Reflections on developing pediatric neurosurgery in Sub-Saharan Africa

I n 2011, the World Bank estimated the population of Sub-Saharan Africa (SSA) to be 874,841,049, with 44% of the population being 1-14 years old (http://www.tradingeconomics.com/sub-saharan-africa/populationtotal-wb-data.html).Millions of children in SSA have hydrocephalus, spina bifida, and other common pediatric neurosurgical conditions.Kijabe, Kenya, is a village of approximately 5000 people located 65 km northwest of Nairobi, at an altitude of 7220 feet within the Rift Valley Escarpment.It is home to Kijabe Hospital and was founded at that site by missionaries in 1915, because its elevation was too high for malaria-bearing mosquitoes.The hospital is a 283-bed general hospital under the auspices of the Africa Inland Church.Its consultant staff consists of approximately 20 Kenyan physicians and 20 expatriate medical missionary physicians.Dr. Dick Bransford, a career missionary general surgeon, initiated pediatric neurosurgery (PNS) in Kijabe in 1997, when he began treating children with hydrocephalus and spina bifida.The number of those children increased steadily, and in 2001, Dr. Bransford inserted 119 ventriculoperitoneal shunts and closed 61 myelomeningoceles (MMCs).In 2002, he sent an email to me with the subject "Neurosurgeon Needed," requesting help in the management of such children.I began going to Kijabe for 2-3 weeks most Januaries thereafter to teach and operate.My wife, Susan Ferson, a pediatric nurse practitioner, and I moved to Kijabe on September 1, 2010, to teach and to perform PNS.We ended our work there in January 2015.In this manuscript, I offer my reflections on developing PNS in Kenya and in SSA in general. Pediatric Neurosurgical Education in KijabeThere are no fellowship-trained pediatric neurosurgeons on the University of Nairobi faculty, as is true of almost all other African neurosurgery faculty.Approximately 12 neurosurgery residents from Nairobi came to Kijabe for their PNS rotations, which were structured like resident rotations in the US.Our intent was to teach them how to evaluate patients, to identify therapeutic options, to read scans, to operate, to do clinical research, and to publish manuscripts-basically, how to be neurosurgeons.Eighteen US neurosurgery residents (from 12 American residencies) and two US PNS fellows came for rotations of 2-4 weeks.Residents were usually in the postgraduate Year 5 or 6, so that they could help with the workload as well as learn.They evaluated and helped operate on many children with disorders they would rarely see in their home institutions.For example, approximately 250 children with MMCs were operated on in 2011 and a similar number in each subsequent year, and several children with frontonasal encephaloceles were treated every year.Teaching of fellows and residents was augmented by 14 pediatric neurosurgeons who visited for 2-4 weeks from the US and Canada.When we moved to Kijabe, my main teaching hope was to train pediatric neurosurgeons.The Medtronic Foundation provided grant support for 3 years for PNS fellowships.The first fellow was Ugandan neurosurgeon Dr. Humphrey Okechi, who had just completed his neurosurgical residency in China and who began his fellowship in November 2010.His fellowship was similar to those offered in the US, with daily rounds, evaluation of outpatients, daily operations, presentation of a paper at the International Society of Pediatric Neurosurgery meeting, and publication of manuscripts.During the year, Dr. Okechi did or assisted on some 750 cases.He was given written examinations every 4 months, based on the second edition of the textbook Principles and Practice of Pediatric Neurosurgery, 3 and he authored or coauthored 7 manuscripts.After working with me for 2 years, he became a BROCA'S AREA