Cape Verde.

Cape Verde is a 10-island archipelago of Sub-Saharan Africa located about 450 km off the Senegalese coast with approximately 500,000 inhabitants [43]. Portuguese colonizers arrived in 1460, converting the archipelago into, “…an open-air hypermarket” for slave commerce [44]. Indeed, slave trade and geostrategy constituted the principal objectives of colonization [45–47]. The socioeconomic and cultural repercussions of this colonial legacy were profound, lasting over 400 years. This period indissolubly linked the archipelago’s destiny to the African mainland, Europe and the Americas through the Transatlantic slave trade; it functioned as a living, mercantile laboratory for experimentation with animals, plants and human beings [48].

Cape Verde has been dubbed a “success story” in African development. Strong governance, prudent resource management, and economic growth stimulated by the Cape Verdean Diaspora have facilitated health system achievements e.g. improvements in life expectancy, maternal and child health, and managing infectious diseases [43]. Nonetheless, structural vulnerabilities such as lack of essential medications, infrastructure, equipment, and specialized physicians such as neurosurgeons, obligate Cape Verdeans to resort to dependence upon humanitarian aid, interisland medical transfers or evacuations abroad for neurosurgery as well as other subspecialty care, through a complex, bureaucratic process that often burdens patients socioeconomically [45–47]. In particular transfers for neurosurgical care have accounted for 6–10% of evacuations over the past three years (Table 2).

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Table 2. Cape Verdean transfers.

https://doi.org/10.1371/journal.pgph.0001550.t002

Cape Verde’s current NWD of 0·39 stems from two Cuban neurosurgeons, the first of whom joined the National Health System in 2014. The contributions of both neurosurgeons are vital, yet inadequate to meet the country’s neurosurgical disease burden, especially as eight of the nine inhabited islands still lack even one neurosurgeon.

Brazil.

Portugal’s principal wealth-generating colonial enterprise was a systematic exploitation of 4·9 million Africans transported to Brazil from the time of Portuguese Maritime Expansion through abolition of slavery in 1888 [50, 51]. Preceding this, several movements tended towards emancipation, e.g. the Malê Revolt of Salvador in 1835 led by African Muslim freedom fighters. During this period, African descendants represented 78% of the population; 40% of them were slaves [52]. Currently, Salvador is the Brazilian city most densely populated by African descendants who are racially characterized as “black,” and experience profound social inequity [53]. In 2018, the average income of black people was 32% of their white counterparts’ income, revealing the socioeconomic dominance of a white Brazilian minority [53]. Structural racism resulting from Brazil’s colonial history was exemplified by the creation of “Land Laws,” which were legislative attempts by dominant landowners to prohibit black ownership of property [54].

Brazil’s colonial legacy of racism persists in medicine: graduating medical students in 2019 were 67·1% white, 24·3% brown, 3·4% black, and 5·2% of undeclared or other race/ethnicity [28]. By comparison, racial demographics for the nation included: 46·7% brown, 44·2% white and 8·2% black [55]. “Whites” were therefore overrepresented in medicine by 52%, while “browns” and “blacks” were underrepresented by 48% and 59%, respectively. Similar disparities persist in neurosurgery through inequitable countrywide distribution of Brazil’s 3,682 neurosurgeons: the predominantly white state of São Paulo has an NWD of 3·71, which is over double the NWD of the world’s wealthiest economies [13]. By contrast, the predominantly black state of Bahia has an NWD of 0·74, translating into less than 20% of São Paulo’s NWD [28]. The black and brown populations predominate in the North and Northeast of the country, which concentrate respectively 5·2% and 15·4% of Brazilian neurosurgeons, and have the lowest NWD [28]. Thus, racial/ethnic inequities in Brazilian neurosurgery are evident in both the disproportionate underrepresentation of black and brown African descendants in Brazil’s neurosurgery workforce, as well as the related geographic disparities of access to neurosurgical care that adversely affect regions more densely populated by Brazilians of predominantly African descent. While the causes of these neurosurgical inequities are likely multi-factorial, the legacy of Brazil’s history of slavery and colonialism informs structural racism against Brazil’s African descendants that contributes to these inequities.

Ghana.

Ghana is a West African country with about 31 million inhabitants. European colonizers dubbed Ghana the Gold Coast upon their arrival in the 1400s [56]. The Portuguese were the first to stake their claim on the colony, followed in quick succession by Dutch, Danish, French, and British colonizers who exploited the country’s human (via slavery) and natural resources (gold, bauxite, timber) [57]. Ghana became the first independent post-colonial African nation in in March 1957 under Dr Kwame Nkrumah’s leadership. However, the post-independence renaissance was short-lived with Nkrumah’s overthrow in 1966, followed by a series of military-style leaders until1992 when Jerry Rawlings, the last of the military dictators, instituted democratic elections [56].

Throughout Ghana’s development, healthcare delivery has been fraught with challenges including inadequate human resources and infrastructure [58]. With increasing healthcare demands in the post-independence era, and neo-colonial pressure from the BW institutions to meet the conditions of government financing assistance, Ghana implemented a user fee-driven health financing strategy called “cash-and-carry” [59, 60]. Despite data suggesting that the system advanced development, cash-and-carry increased financial burden and worsened health outcomes for vulnerable populations [59, 60]. In some instances, all anticipated hospital fees required prepayment; otherwise, patients were sequestered in hospitals until fees were paid. In the early 2000s, the National Health Insurance Scheme was established to mitigate these costs, though patients continue making significant out-of-pocket payments for care [58, 61, 62]. Additionally, care delivery is complicated by poor infrastructural support and inadequacy of trained personnel, diagnostic tests, imaging and surveillance [63]. Patients generally seek care at hospitals, though many consult traditional healers either as an adjunct or alternative to Western medicine [64, 65].

In neurosurgery, health system limitations are further compounded by resultant frustrations for the country’s 24 neurosurgeons and the patients they serve [17]. Ghana’s low NWD is concentrated in a few urban hospitals, and attributable to several workforce development barriers, e.g. the lengthy structure of training which is influenced by the British educational system [17]. Ghana’s neurosurgery training pathways include the programs of the West African College of Surgeons or the Ghana College of Physicians and Surgeons [17]. Lack of neurosurgical capacity has led to delayed or inappropriate care for patients and limited access to diagnostics and post-acute rehabilitation. In this manner, the colonial legacy has continued to drive neurosurgical inequity for most Ghanaians.

Haiti.

In 1492, Columbus’s landing on Hispaniola ignited a 200-year period marked by the genocide of Taino Arawaks by Spanish colonizers, the systematic importation and enslavement of Africans, and the arrival of competing European forces like France [66–68]. After gaining the western third of the island in 1697, France continued to import African slaves in the renamed colony of Saint Domingue for its wealth-generating sugar plantation business [67]. Slavery ended a century later when African slaves and their descendants revolted against France, creating the Republic of Haiti on January 1, 1804 [69].

Haiti’s revolution resulted in westward territorial expansion of the U.S. through the 1803 Louisiana Purchase. Nonetheless, France and the U.S. refused to recognize Haiti’s sovereignty until 1825 and 1862, respectively [70]. Postcolonial relationships between Haiti and these superpowers systematically undermined Haiti’s viability. France’s recognition required Haiti to pay a reparations indemnity for loss of slavery-based sugar business; currently valued at $21 billion USD, Haiti completed payment in 1947 [71, 72]. U.S.-Haiti relations were punctuated by similar neo-colonialism, including periods of US military occupation and support for dictatorial regimes [73, 74].

Haiti’s resulting struggles include an impoverished neurosurgical landscape from inadequate training opportunities and healthcare investment [75, 76]. Neurotrauma, stroke and hydrocephalus are major causes of morbimortality harkening the need for access to neurosurgical care [77]. Only three neurosurgeons currently serve Haiti’s 11 million inhabitants, and sparse resources like neuroimaging hinder care while obscuring the real epidemiology of neurosurgical disease [76, 78, 79]. Despite recent humanitarian projects led by foreigners, the colonial impact on Haitian neurosurgery has persisted, now characterized by NGO-dependency. High-income countries like the US, Canada and France still finance projects that prioritize their interests over the national interests of Haiti’s public sector, thus perpetuating neo-colonial barriers to sustainable development. Haiti’s economically fragile and vulnerable public sector consequently fails to deliver comprehensive neurosurgical care to all Haitians who need that care, even as some foreign NGO projects manage to intermittently deliver such care to some, more fortunate Haitians. While comprehensive understanding of the drivers of neurosurgical inequities in Haiti will require further analysis of the political economy of Haitian neurosurgery, that analysis must be grounded in a study of the contemporary repercussions of Haiti’s colonial history. Global neurosurgery initiatives that seek to address Haiti’s neurosurgical inequities will therefore require decolonial partnerships that empower local capacities for neurosurgical care [76, 80].

Cameroon.

Cameroon’s health system, including the country’s ability to provide neurosurgical care, is intrinsically linked to Cameroonian colonial history. Germany annexed Cameroon’s littoral regions in 1884 using evangelism, trade, and military domination. The colonizers signed exploitative treaties with traditional rulers and renamed the region Kamerun. Following the First World War, Kamerun came under British and French rule, and was geographically partitioned to accommodate the new colonial powers. Western Kamerun was annexed to British Nigeria and became English-speaking Cameroon, while eastern Kamerun became Francophone Cameroun under France. The differing German, English, and French brands of colonization had varying impacts on the health system. British rule utilized pre-existing power structures, whereas France imposed its culture and values through forced assimilation [81]. The two resulting Cameroons developed dissimilar levels of autonomy, infrastructure, and sustainability between 1918 and 1960.

In French Cameroun, local healthcare workers were marginalized and traditional medicine was discouraged, which had serious implications for neuroscience because neurological disorders are often believed to be metaphysical rather than biological [82]. This alienation of local and traditional healers from colonial health structures adversely impacted health-seeking behaviours and contributed to care-seeking delays for Cameroonian patients with neurosurgical disorders since patients requiring neurosurgical care often sought the care of such healers first [83]. Christianity was central to healthcare throughout both sides of Cameroon, as pastoral outposts were the administrative bases for colonial interventions and religious facilities long served as the sole primary care centres in most communities. Moreover, these outposts were laboratories for human experimentation up until independence and set the stage for abuses and significant health disparities [84]. Christian health facilities still play a critical role in delivering nearly one-third of care, which likely explains the health disparities of the three majority Muslim Northern regions despite that they comprise nearly 40% of the population [85].

When the two Cameroons gained independence and unified, the larger francophone Cameroun became dominant, extending the French administrative and healthcare blueprint over its anglophone counterpart. Power and decision-making were concentrated in the capital, Yaoundé, where a single medical school trained physicians mostly in French for decades following independence. Despite offering surgical training, lack of neurosurgery training long obligated aspiring neurosurgeons to emigrate. Moreover, socioeconomic vulnerabilities of referral hospitals outside of the Centre and Littoral regions, resulting in part from Cameroon’s colonial legacy, have limited infrastructure and inadequate funding and authority to increase access to neurosurgery. As a result, patients from eight of the ten regions of Cameroon, must travel long distances to get care from one of the country’s 26 neurosurgeons in Yaoundé or Douala [17, 83]. Understanding the legacy and contemporary repercussions of Cameroon’s shared French, British and German colonial history is therefore vital to global neurosurgery initiatives that aspire to advance equitable neurosurgical care for all people of Cameroon.

Rwanda.

Rwanda, a landlocked East African country with approximately 13 million people, was a German colony from 1897 to 1919. Following World War II, it was placed under Belgian mandate [86–88]. Belgian health policy was mainly organized in an authoritarian way [89]. Recurring famines weakened the region. Maternal and child mortality reached alarming levels. Many endemic diseases affected the population and deadly epidemics followed. Living conditions were harsh with rudimentary hygiene, in a context of almost generalized poverty. In 1985, Rwanda adopted a health development strategy based on decentralization and district-level care [90]. Decentralization began with the development of provincial-level health offices for health system management. The country’s progression was completely disrupted by the 1994 Genocide that took over 800,000 lives. The health sector was also compromised by loss of health professionals and destruction of much of the health system and its infrastructure.

Rwanda has made remarkable progress towards recovery characterized by increased stability, rebuilt national security, and multisectoral reinvigoration, including healthcare. In February 1995, the government issued a new policy to guide health system reconstruction. Rwanda surpassed many of its pre-1994 health targets, including reduction in HIV/AIDS prevalence, under-five mortality and road traffic accidents. Health insurance became mandatory for all individuals in 2008; in 2010 over 90% of the population was covered [91]. In 2012, only about 4% were uninsured. Nevertheless, Rwanda continues to face a high disease burden, with mortality stemming primarily from complications of HIV/AIDS, severe malaria, pulmonary infections, and trauma. Traditional medicine remains also widely used. Sick people are as likely to consult traditional practitioners as their modern healthcare providers, depending on the nature of the problem [92].

The University of Rwanda (formerly National University of Rwanda) restarted medical school in 1996 and its first surgery training program in 2005. Before then, such specialists were trained abroad, mainly in South Africa, West Africa, East Africa and Europe [24]. Until recently, major neurosurgical procedures could not be performed and patients required referral abroad. Numerous salvageable patients died due to non-operated neurotrauma, while undiagnosed brain and spinal conditions remained common [24]. Previous neurosurgical care was provided by foreign surgeons. In 2007, the country had only one CT scanner, no MRI, and only one Rwandan neurosurgeon. In 2010, a 1.5 Tesla MRI was serving the entire nation. In 2012 a local postgraduate training program in neurosurgery was initiated [24]. By December 2021, the country counted six neurosurgeons and some trainees.

Structural violence.

Harm resulting from neurosurgical inequities is a form of, “structural violence” [10]. The term more than doubled its frequency of occurrence in the biomedical literature of 2021 (72 results) versus three years prior (Fig 1A). Structural violence in GN can occur when social determinants of health such as race, occupation, or domiciliary status directly impact whether people suffer from neurosurgical disorders, the severity of disease at the time of diagnosis, (3) availability of therapy and (4) patient outcomes.

Structural racism.

Since race is not biological, but rather a socially constructed classification based on natural variations in human appearance, the rarity of explicit race-based discrimination poses a challenge to decolonization because the latter seeks to dismantle phenomena that are not universally acknowledged to exist [37]. Nonetheless, the vignettes above illustrate how coloniality has structurally shaped current racial disparities that impact all areas of global health, including GN. Understanding the institutionalization of the racist premises of colonialism in modern health systems is therefore vital to decolonization, and may explain the growing use of the term, “structural racism” in the biomedical literature (Fig 1B).

Anti-racism.

The term, “Anti-racism,” is defined in Table 3, and was observed to be utilized with a nearly 10-fold increase in frequency of occurrence in the biomedical literature of 2021 compared to only two years prior (Fig 1C). Anti-racism may include promoting leadership in GN by practitioners whose demographics match those of the community served. Such approaches can radically transform structural racism by mitigating mistrust from marginalized communities and strengthening the cultural effectiveness of GH workers and the teams they lead [34].

Critical consciousness/Conscientization.

“Critical consciousness” and “conscientization,” used interchangeably here, are approximate translations of the Portuguese term, conscientização, promulgated by the Brazilian education scholar, Paolo Freire [33, 35]. While “critical consciousness” is the term of increasing frequency, “conscientization” will be used below (Fig 1D and 1E). As an introspective and dialogic process that can support transformative education, conscientization has great relevance for the decolonization of GN [33].

Conscientization and anti-racism as decolonial praxes.

Modern neurosurgical inequities are a form of health system-related structural violence in that they discriminate by generating both the privileges of the most fortunate, who enjoy access to neurosurgical care, and the misfortune of the destitute sick who suffer from lack of such access. Recognizing GN inequities as a form of structural violence may empower GN stakeholders to channel humanitarian motivations into a decolonial humanism. Conscientization and anti-racism are complementary approaches that can support reflective, transformative practices that inspire this decolonial humanism [32–35].

Dialogic conscientization.

Conscientization may be implemented by GN practitioners through deliberate reflection primed by acknowledging the existence and influence of colonial power dynamics in GN relationships [33]. In the process of locating themselves within sociohistorical hierarchies, GN stakeholders can initiate transformative dialogues that enable decoloniality. For instance, when HIC neurosurgeons meet their LMIC counterparts, the former may grow in cultural humility from conversations that enable them to see how the randomness of place of birth thrusts HIC partners into the (neo-)-colonial role of “oppressor” vs. the LMIC partner’s role as, “oppressed.” [35]

When the racially, socially and/or economically disadvantaged position of “LMIC partner” results in that partner’s absence from conversations that shape her/his/their healthcare reality, default approaches to problem-solving structurally perpetuate the colonial legacy. Enabling historically disempowered voices to shape our GH dialogues can instantly transform traditional power dynamics, and advance equitable, decolonial solutions to GH problems by liberating HIC and LMIC partners from the inherited, dichotomous colonial roles of “oppressor” and “oppressed” [35].

Moving beyond this praxis and its inherent shifting frames of reference, GN actors may further engage in conscientization through introspection exploring the colonially inherited pretence that the privilege of whiteness, or the disadvantage of blackness, confers real gradations of superiority or inferiority onto human beings [33]. This level of introspection can further inform authentic cross-cultural communication that nurtures decolonial GN partnerships, particularly when a common language, centring the native tongue of the LMIC partner, is prioritized to enable an equitable dialogic plane.

Anti-racism.

Anti-racism may be thought of as a corollary to the transformative process of conscientization, and is any form of opposition to racism or a racist structure [32, 34]. The concept provides an actionable posture for dismantling structural inequities that underlie GN disparities, and it may take the form of proactive advocacy for policies and practices that protect and empower people from disenfranchised racial groups, such as countering surgical colonialism in clinical endeavours abroad, or deferring first- and senior-authorship roles in GN manuscripts to LMIC partners and racially marginalized actors [3, 97]. Anti-racism may also take the form of advocacy against racist laws or policies that discriminately harm people from underserved groups, which in many societies are “black” people of presumed African ancestry [32]. For instance, neurosurgeons in the USA who care for victims of penetrating brain trauma can be influential anti-racist advocates for gun control in the face of data revealing that black men in that country are 14 times more likely to be killed by firearm than white men [100].

Table 4 presents a guide for reflection, dialogue and project assessment in GN endeavours. Based upon the introspective and dialogic practices recommended above, we are hopeful that it will serve as a practical tool that facilitates decolonization in modern GN.

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Table 4. A guide for reflection, dialogue and project analysis to decolonize global neurosurgery.

https://doi.org/10.1371/journal.pgph.0001550.t004