In their article, “A model for neurosurgical humanitarian aid based on 12 years of medical trips to South and Central America,” Mainthia and coauthors4 have described the methods, evolution, and impact of their sustained endeavor to provide neurosurgical treatment for children in 4 countries of Central and South America. This descriptive report is an unusual yet valuable contribution to the literature, because it highlights the need of children in developing countries for better access to specialized surgical care and demonstrates a model in which an American pediatric neurosurgical team has made a sustained and organized contribution to a solution. Children younger than 15 years of age comprise roughly one-third of the human population, but their distribution is concentrated in regions where the resources for healthcare in general, and neurosurgery in particular, are the most limited. In Guatemala, for instance, where the authors report having performed the majority of their work, 43% of the population is younger than 15 years old compared with 20% in the US.5 Contrasting the 2 countries where I have lived and worked exemplifies the inequities among the children of the world when it comes to accessing neurosurgical care. In the US, the ratio of neurosurgeons to children younger than 10 years of age is about 1:12,000 compared with a ratio of 1:2,600,000 in Uganda.6 Existing models for providing neurosurgical care to these children principally involve importing neurosurgical teams from more developed countries in the North to less developed countries in the South, exporting children from the South to the North, or building neurosurgical capacity within the country through the training and equipping of national surgeons or neurosurgeons. A great strength of the International Hospital for Children model Mainthia and colleagues have reported is that it incorporates all 3 elements. The authors describe a program in which children receive a high level of care from the visiting team and local partners are mentored and included in the enterprise. Transport to the authors’ home institution in the US (Virginia Commonwealth University Health Systems) is arranged for children whose problems are deemed too complex for safe management in the local environment. Senior neurosurgery residents participate in each trip. This not only undoubtedly augments their clinical training, for instance, in having the opportunity to close a number of myelomeningoceles, but also probably proves personally formative through the singular experience of delivering much needed care in a challenging practice environment. Clinical follow-up in a poor rural population is extremely challenging, but the authors have made all reasonable efforts to minimize losing track of patients, and the methods they have established to do this are outlined in their report. Over the course of the program’s 12 years, the authors have noted an increase in the average age of patients and a decline in the fraction of total operations accounted for by myelomeningocele repairs from 58 to 11%. They attribute part of this to their contribution toward increasing the neurosurgical capacity within the country, but they also rightly acknowledge that this could have resulted from the introduction of a national program of folic acid fortification. In 1981, Dr. Richard Bergland eloquently warned of the plight of “neurosurgery in a zero-sum society.”1 I would suggest that, in the context of the 21st-Century global community in an increasingly “flat” world,3 the pediatric surgical disciplines stand on the threshold of a non–zero-sum opportunity. Most of the world’s children live in the southern hemisphere, whereas most of the resources and expertise to treat pediatric surgical diseases are in the northern hemisphere. Conversely, however, the declining fraction of children comprising Northern populations threatens to limit opportunities for training and research in the pediatric surgical disciplines, including in pediatric neurosurgery. It is apparent that innovative strategies to organize and fund the progressive engagement of the North and South could simultaneously provide surgical care to children who would otherwise not receive it, build capacity within the region to provide specialized pediatric surgical services, create opportunities for training North American and European residents, and facilitate globally oriented research that is energized by data derived from large populations. It may be helpful to evolve from the idea of “neurosurgical humanitarian aid” toward the concept of global neurosurgical partnerships in which aid is not delivered but rather via strategies of “social entrepreneurship,”2 non– zero-sum engagements between the North and South are formed in which everyone wins. Pioneering projects such as those described by Mainthia and colleagues, as well as similar endeavors by others in our discipline, serve as guideposts on the road ahead. J Ne osurg Pediatrics 4:1–3
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Mar 21, 2013
Mauro Boianovsky 
