Improving Global Access to Neurosurgery Roxanna Garcia, MD, MPH

• Garcia details her career path from medical student to now joining the Department of Neurosurgery at Northwestern Medicine. She knew early on in her career that she wanted to pursue a career in medicine and  would end up in global health and public health in the long term. 
• Neurosurgery intrigued her more than any other surgical subspecialty and Garcia knew the field of global neurosurgery had challenges but that she was excited to take them on.
• Some issues that arise in global neurosurgery include lack of neurosurgeons in low and middle income countries. There are approximately 5 million unmet surgical procedures just within neurosurgery alone. She says a lot of that has to do with the distribution of neurosurgeons around the world.  But she says progress is being made as the World Health Assembly prioritized surgical care as part of universal health care coverage back in 2015.
• Garcia says ideas to solve this problem include creating training centers in places where they not only accept the local trainees, who are interested in building neurosurgical care, but also trying to create more opportunities even for more distant learners.
• As part of her HBNU New Fogarty Global Health Training Program, Garcia had the chance to live in Lima, Peru and work with investigators and neurosurgeons at Universidad Peruana Cayetano Heredia in Lima under the mentorship of Patricia Garcia, MD, PhD, MPH.  Her research focused on evaluating the neurosurgical capacity for traumatic brain injury in Peru.

Robert Murphy, MD [00:00:05] Welcome to the Explore Global Health Podcast. I'm Dr. Rob Murphy, executive director of the Heavy Institute for Global Health here at Northwestern University Feinberg School of Medicine. It's estimated that 5 billion people around the world cannot access safe, affordable and timely surgical care. This lack of access is most common in low income and middle income countries, where basic surgical care is out of reach for nine out of ten people. And more specialized procedures such as neurosurgery, for example, are quite rare. Today's guest wants to change all that. And I'm happy to introduce Dr. Roxanna Garcia, who just finished her neurosurgery residency at Northwestern, is currently now a fellow at the University of Chicago, but she's going to be returning. While Roxanna was here at Northwestern, she took part in our HBNU Fogarty Global Health Training Program. HBNU stands for Harvard, Boston University, Northwestern University and University of New Mexico, four schools that have about 25 relationships around the world. Roxanna spent a year in Lima, Peru, working with the Peruvian Ministry of Health on several projects related to neurosurgery. Welcome to the show, Roxanna.

Roxanna Garcia, MD [00:01:17] Well, thank you for having me on the show, Rob. I really appreciate it.

Robert Murphy, MD [00:01:21] Global Health has been on your radar screen for a long time before you came to Northwestern for your residency training. Tell me about your academic career and then personally why you set your sights on global neurosurgery.

Roxanna Garcia, MD [00:01:34] I have been very fortuitous in my academic career to early on identify global health and public health as an area of interest. And it is actually the primary reason why I ended up in neurosurgical practice. For some, that may seem kind of like a stretch or atypical, but I actually went to medical school with the idea that I would end up in global health and public health in the long term. And it wasn't until later on in medical school where I found neurosurgery as a clinical practice and then realized the great need for people with my interests and my basic understanding of fundamentals of public health practice. And so that's where everything started. Honestly, it started actually as a college student with an idealistic idea that one day I would be a physician working in public health. And then once I got into clinical practice, I, of course thought I would end up in one of the more popular specialties that generally tends to support more global health research, but just fell in love with neurosurgical practice. And then during the course of my neurosurgical training, many international initiatives had been launched at the level of the World Health Organization that have really helped support my area of interest in an academic lens.

Robert Murphy, MD [00:03:08] So tell us a little bit kind of how it all started. Where did you go to your undergraduate school? Where was your undergraduate training and what specifically kind of triggered this passion?

Roxanna Garcia, MD [00:03:18] I actually went to Cornell University in upstate New York and it now has more of a global health vibe and more global health work on the undergraduate campus, the Cornell undergraduate campus is located in upstate New York, and then the Cornell Medical Campus is actually in Manhattan. And so I didn't really interact with many medical physicians, but during the latter half of my college years, I intersected with a woman named Laura Harrington, who still remains, you know, an important mentor for shaping my interests, was actually a vector biologist. With her, I did research. She supported me for a summer to work at Johns Hopkins through one of her colleagues, doing also vector borne related research and just really fell in love with public health and took all the public health and health inequity classes and demography classes as an undergrad and then really set my sight on medical school thinking that that would be the next logical step for me with my interest, because I originally actually went to Cornell thinking that I would become a veterinarian. That changed later on in the course of my undergraduate in finding mentors that I could really admire and trust or doing work that was meaningful and they felt passionate about. And then I ended up fortunately transitioning to one of the smallest programs in the country that supports physicians who are interested in public health practice through UC Berkeley and UCSF called the Joint Medical Program. Through that program it was a wonderful experience. The first three years were integrated, meaning that I had done a master's degree related to Chagas disease, actually, and did my preclinical work. And then I transitioned to the clinical clerkship years at UCSF and was still hoping, hoping to still do internal medicine and still do a subspecialty within internal medicine or the like , and ultimately just gravitated towards neurosurgery, which is interesting because I really didn't gravitate towards any of the other surgical specialties. I didn't really feel excited about the day to day. I didn't feel excited about the surgical procedures. I feel fortuitous that UCSF has a wonderful department of neurosurgery. So I was exposed to so many experts within basic and advanced neurosurgical care, but there was no one into the department. And to the best of my knowledge, right now, there really isn't anyone in the department at UCSF spearheading any global health work.

Robert Murphy, MD [00:05:53] Well, that's a good lead in to my next comment about neurosurgery in general. What is really the state of global neurosurgery today? In recent years, it was referred to sometimes as the neglected stepchild of global health, because there was a lack of funding and support for global neurosurgery. I mean, even surgery, general surgery is lacking in these many places. Some say it's too expensive to implement long term programs in these countries. But you were the author of a review of the literature on this topic. And what is the state of global neurosurgery today and what have you learned already?

Roxanna Garcia, MD [00:06:27] I think it's a wonderful question because I think if you ask the leading figures right now in global neurosurgery that are much more senior than me, they would have a lot to say about this topic, particularly because I don't think it's unified just yet. I think that we have made significant progress, particularly since the World Health Assembly prioritized surgical care as part of universal health care coverage back in 2015. But our national organizations and internationally, the leading departments that, you know, championed research for neurosurgical care are still grappling with how to really embrace this as a priority area, either for neurosurgical practice and also research. So right now, it's estimated that there are 50,000 neurosurgeons globally. What we're finding with that number is, as we know, there's 7 billion people on the planet. So the distribution of those neurosurgeons is incredibly variable. And of course, most of these practitioners are in high income countries. The areas that have the least number of neurosurgeons, of course, as are other circumstances within global health, are located in the African continent. In addition to that, we have been able to characterize through survey data the unmet neurosurgical need, and it's estimated based on survey data from the Harvard Group, Paul Farmer's Program for Social Change, that these unmet surgical procedures are somewhere on the scale of around 5 million, meaning that across the globe, particularly in low and middle income countries, there are approximately 5 million unmet surgical procedures just within neurosurgery alone. A lot of that, again, has to do with the distribution of neurosurgeons, but also, like you mentioned, the availability of essential equipment, resources, supplies, the system as a whole. Neurosurgical care, as you have also commented on, is expensive. And so we're tasked with trying to think about it in a way that will allow for delivery of essential care, but also recognize the competitors in the system, which are certainly not as expensive but certainly as important as some of the basic life saving procedures. In my experience so far, I really think focusing on the essential procedures that are life saving and that could potentially be task sharing procedures are probably the most translatable for countries and settings that are low resourced where there isn't enough resources to be distributed. And so there are many people interested in this area of research. There are certainly many groups and universities, particularly in the United States, who are really trying to target this research. But it's still not as unified as we would like. And I'm excited to be part of this work because I think that there's just so much to do.

Robert Murphy, MD [00:09:48] You know, right now, especially with the surgical subspecialties. And this goes for not only neurosurgery, but really a lot of them, they rely on these sometimes very short term medical missions for subspecialty surgeries. And there's a lot of controversy about this approach. Judith Lasker, who was the first person we had on this podcast, is kind of an expert in the ethics of that and has written about it. Basically, she said, You're not doing anything for anybody other than putting out a Band-Aid if you're there for less than three weeks. A lot of these programs, I mean, they're great. They can do a couple procedures and then they're gone. And what's the follow up and how do they deal with the next one? Do they have to wait another year for these people to come back if they even come back? So maybe you could tell me, what do you think about those things? Is there any good to them or, you know, what's a better approach?

Roxanna Garcia, MD [00:10:41] I've never actually done my own surgical mission trip as a surgeon, mostly because I think that there are a lot of ethical issues surrounding temporary care. As a surgeon myself, I need to be able to see my patients as a long term, and I would trust that other people would be able to make assessments of my own surgical patients when I take care of them. But I know that as a well-trained surgeon, coming from a very academic institute, the culture that I have learned is that I should take full responsibility for those humans. I think that you are correct. The culture of surgical mission trips has been predominant, meaning that surgeons have done this for decades upon decades, and I'm uncertain of the actual benefits of it in the long, long term. Meaning that I think it offers potentially some good, but that good sometimes is short lived. And for me personally, and I'm only going to speak to my own personal experience because again, I have not been part of surgical mission trips myself and that's been somewhat intentional, is that I really feel that in order for us to make the sustainable changes that we want, we really need to move away from these models. And I really believe that surgeons as a whole want to contribute to sustainable acts. It's just I don't know that they intensively know how to conceive of this, either through nonprofit organizations, international organizations, or even through a research geist that could help them create more sustainability around it. I have actually written a piece recently for our national organization around this issue related to residents because there's a lot of interest for resident trainees, particularly in surgical specialties, to go abroad for these short lived mission trips where they get a ton of exposure to pathologies that they wouldn't otherwise see because most of these trainees come from high income settings. But I'll argue, and this is again my own ethical perspective on it, I'll argue that they probably get more out of the experience in the longer term than those people on the ground in the communities that they go to. And for me, when I had this opportunity, of course, with your mentorship and help to go to Lima, I purposefully didn't go into the O.R. as a surgeon. I was invited multiple times, but I made it very clear that my role there was not to be a surgical trainee. My role there was to understand the system so that we can create more sustainability around the system.

Robert Murphy, MD [00:13:24] There's many countries that don't have any neurosurgeons. How do you think these low and middle income countries can develop their own long term program?

Roxanna Garcia, MD [00:13:32] It's a great question that I am actually part of an international group that is targeting this issue firsthand, which is the World Federation for Neurosurgical Societies. I've been fortunate to be part of the organization since I was a PGY five in neurosurgery. It's our largest organization. It was founded back in 1955. And this organization has actually really championed the idea of creating training centers in places where they not only accept the local trainees, you know, who are interested in building neurosurgical care, but also trying to create more opportunities even for more distant learners. But there's so much in the way that needs to be done here, and there's just so much opportunity that I see. And I've been also part of groups nationally that have been really trying to push the envelope for virtual-led curricula, particularly now that we're in this hybrid mode where we're recovering from a global pandemic. And people have adapted these virtual means to learning that previously maybe we used but didn't rely on. Now there have been many more groups and nonprofit organizations trying to develop basically like virtual operating room opportunities. Virtual will say standard of care learning for surgical practice. Particularly in neurosurgery. And some of these groups are really trying to pilot models that would target for the most common disease entities that most neurosurgeons might face, which would be related to traumatic brain injury and actually pediatric hydrocephalus. Right now are the two areas of interest, but the idea being that we would be able to leverage the virtual space and create more training opportunities for trainees that may have an interest but don't have any access.

Robert Murphy, MD [00:15:37] You know, all our programs during the pandemic, we actually never stopped. I mean, we had been traveling excessively and we just stopped traveling and we did everything virtually. It's not ideal, but we survived and we even wrote new grants and everything together. I mean, it really, I think, opened up a lot of people's eyes as to really how much in-person you really need or how much benefit you can get from these virtual approaches.

Roxanna Garcia, MD [00:16:00] Yeah. And then it also speaks to the whole movement in telemedicine as well. Right? I think practically right. Clinicians realize that they don't always have to see the patient physically to make a good assessment of what is going on. So I think leveraging that space too is going to be incredibly vital to creating opportunities for places that don't have neurosurgical training. But I just also want to mention the idea of task sharing. That's something that I think carries a lot of value, particularly in places that have more remote populations that are highly dense and don't have access to good surgical care, be it any of the surgical subspecialties, any of the basic general surgery procedures. But really speaking to the idea that if there's someone with some even, you know, tendency for surgical or procedure related skill set, really trying to foster task, sharing meaning and training them in a very limited way to do basic procedures. Because not all the procedures that I do as a neurosurgeon are incredibly complex, although for many people it seems, you know, daunting and a black box in some ways, I can tell you that you can train someone very easily to do burr holes for a subdural evacuation quite easily. And that doesn't require anything super advanced, just someone who has a basic skill set and how to do procedures. And I love the idea of potentially using that as the transitional step to building capacity for places that don't have it.

Robert Murphy, MD [00:17:32] Can you explain to us what actually happens now in a low and middle income country that has limited neurosurgery resources? If somebody does sustain a traumatic brain injury, how are they cared for? And how does an injury like this impact the family and the community?

Roxanna Garcia, MD [00:17:48] I'll speak to my experience, you know, firsthand in Peru after I interviewed many neurosurgeons throughout the country to get a sense of this. And the realities are really tough. Of course, it is definitely dependent on where you are and when the injury happens. If you happen to be close to a primary or secondary level hospital and there is a physician available for a primary evaluation, they usually transfer you to a hospital for which there's at least a trauma shock unit available for some people that could be 30 minutes away. For some people, that could be 4 hours from their home. And it really can be devastating for patients and patient families who don't have the economic means for traveling with their family members. So often these people will be transferred independent of their family members because usually they're not allowed to ride in the allotted ambulance vehicles just because they tend to be a little bit smaller as the roads in some of these more remote places that I visited are located. But I think the starker reality is when people actually arrive to the locations where they actually have neurosurgeons on staff who can make accurate assessments and do the right thing if they have the right information. And so much of it hinges on what else is happening during that time of initial evaluation. Meaning are there other patients who are similarly sick competing for the same resources? For my experience, at least in Lima and in talking with others throughout Latin America, neurosurgical care is not really prioritized. There has, as you know, been a long standing movement of global women's health. And I, I was impressed by the number of neurosurgeons who commented on if there is a pregnant woman in extremis, she will get priority no matter what. And I think that speaks to the wonderful work that, you know, women's health in obstetrics care has done internationally and the long history there of advocacy and movement. But it's. Doesn't balance out. The priorities of other urgencies are emergencies, which speaks to the system, right? I don't think anyone personally is to blame. It just speaks to the system of resource limitation. So often my impression was that these patients tend to be not prioritized, particularly if they were in a near comatose state. Often there weren't functional equipments available, even sometimes to do basic lab work. More important for neurosurgeons is what we see on imaging. Meaning is there a mass occupying lesion that we can act upon and in what timeframe in access to even CT scans was often very difficult for many neurosurgeons trying to take care of patients who are very sick. So surgical intervention was often delayed for many TBI patients.

Robert Murphy, MD [00:20:54] Let's switch gears a little bit and talk about your experience in Peru. You were part of the 2019 2020 HBNU Fogarty Global Health Training Program. And can you tell a little bit more about that experience? What attracted you to that program and why you would commit? This is a program, by the way, that you have to commit one year.

Roxanna Garcia, MD [00:21:15] I was incredibly interested in the idea of spending time dedicated, doing research in global health with the mentorship and the guidance that is available through the program, which is tremendous. And then I just happened to be fortunate to match at a program in neurosurgical training that also happened to have a site for Fogarty formerly. And obviously the institute here is tremendous and has had much success in sending many scholars internationally. And so it kind of just made the most sense, honestly, because at that time in my career development, I was really wishing to spend more time internationally focused on neurosurgical care. And of course, through your support, Rob, you were able to introduce me to Patricia Garcia, who is not a neurosurgeon, but a global health expert and prior minister of health of Peru and has served as mentor for other Fogarty fellows and currently serves as a mentor for active fellows. And she happened to want to do work related to neurosurgical care. And the project that we worked on together through my year there was targeting really a basic needs assessment so that we can design other studies in opportunities to do research together. I just happened to work out in terms of timeline and also I happened to be in a department of neurosurgical practice where my chair supported my role and my interest, and as such, he is inviting me back as a faculty member.

Robert Murphy, MD [00:22:56] So you went there in 2019 and then at the beginning of 2020, something kind of weird happened in the world, the beginning of the pandemic. And as you know, Peru has had a real struggle with the pandemic despite having a pretty good public health program. Can you tell us how the pandemic detoured you a little bit and then and what you did to get around it?

Roxanna Garcia, MD [00:23:20] I arrived late July, and then because of circumstances related to the pandemic, left early March. Fortunately, by the time I had hit that March date, I had collected most of my qualitative data. So I worked on most of my analysis and wrote the manuscripts that were in process of submission currently. But as you have stated, it has been a very difficult couple of years for Peru after the pandemic hit. Despite the case volume, there was political turmoil. There has been a president that has left riots, instability, all of which I think are not unique in any way to Peru. It's more of the temperament of realizing that that sometimes happens in global health research and you have to adjust appropriately. And sometimes you do have to wait until things settle down as we're currently doing. You know, I was also fortunate enough to be supported by the Institute and start a registry which is still in the early infancy just because the country has been so slow to take up research unrelated to COVID even now. And so we're still hopeful that we're going to be able to do the project that we originally set out to do two years ago. But it has really changed the landscape of what people do. And I love that there have been so many global health projects and works that have been able to prosper during the pandemic.

Robert Murphy, MD [00:24:50] We didn't slow down at all. Matter of fact, we increased. Can you tell us about Congress of neurosurgery in Bogota, Colombia, and what did you present there?

Roxanna Garcia, MD [00:24:58] I have been able to attend the last two conferences. One was in China during actually my. For a year where I presented kind of a topic related to global neurosurgery and really my pulpit to really advocate for it to be accepted as an academic lens of inquiry for neurosurgical trainees. And then at the most recent one in Columbia, I presented my work related to Peru and then presented a slew of topics related to, you know, my current area of interest, which is advancing not only neurosurgical care but neuro intensive care internationally. And also some of the work related to my experience working at University of Chicago with penetrating brain injury.

Robert Murphy, MD [00:25:43] Well, that's that's a good segue into my last question. You're finishing up your fellowship at the University of Chicago, coming back to Northwestern. Tell us, what are the next steps in the career of Dr. Roxanna Garcia?

Roxanna Garcia, MD [00:25:56] I'm coming back to the university with a lot of enthusiasm to build a very strong neurosurgical practice clinically, but also really give to my department and the university and the institute, you know, all my interest in efforts within global neurosurgical care. So with that, I'm hopeful to build a real academic portfolio that reflects that where I will be working not only within Lima and Patty in the short term and ideally the long term, but other sites internationally to build neurosurgical capacity, advanced neuro critical care internationally and create opportunities. Also, I feel very strongly about mentorship. I believe that my success, all the things that I've accomplished in my life, have been really because I've had good mentors and access to people. And I think now we're in this wonderful era of virtual space where serving as a mentor for people has been made much more easy. So I would love to create a formal mentorship program that will help encourage the next generation of global neurosurgeons.

Robert Murphy, MD [00:27:06] Well, that's great, Roxanna. And that is going to conclude our podcast today. Thank you very much for joining us.

Roxanna Garcia, MD [00:27:12] No, thank you, Rob. I appreciate the time today.

Robert Murphy, MD [00:27:20] Follow us on Apple Podcasts or wherever you listen to podcasts to hear the latest episodes and join our community that is dedicated to making a lasting, positive impact on global health.