Neurosurgical Disparities in Northeast India: Present Scenario and Necessary Steps Suggested to Build Sustainable Neurosurgery Centers

Neurosurgical services in low- and middle-income countries (LMICs) are often hampered by limited infrastructure, workforce shortages, and financial constraints.[1] Northeast India, a geographically isolated region with diverse ethnic populations, exemplifies these challenges, with neurosurgical care heavily concentrated in a few urban centers.[2] The region’s unique topography, characterized by mountainous terrain and riverine landscapes, further complicates access to healthcare services.[2,3] The burden of neurological disorders, including traumatic brain injury (TBI), stroke, and brain tumors, is substantial in Northeast India.[3,4] However, the availability of specialized neurosurgical care remains limited, leading to delayed diagnoses, suboptimal treatment, and poor patient outcomes.[3] Besides this, there is lack of disease awareness especially in the remote areas leading to delayed diagnosis and inadequate treatment. Understanding the regional disparities and comparing them with global LMIC benchmarks is crucial for developing targeted interventions and improving neurosurgical outcomes. Data Collection Data were collected from various sources between January 2018 and December 2024. The sources included: Hospital records from major medical colleges and district hospitals in Northeast India. Neurosurgeon’s directories maintained by the Neurological Society of India, Neurological Surgeons’ Society of India, and Neurosurgical Association of Northeast India. Population data from the 2011 Census of India and 2021 projected estimates from the Unique Identification Authority of India (UIDAI).[5] Data analysis The number of neurosurgeons per location was analyzed to assess the disparity in distribution. Workforce density was calculated as the number of neurosurgeons per million population and compared with India’s national average and global LMIC benchmarks, specifically data from Sub-Saharan Africa and Latin America. Neurosurgical workforce density [Table 1] Total neurosurgeons in Northeast India: 55 Total population (2021 estimates): ~51.67 million[5] Neurosurgeons per million in Assam: 1.82 Neurosurgeons in northeast India per million 0.35 Table 1: Neurosurgical workforce density comparisonComparison: India (National Average): 1 per million[6] Sub-Saharan Africa: 0.1 per million[7] Latin America (LMICs): 2 per million[8] Geographic disparity in neurosurgical care The data reveal a significant concentration of neurosurgeons in Guwahati, with 37 out of 55 neurosurgeons are practicing in the city [Table 2]. The numbers of neurosurgeons have increased drastically from the past 6 years; prior to that, only 30 neurosurgeons were there in entire northeast. Many remote districts have limited or no access to neurosurgical care. Mizoram still has no neurosurgeon.Table 2: Neurosurgeon distribution by cityLack of neurosurgical subspecialties [Table 3] Pediatric Neurosurgery: No dedicated pediatric neurosurgeons are available. Children with complex congenital diseases and deformities had to be referred outside the Northeast. Neuro-oncology: No dedicated neuro oncology centers exist. There is no dedicated neurosurgeon in B Borooah Cancer Institute or other state cancer institutes. Functional Neurosurgery: Deep brain stimulation (DBS) services for Parkinson’s disease could not be started yet; epilepsy surgeries are limited. Vascular Neurosurgery: No endovascular neurosurgical expertise; stroke treatments are largely managed conservatively, and aneurysms for endovascular neurosurgery are referred out to Shillong and Guwahati. There is lack of dedicated subspecialities in pediatric neurosurgery, neuro oncology, functional neurosurgery, and vascular neurosurgery Infrastructure Deficiencies: Only five hospitals in NE India (Guwahati Medical College Hospital, Assam Medical College Dibrugarh, Regional Institute of Medical Sciences Imphal, Jorhat Medical College and Hospital and NEIGRIHMS Shillong) have modern operating microscopes and neuronavigation. There are 13 medical colleges in Assam, but only three have high end neurosurgical facilities; other nine even lack basic neurosurgical care. Table 3: Neurosurgical subspecialty availabilityLack of dedicated neurocritical care units Present Scenario: No hospitals in Northeast India have a dedicated Neuro ICU [Table 4]; neurosurgical patients are managed in general ICUs and only single-stroke ICU. Comparing with LMICs lacks dedicated neurocritical care; however, some Latin American countries have started developing specialized neuro ICUs, which are absent in Northeast India.[3] Table 4: Critical care neurosurgical services availability Inadequate comprehensive stroke care Current Scenario: No hospitals have a dedicated stroke unit. Thrombolysis for ischemic stroke is available only in Guwahati, but door-to-needle time exceeds 90 minutes in most cases. Comparison with LMICs: Brazil and Mexico have established regional stroke centers, whereas India, especially NE India [Table 5], lags in structured stroke care outside metro cities.[9,10] Table 5: Neurosurgical infrastructure in LMICs Suggestions and Recommendations The following possible steps suggested are given below to bridge the gap. Decentralization of neurosurgical services Upgrading all existing medical colleges with neurosurgical capabilities for emergency cases will improve accessibility for patients residing in the interior part of the region. This requires substantial investments in infrastructure and equipment.[11] Workforce expansion and subspecialty development Fellowships in subspecialities are required. Developing infrastructure in existing medical colleges and providing accommodation with financial incentives for neurosurgeons to work in underserved regions can help address the workforce shortage.[12] Development of neurocritical care and stroke units Establishing dedicated neuro ICUs in medical colleges with trained neuro intensivists is critical but requires investment in specialized equipment and training of healthcare professionals.[12,13] The establishment of dedicated stroke units, as seen in Brazil and Mexico, demonstrates the feasibility and benefits of such initiatives in LMICs.[10] Technology and telemedicine Implementing tele-neurosurgery programs can support remote consultations for management of Stroke as already advocated by the Ministry of Health and Family, Government of India, a stroke ready hospital facility to be available round the clock. This can bridge the gap between urban centers and remote districts, providing timely access to expert advice.[6] Artificial intelligence (AI)-based decision support systems can assist in stroke and TBI triage, improving the efficiency of emergency care. Public education and awareness: A critical component Beyond direct healthcare interventions, a fundamental shift in public perception and understanding of neurosurgical issues is vital. Short, captivating, and informative videos on television and in public places, such as community centers and bus stops, can significantly raise awareness about neurological conditions and the importance of early intervention. These videos should highlight common symptoms of conditions like stroke or traumatic brain injury, emphasizing the critical need to attend the hospital as soon as possible. Such accessible educational content can demystify neurosurgical procedures and reduce apprehension among the general population, fostering a proactive approach to health. Furthermore, these public awareness campaigns can serve a dual purpose by inspiring the next generation. Showcasing the true heroism and dedication of neurosurgeons, even when faced with practical limitations and challenging circumstances, can deeply impress young students. By illustrating the profound impact neurosurgeons have on lives, these narratives can spark greater interest among students in pursuing the subject, ultimately benefiting both the individuals who choose this noble profession and the future of healthcare in the country. Policy and funding improvements Advocating for increased government investment in neurosurgery infrastructure is crucial. The Ayushman Bharat Insurance scheme has helped the poor patients to get the required treatment, but the service is available only in a few centers. National Rural Health Mission in Northeast significantly improved public health outcomes by reducing maternal and infant mortality rates and controlling common disease like tuberculosis and malaria, and PM-DevINE (Prime Minister development Initiative for NE India region) scheme is also likely to give huge boost to cancer care in Northeast India. The Health and Family Welfare department along with NHM Assam is providing free operations for children with congenital heart diseases outside the state, but the focus should be on improving infrastructure and getting these patients operated here in the state only. There is no national program focusing on neurosurgical diseases like brain tumor. National programs concentrating on the development of neurosurgical care are of outmost importance, like national control on and prevention of deafness. Modifying surgical procedures by neurosurgeons to suit low- and middle-income patients may improve patient care.[14,15] Public–private partnerships can also play a role in improving neurosurgical services. Barriers and limitations Implementing these recommendations faces several barriers, including financial constraints, political challenges, and logistical difficulties. The geographical isolation of Northeast India and the diverse ethnic populations pose unique challenges to healthcare delivery. The lack of awareness and delayed patient presentation further complicate the situation. The observation is based on retrospective analysis of available data, which may be incomplete or slightly inaccurate. Conclusion Northeast India faces significant neurosurgical disparities, mirroring trends in other LMICs, the concentration of services in urban centers and the lack of subspecialties, neurocritical care, and comprehensive stroke management, which pose substantial challenges. Addressing these disparities requires a multifaceted approach, including decentralization of services, workforce expansion, subspecialty development, technology integration, and policy reforms. Collaborative efforts from the government, healthcare institutions, and private sectors are essential for timely management for better neurosurgical outcome. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.