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Perspective - Global Neurosurgery
Commentary on:
Publish or Perish? Publish and Perish? Global
Neurosurgery in the COVID-19 Pandemic Era
by Andrews RJ. World Neurosurg 2021
https://doi.org/10.1016/j.wneu.2020.09.018

The COVID-19 Pandemic and Global Neurosurgery: The Situation in Japan and thePhilippines
Hideaki Matsumura1,2, Kevin Paul Ferraris3, Arihito Tsurumi2

We have read with great interest the article byAndrews1 that summarily describes the current
literature on Global Neurosurgery as mostly defining
the problems, but less so on the solutions. We agree that theCOVID-19 pandemic has somehow upended Global Neurosurgery as a movement, and yet the times would surely present
more opportunities. We would like to describe the situation—in
our countries of differing income levels—along both lines ofidentifying the problems and pointing toward potential solutions.

DIFFERING PROBLEMS AND CROSS-COUNTRY DISPARITIESIn Japan, the number of COVID-19 patients rapidly increasedfrom the end of March. Universal health insurance coverage, thelarge number of hospitals, and the free and equal access tohealth care are Japanese health care characteristics that havehelped maintain the quality of medical care. To maintain thishealth system, the guidelines for neurosurgical treatment during
the pandemic published by the Japan Stroke Society give priorities to minimize the risk of infection among health care
workers.2 Based on the guidelines, hospitals should take utmost
care to prevent infection spread. The biggest problem foruniversity hospitals or core hospitals is that once an infectedpatient is admitted to the hospital, it requires a lot of workforce
and time, limiting regular medical care. Another critical problem
for clinics or small regional hospitals in Japan is that patientsare reluctant to visit outpatient clinics for fear of infection in thehospital. The number of patients in a private regional
neurosurgical hospital, Tsurumi Hospital, which has 29 beds

Key words- COVID-19- Disparities- Global neurosurgery

and approximately 140 annual surgeries, dramaticallydecreased. In April, the number of new patients, total patients,
emergency transportations, and surgeries decreased from 275
to 74 (27%), 1407 to 1144 (81%), 33 to 19 (58%), and 16 to 8(50%), respectively, compared with the same month last year.
This reluctance to seek essential neurosurgical care is
worrisome for a worsening of overall public health.
In the Philippines, the spread of COVID-19 continues unabated,
and while the pandemic rages on, other illnesses requiring
inpatient neurosurgical care are in no way decreasing. At baseline, financial and geographic barriers have long existed, andpoorer patients undergo neurosurgical treatment from publicly
funded hospitals.3 However, the pandemic has highlighted theinequities of access to neurosurgical care as a result of thepreexisting maldistribution of facilities, health staff, andspecialists. The current situation disproportionately affects
socioeconomically disadvantaged patients due to greaterbarriers to neurosurgical care. At the Jose R. Reyes Memorial
Medical Center, a public multispecialty referral hospital in thecapital region, there was a 50%e60% decrease inneurosurgical operative volume during the past months, mostly
because elective surgeries had to be cancelled. Neurosurgicaloutpatient care abruptly transitioned into the telemedicine
format, and we found this aid of technology to our existing
services to be responsive to the poor segments of thepopulation in particular.4 However, in the rest of the country,
those needing urgent neurosurgical evaluation still findthemselves less prioritized by hospitals that become

From the 1Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki,
Japan; 2Department of Neurosurgery, Tsurumi Hospital, Koga, Ibaraki, Japan; and 3Section ofNeurosurgery, Jose R. Reyes Memorial Medical Center, Manila, Philippines
To whom correspondence should be addressed: Kevin Paul Ferraris, M.D., M.B.A.
[E-mail: kpferraris@gmail.com]
Citation: World Neurosurg. (2021) 148:163-164.
https://doi.org/10.1016/j.wneu.2021.01.083

WORLD NEUROSURGERY 148: 163-164, APRIL 2021

www.journals.elsevier.com/world-neurosurgery

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PERSPECTIVE - GLOBAL NEUROSURGERY

increasingly overwhelmed with patient volume as a result ofCOVID-19. Resource-intensive noncommunicable diseases that
commonly require neurosurgery as part of treatment—such as
stroke and ruptured brain aneurysms—have seen delays inmanagement. Given that patients in the Philippines are more
likely to die from ischemic and hemorrhagic stroke than inJapan,5 the recent pandemic situation now severely highlights
the disparities of outcomes among patients based on theircountry of origin.

revert to prepandemic normalcy. While the world looks forward to vaccination as the best way to end the pandemic,
there are surmountable challenges before it becomes an endall solution: the capacity to produce billions of vaccine doses,
the funding to pay for them, and systems to deliver themworldwide. Similarly, we find that those 3 aspects—capacitybuilding, financing, and health systems improvement—appear
to be the way forward in ensuring better access to neurosurgical care across countries and settings of varying incomelevels.6

SOLUTIONS ARE INDEED “FAR BEYOND THE NEUROSURGICALOPERATING ROOM”

Surgical care is indeed necessary in this day and age,7,8 and thetimes call for the global medical community to realize that muchwork remains to be done in bridging the gap between the ideal
and the realities of neurosurgical care. Similar to how thecurrent times have taught us that temporizing measures forthe problem of COVID-19 lie beyond pure basic medical science, problems in the delivery of specialized surgical care thatis neurosurgery might find corresponding solutions in spheresthat lie at the outset of individualized patient care. Revisiting ahealth-systems approach9 that accelerates technology
diffusion10 and that also reorganizes relevant financing andgovernance arrangements,11,12 can gradually, but surely,
bridge the gap in neurosurgical care for the moresocioeconomically disadvantaged populations of the world.

Indeed, the COVID-19 pandemic has affected populations
across international borders. At a time when public-healthmeasures—however lacking or excessive—have become themainstay of interventions for global health systems brought
about by the pandemic, the routine care of patients who needneurosurgical treatment has been subjected to externalities likenever before. In this regard, we agree with Andrews that potential solutions also lie beyond the sphere of everyday
neurosurgical practice.
Uncertainty in outlook seems to be the rule for now. We do
not know when neurosurgical care for non-COVID patients will

REFERENCES
1. Andrews RJ. Publish or perish? Publish andperish? Global neurosurgery in the COVID-19
pandemic era. World Neurosurg. 2021;145:45-47.
2. COVID-19 Control Project Team of Japan Stroke
Society. Japan Stroke Society Protected Code
Stroke: JSS-PCS. Jpn J Stroke. 2020;42:315-343.
3. Dayrit MM, Lagrada LP, Picazo OF, et al. The
Philippines Health System Review. Vol. 8 No. 2. New
Delhi: World Health Organization, Regional Ofﬁce for South-East Asia; 2018.
4. Ferraris KP, Golidtum JP, Zuñiga BK, et al.
Recapitulating the Bayesian framework forneurosurgical outpatient care and a cost-beneﬁt
analysis of telemedicine for socioeconomicallydisadvantaged patients in the Philippines during
the pandemic. Neurosurg Focus. 2020;49:E14.
5. NCD Countdown 2030 Collaborators. NCD
Countdown 2030: pathways to achieving sustainable development goal target 3.4. Lancet. 2020;396:
918-934.

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6. Ferraris KP, Matsumura H, Wardhana DPW, et al.
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CD011085.
Conflict of interest statement: The authors declare that thearticle content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Citation: World Neurosurg. (2021) 148:163-164.
https://doi.org/10.1016/j.wneu.2021.01.083
Journal homepage: www.journals.elsevier.com/worldneurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2021 Elsevier Inc. All
rights reserved.

WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2021.01.083