis skills.
“Without CT scans and MRIs and all that other technology that we use here, it makes you examine the patients even more and think about what is wrong with them on a more fundamental level,” said Bonfield, who started doing neurosurgeries internationally seven years ago and has done work in three nations. “It boils neurosurgery down to its most basic elements.”
Dewan, who has been to Uganda multiple times, is part of a research group that is working to quantify the shortage of neurosurgeons internationally and devise a logistics system for better utilization of expertise. While the work is a humanitarian mission, he agrees with Bonfield that neurosurgeons learn new approaches, citing the work of Benjamin Warf, MD, a professor of Neurosurgery with Harvard Medical School who devised a new surgical procedure for hydrocephalus while working in Uganda. Warf, a mentor to Dewan, was awarded a MacArthur Fellowship in 2012 for his work. But the primary objective is to share expertise with physicians in countries with severe shortages of neurosurgeons.
“It is important to teach and train local surgeons in this skill set so that ultimately when you get back on the plane and fly back you’re leaving something permanent there and something that is more sustainable,” Dewan said.
Dewan has authored articles in medical journals about this topic. Only 25 percent of the population in sub-Saharan Africa has access to neurosurgical services within a two-hour window, according to an article published January 2018 in World Neurosurgery. Another article published April 2018 in Journal of Neurosurgery estimated that about 23,300 additional neurosurgeons are needed to address more than 5 million patient cases that go unmet annually in low- and middle-income countries. A gross disparity exits in Africa and Southeast Asia, where large geographic treatment gaps exist, he wrote.
Sivaganesan went to the war-affected Tamil homeland in the northeast of Sri Lanka, where a shortage of neurosurgeons was exacerbated by an ethnic conflict from 1983 to 2009 — a war that sent most of his family fleeing from their homeland.
“It is very satisfying and fulfilling to realize that Vanderbilt has given me a very specific skill set and knowledge set,” Sivaganesan said. “To be able to go to a part of the world that has a special place in my heart and be able to transfer some of that knowledge and skill set is very empowering.”
He recalled one conversation with a physician in Sri Lanka in particular.
“Every piece of information I was telling him, he was soaking up like a sponge,” Sivaganesan said. “I could tell it was going to affect the care of patients the very next week.”
This summer, Thompson, Bonfield and Vance plan to return to Tanzania but they will stagger their service times and bring more team members to have a bigger impact.
“My favorite thing about working in Africa is the people,” Vance said. “They are truly amazing. It is an honor for me to meet them during a time of great need and be able to provide care that they otherwise might not receive.”
The people there are incredibly resilient, waiting days for the surgery they need in less than ideal hospital environments, Thompson said. He recalled doing surgery on a patient with a brain abscess, a man who had suffered a fracture on the frontal sinus that had become severely infected. He went to bed worried with the image of street vendors selling caskets on his mind.
“I didn’t sleep a wink all night,” Thompson said. “I was really fitful and worried about him. I was worried that he might have a hemorrhage or something terrible.”
The abscess was so bad it took up about a quarter of his brain.
Thompson then pointed to a photo on his phone and said, “This is him standing up the next day, walking around.”