IGNATIUS N. ESENE

PASSION, DETERMINATION, LOVE TO AFRICA, DREAMING AND FLYING HIGH...

The WFNS Young Neurosurgeons Forum is truly fortunate to count on the leadership of this bright academic.

After a successful international career, this talented man is rapidly raising the level Neurosurgery in Cameroon while involved in many international activities. His credited also to have incorporated in the standard neurological examination the medial hamstring reflex for the diagnosis of L5 radiculopathy.

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Fig. 7 Chairing an Educational Webinar of Young African Neurosurgeons

What is the profession of neurosurgeon in Cameroon like?

Neurosurgery in Cameroon is relatively nascent. With a population of about 25 Million inhabitants, Cameroon can boast of about 25 Neurosurgeons, the majority of whom are located in two major cities and practicing at tertiary hospitals. Like in most African Countries, the workforce is inadequate with no specialized complementary staff (neuro-anesthetists, neuro-radiologists…). There is limited access to advanced neurosurgery equipment with most Neuroimaging (69% of CT scans, 100% of MRIs) located in the economic and political Capitals. Less than 20% of neurosurgery patients have health insurance. The trauma system referral platform is centralized. Electronic Medical Record are uncommon.

Patient care is variable depending on the setting in which surgical care is delivered but on the average, good, as Cameroon receives referrals from neighboring countries. The government strives to make healthcare access to all via a Universal Health Coverage Policy. In totto, there is access to essential neurosurgical care in Cameroon albeit inadequate with disproportional geographic (rural-urban) disparities.

How is Neurosurgery developing in Africa?

African Neurosurgery is in a transition. Although its Neurosurgical workforce is ranked least globally, secular trends reveal an increase with a tripling (361 in 1996 to 1333 in 2018) over the last 3 decades. Females Neurosurgeons now stand above 240 with many in training. Many countries can boast of local training facilities and programs in addition to an increase in the WFNS Reference Centers (for the training of young neurosurgeons). Sub-specialization is becoming a common place and more centers are equipped with up-to-date equipment.

In brief, the trends are promising with an increasing training capacity and workforce, improved infrastructures and equipment and better service delivery. There is more local governmental, regional, continental and global engagement to developing neurosurgical care in Africa.

How is clinical research spreading in low income countries?

There is a substantial qualitative and numerical increase in research output over the last decade. The number of PubMed indexed articles published by LMIC-affiliated researchers is increasing exponentially albeit lagging those from HICs. As of January 13, 2021, LMICs had published 80,061 articles: 11,309 (14.1%) case reports, 662 (0.8%) observational studies (cross-sectional, case-control, and cohort studies), and 2,119 (2.6%) randomized controlled trials. Of these, 35.6% (n=28,524 articles) were published between 2015 and January 13, 2021.

There is an increasing awareness and appreciation for the value of scientific research as an important tool for health and social development, and economic progress.

Fig. 2 Publications Trends in LMICs (Pubmed Searched 13/01/2021 (Results 80,061 results))

Why are there so few scientific studies published by African neurosurgeons?

Currently, African neurosurgeons have contributed to 3,215 publications – i.e. 4.1% of LMIC neurosurgery articles. This is insufficient! Barriers to research are multifold and include insufficient research skills stemming from inadequate research education and training for neurosurgeons/trainees, lack of supportive research team, and shortage of funding and research resources. Other challenges include: data collection (from poorly managed paper archives), lack of career development opportunities, inadequate appreciation for the value of health care research as an essential tool for progress, lack of protected research time, limited access to health informatics and limited intra-continental collaboration. 

We are working towards the improvement of this situation not only for Africa but also for all LMICs by the training of young neurosurgeons on research principles, methodology and skills (key component required for the development of research infrastructure). The trends in the quality and quantity of research are positive albeit the pace has to be accelerated.

Which pathologies have more incidences in low and middle-income countries?

Recent research reveals the most common neurosurgical diseases in LMICs are: traumatic brain injury (41.5%; n=4,458,615 cases), stroke (22.4%; n=2,407,551 cases), and epilepsy (10.8%; n=1,166,036 cases). In general, common neurosurgical problems in the LMICs are trauma, CNS infection, hydrocephalus and congenital diseases. With demographic and epidemiologic transitions, the incidence of cancer and  cerebrovascular disease is on the increase. The latter will need further development in neurosurgical services and an adapted workforce.

The aforementioned epidemiologic profile is complicated by the late presentation of patients in LMICs, which leads to even “benign conditions” becoming “advanced pathologies” and in most cases incurable.

You have a splendid education, how did you achieve this?

My Life’s story is an admixture of opportunities, determination, perseverance and passion. I have been trained and prepared for a career as an Academic Neurosurgeon (one who does not only treat patients but is actively involved in Research, Education and training of future neurosurgeons).

I completed high school from the prestigious Cameroon College of Arts, Science and Technology, majoring in sciences (all “A” Grades, graduating as the valedictorian,). I obtained my Medical Doctorate Degree (MD) from Cameroon and was awarded the Academy of Research and Higher Education scholarship to undertake a Masters in Public Health (in Brussels, Belgium), graduating with a Magna Cum Laude (valedictorian,). I then proceeded to Cairo where I earned a Masters in Neurosurgery (Minor Neurology) with a cum laude and a Doctorate Degree in Neurological Surgery under the aegis of the World Federation of Neurosurgical Societies and auspices of the Cameroonian government.

Success in Neurosurgery requires sub-specialization and complementary knowledge in allied sciences hence my acquisition of expertise in Health Economics (Bonn, Germany), International Health (Leeds, UK) and Advanced Research Methods and statistical (ULB, Brussels)., Pediatic Neurooncology (Children Cancer Hospital, Cairo), Neurovascular and skull base (NIH-StrokeNet and FIENS Fellow in UW-Madison)

To stay abreast with the changing knowledge tides, I am hitherto affiliated to numerous educational organizations like FIENS (Foundation of International Education in Neurological Surgery), IBNC (International Basic Neurosurgery Course), BRAIN (Brain Research Africa Initiative), the Cairo Gamma Knife Center (Research Associate) and Encyclopedia Neurochirugica (France) etc.

All the years dedicated to the acquisition of knowledge have been in preparation for a career in academic global neurosurgery.

Fig. 3 Endoscopic Lab. SIMULATION (UW-Madison Skull Base Lab).

What is your best memory of this era?

The most exquisite moments in my neurosurgery career were the publication of our research papers on “The diagnostic performance of the Medial Hamstring Reflex (MHR) for L5 radiculopathy” and the development the statistical proof of the maximum sample size for “Case Reports”. The latter has led to the universal re-definition of the “Case Reports” in biomedical research (currently on instruction to authors’ page of the ‘Journal of Neurosurgery’) and the former to the inclusion of the MHR in routine neurologic examination. These vivid memories which take me back to my days as a PGY 3 resident were my moments of epiphany and have greatly influenced the course of my career.

How do you organise yourself every day to carry out as many activities as you do?

First, I have set up distinct and lofty short, Intermediate and long term goals for my career. My long-term goal is to be a Neurosurgeon “Useful” to my “Patients” thus my country, Continent and the world. I have set up my standards, hardly conform and aggressively explore opportunities that come my way. Every Sunday I put up a plan for the week (making allowance for emergencies). Mondays, Wednesdays and Friday (Mornings) are set aside for consultations, Tuesdays and Thursdays for elective surgeries, and Friday afternoons, Saturdays and Sundays for Research activities. To avoid dropping from exhaustion, my activities are classified into four quadrants (Important and Urgent, Important and Not Urgent, Not Important but Urgent and Not Important and not Urgent) permitting me to prioritize my work. My days are usually busy with early mornings and late nights but I stay focused on the BIG PICTURE while paying attention to details always.

Fig. 4 Teaching Medical Students in the theatre

What advice do you give to the young neurosurgeons in Africa, with whom you collaborate so much?

“This is New Africa”…. “Africa Rising”… “Let’s Build the Africa we want” are amongst the motivational slogans I use to inspire my peers.  “The future of African Neurosurgery is in the hands of Young Neurosurgeons”, I reiterate always. My conviction is that the story of African Neurosurgery will be changed via investment in Education and Research. The Young African Neurosurgeon should avoid shortcut to success. Good education and training are the key to enhance social change. Confidence comes with knowledge which can only be acquired via years of relentless dedication, determination and perseverance in learning and practicing Neurosurgery. Neurosurgical excellence needs a combination of a well-trained brain with skillful hands and an empathic, honest and humble personality. Today, Neurosurgery is no longer a one-man show; team spirit and networking are the corner stones for a successful career. Lastly, in this evidence-based era, I encourage every young neurosurgeon to cultivate a habit of evidence-based practice for optimal patient care and to enhance communication with the scientific world.

Fig. 5 Doing More with Less (In the absence of an electric Drill we use a Hudson Brace)

Fig. 6: A) Crossing the Congo River (in a Boat)  with Young African Neurosurgeons to participate in a Workshop in Kinshasa, DR of Congo. 

Fig. 6: B) With Nqobile Thango (Middle) and James Balogun (Right)

You love reading fiction, is Neurosurgery with so much cutting-edge technology fiction or reality?

In developing settings, Neurosurgery is erroneously considered a luxury specialty. However, lack of its development impedes improvement in global health care and infringes basic human rights.

Although being one of the most cutting-edge disciplines in the world of science involving the use of the most advanced technologies currently available, Neurosurgery is an essential and fulfilling specialty that is life changing to patients in need of it. There is no doubt that Neurosurgery is an elite specialty in its own category, however, it should be a priority as the level of development of Neurosurgical Services in any health institution reflects the overall level of care. With high technology, one is able to offer better care to patient such as “bladeless and bloodless” radiosurgery, minimally invasive micro- and endoscopic surgeries etc. Contrariwise, with basic surgical tools, one can perform life-saving surgeries for hydrocephalus and traumatic head injuries. Every institution should thus strive to develop and deliver neurosurgical services.

You work with one of the most active WFNS Committees. How do you see the YOUNG NEUROSURGEONS FORUM collaborating with the WFNS Foundation?

A recent survey by WFNS YNF revealed, barriers in delivering an adequate neurosurgical service (inadequate workforce, lack or no insurance coverage, lack of equipment and imaging facilities) and barriers in Personal Practice (limited education and research opportunities, inadequate networking/mentorship, lack of access to neurosurgical journals, neurosurgical textbooks, access to cadaver dissection labs, and resources to attended a WFNS-endorsed conference).

The WFNS Foundation can collaborate WFNS YNF in elaborating strategies to meet up with these needs. For a pressing need like research, the Foundation can sponsor regional research courses, sponsor best abstract awards, and offer research grants to early career researchers and continue to sponsor fellowships.

Last Words…

I believe the circumstances of one’s birth should not be a limitation to one’s ability to dream and fly high. Where one trains and practices neurosurgery should not impede one’s ability to innovate, contribute, and influence science.  I am an optimist, and a highly motivated person. Having had a fair share from life, I am morally compelled to create similar opportunities for my peers and junior colleagues. My dream is to contribute to the development of neurosurgery in my country, Africa and Worldwide. This is already happening with the confidence bestowed on me to lead Young African Neurosurgeons Forum and WFNS YNF, and my recent appointment as the Deputy Editor-In-Chief of the Journal of Global Neurosurgery. So far My journey in Neurosurgery been rewarding, gratifying and satisfactory and I am looking forward towards more blossoming days.

Acknowledgment

I will like to acknowledge the support and collaboration of my colleagues and friends:  Angelos Kolias, Amro AlHabib, Faith Robertson, Kerry Vaughan and all the WFNS YNF committee members, Nqobile Thango and Ulrick S. Kanmounye and all Young African Neurosurgeons, Dr Kee Park and the entire Journal of Global Neurosurgery Team, Egyptian Society of Neurological Surgeons, Turkish Neurosurgical Society and  CAANS AC Members.

Sincere appreciation to my hospital Director (Dr Aboubakar Sadjo) and Dean of the Faculty of Health Sciences, University of Bamenda (Prof. Gloria Ashuntantang).

Lastly, thank you to the Giants on whose shoulders I stand: Pr. Robert Dempsey, Pr. Madjid Samii, Pr. Kazadi Kalangu, Pr. Gilbert Dechambenoit, Pr. Eloundou Ngah Joseph.