Child's Nerv Syst (1988) 4:317-320 m6NS © Springer-Verlag 1988

Pediatric neurosurgery around the wor ld- Asia and Australasia*

O s a m u Sa to

Tokai University School of Medicine, Department of Neurosurgery, Bosei-dai, Isehara, Kanagawa, Japan 259-11

When one looks at the world map, Asia covers a vast area - sprawling from Turkey in the West to Japan in the Far East. In preparation for the topic "Pediatric neurosurgery around the world," I have collected data from several Asian countries. The questionnaires were mailed to neurosurgeons in those countries whose major interest was thought to be pediatric neurosurgery, although no information had so far been available on some nations. Statistics such as the num- ber of neurosurgeons in each country are based on the fig- ures that appear in World Directory of Neurological Surgeons edited by the Congress o f Neurological Surgeons in 1985. Other figures such as territorial area in square kilometers and population are f rom the Asahi Almanac, the 1987 edi- tion.

Questionnaire

The questionnaire, which was sent to each country, con- sisted of the following questions:

I. Is pediatric neurosurgery a recognized speciality? 2. H ow many hospitals are devoted to the treatment of chil- dren alone? 3. What is the total number of beds available for pediatric neurosurgical care? 4. What is the number of fulltime pediatric neurosurgeons currently in practice? 5. Are there any special programs devoted to training pediatric neurosurgeons? 6. How many positions for pediatric neurosurgery are avail- able for training per year? 7. What is the length o f the training? 8. Is there a specific society devoted to pediatric neurosur- gery? 9. Are there any special meetings for pediatric neurosur- geons? Annual or other? 10. Are there any special journals published for pediatric neurosurgery? 11. Do you have a so-called Hospital Ethics Committee?

* Presented at Symposium on Pediatric Neurosurgery Around the World, at the 15th Annual Meeting of the International Society for Pediatric Neurosurgery, New York 1987

Responses

Responses were obtained from 12 countries, which are shown in Tables 1-11 and the countries are arranged in alphabetical order. The populations are listed in million, and the number of neurosurgeons and number of ISPN members are listed individually in Table 12.

China (territory: 9,596,961 km 2)

There are 26 provinces and 3 municipalities. Each province has 1 children's hospital and every municipality has 2 or 3, namely, 3 in Beijing and another 3 in Shanghai. There are usually only 3 - 5 beds available for neurosurgery in these hospitals, and the rest of the cases are handled in general hospitals. At major institutes, however, quite a few beds are available for pediatric neurosurgery. Beijing Neurosurgical Institute, which is one of the outstanding institutions in China, provides 40 beds for pediatric neurosurgical care. Hydrocephalus has never been treated in many places, while in Shanghai neurosurgeons place shunts in some 200 cases a year, using Chinese made devices. Shunt devices made in the United States are now available, and there are fewer compli- cations in the major cities.

Table 1. Is pediatric neuro- surgery a recognized special- ity?

Table 2. How many hospitals are devoted to the treatment of children only?

China yes China 30 Hong Kong yes Hong Kong 1 India yes India 6 Israel no Israel 0 Japan yes Japan 8 Korea yes Korea 3 Malaysia no Malaysia 0 Philippines no Philippines 3 Singapore no Singapore 0 Taiwan yes Taiwan 0 Thailand no Thailand 2 Turkey no Turkey 7

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Table 3. What is the total number of beds available for pediatric neurosurgical care?

China 140 Hong Kong 12 India 48 Israel 50 Japan 143 Korea 300 Malaysia 8 Philippines 5 Singapore 0 Taiwan 13 Thailand 15 Turkey 150-200

Table 4. What is the number of full-time pediatric neurosur- geons currently in practice?

China 5 Hong Kong 1 India 0 Israel 0 Japan 22 Korea 11 Malaysia 0 Philippines 0 Singapore 0 Taiwan 1 Thailand 0 Turkey 1

Table 6. How many positions for pediatric neurosurgery are available for training per year?

China 4 (Beijing) Hong Kong 1 India Israel 1 Japan 6-7 Korea Malaysia Philippines Singapore Taiwan 0-1 Thailand Turkey ?

Table 9. Are there any speciality meetings for pediatric neurosurg- cry? Annual or other?

China no Hong Kong seminars India midterm workshops and seminars Israel no Japan yes - annual Korea yes - spring and fall Malaysia no Philippines no Singapore no Taiwan monthly case conferences Thailand no Turkey yes - annual section meeting

Table 10. Are there any special journals published for pediatric neu- rosurgery?

Table 7. What is the length of the training? China no

Hong Kong no, but keen to start one China 5 - 6 years India no

in total Israel no Hong Kong 5 years Japan yes, Nervous System in Children, 6/year

in total Korea no India - Malaysia no Israel 1 - 2 years Philippines no Japan 1-3 years Singapore no Korea - Taiwan no Malaysia - Thailand no Philippines - Turkey no Singapore Taiwan Thailand Turkey 3 - 6 months Table 11. Do you have a so-called "Hospital Ethics Committee?"

Table 5. Are there any special programs devoted to training pediatric neurosurgeons?

Table 8. Is there a specific soci- ety devoted to pediatric neu- rosurgery?

China yes (Beijing) China no Hong Kong yes Hong Kong no India no India no Israel no Israel no Japan yes Japan yes Korea no Korea yes Malaysia no Malaysia no Philippines no Philippines no Singapore no Singapore no Taiwan no Taiwan no Thailand no Thailand no Turkey yes Turkey no

H o n g Kong ( terr i tory: 1,045 kin 2)

Pedia t r ic neurosu rge ry is pa r t o f the t ra in ing in H o n g K o n g , and only a few pos i t ions are avai lable per year for t ra ining.

There is no special ized mee t ing devo ted to pedia t r ic neuro - surgery, bu t seminars are of ten held. In addi t ion , they are

keen to start a j ou rna l for pedia t r ic neurosurgery . A t Queen M a r y Hosp i ta l , they are in the process o f deve lop ing neuro - surgery fur ther . The p lan includes 20 pedia t r ic neurosurg ica l

beds.

China no Hong Kong yes India no Israel yes Japan no Korea no Malaysia no Philippines no Singapore yes Taiwan no Thailand yes Turkey no

Table 12. Number of ISPN members in the countries surveyed

Population No. of neuro- ISPN (millions) surgeons members

China 1059.52 443 1 Hong Kong 5.42 13 2 India 750.90 210 3 Israel 4.23 33 1 Japan 121.05 2060 19 Korea 41.21 237 2 Malaysia 15.56 8 0 Philippines 54.38 16 0 Singapore 2.56 11 0 Taiwan 19.14 58 1 Thailand 51.30 46 1 Turkey 51.42 100 1

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India (territory: 3,287,590 km 2)

There are six children's hospitals, and on average 6 - 8 beds are available for neurosurgical care. There is no specialized meeting, but midterm workshops and seminars have been held every year for the past 4 years. In India, it is felt that some neurosurgeons in full-time teaching departments should devote all their time to further development of pediatric neurosurgery as a subspeciality, provided enough consultant staff is appointed to look after the rest of the patients in the neurosurgery department. However, other neurosurgeons can give good pediatric service in certain areas in which they are particularly interested, e.g., areas of craniofacial surgery, growing fractures of the skull, hydro- cephalus of infective pathology, and tumors like cra- niopharyngioma and posterior fossa lesions (medul- loblastoma, ependymoma, etc.). The pediatric institutes that they have in the country may soon establish neurosurgical services. A fair number of active pediatric neurosurgery departments will be founded by the turn of the century, and then pediatric neurosurgery will be a separate subspeciality.

Israel (territory: 20,770 km 2)

There is no children's hospital in this country, but most of the cases are being handled in two hospitals by three neuro- surgeons, although not fulltime. According to one respon- dent, they are afraid that pediatric neurosurgery is at a standstill at present and for the foreseeable future as well. In the area of malformations such as menigomyelocele, they hope for fewer cases. As for other types, the corrective pro- cedures may be only slightly improved. They see no break- through in the future for hydrocephalus - either in preven- tion or in treatment. However, they feel far better today about the treatment of pediatric brain tumors, although the improvement has come mainly as a result in the improve- ment of oncological treatment.

Japan (territory: 377,801 km 2)

All together, there are 11 children's hospitals and 8 have neurosurgical services. The total number of beds for neuro- surgery in these hospitals amounts to 140. Twenty-two full- time neurosurgeons take care of pediatric cases. However, the author admits that the majority of cases are cared for by general neurosurgeons both at the university and general hospitals. The Japanese Society for Pediatric Neurosurgery was founded in 1972, the same year ISPN was founded, and its very first scientific meeting was held in Tokyo in 1973. The official journal of the society is called Nervous system in children and the first volume was published in 1976.

Korea (territory: 9,848 km 2)

In Korea, pediatric neurosurgery as a subspeciality is well recognized and the Korean Society for Pediatric Neurosur-

gery is now 2 years old and has 80 members. The first president of the society was elected in April 1987. They hold meetings twice a year. Three hundred beds for pediatric neurosurgery are available and 11 full-time neurosurgeons are at work. Five of them are affiliated with universities. Following the economical development of the people's liv- ing standard and improvement of medical engineering and the diagnostic tools, new fields for the treatment of con- genital anomalies of the central nervous system are now available. Preventive medicine of these anomalies has re- cently been studied. For the time being, the national move- ments for the prevention of CNS anomalies and maintaining the social security campaigns for physically handicapped children are receiving strong support from the government.

Malaysia (territory: 329,749 km 2)

At present, all pediatric neurosurgical cases are managed by general neurosurgeons. This has been the case in this coun- try because of an insufficient number of practicing neuro- surgeons. Until 1978, there were only two neurosurgeons in the whole country, one in private practice and another at the government hospital. More recently, they have a total of 8 neurosurgeons. Perhaps over the years, as more neurosur- geons become available and some branch into areas solely concerning pediatric neurosurgery, pediatric neurosurgery may become a separate division.

Phillipines (territory: 300,000 km 2)

They have three children's hospitals but only five beds are available for neurosurgical care. At Phillipine General Hos- pital, one of the outstanding teaching hospitals, a consultant neurosurgeon is assigned to handle all pediatric neurosur- gical cases or to supervise the residents managing these cases. These consultants rotate every 3 months. The rest of the time they handle adult cases.

Singapore (territory: 581 km 2)

There is no children's hospital in this nation and no full-time pediatric neurosurgeons. They have no training program for pediatric neurosurgery, and all cases are handled by general neurosurgeons.

Taiwan, Republic of China (territory: 36,179 kril 2)

There is no children's hospital in Taiwan. Pediatric patients are usually admitted to the pediatric department or division in general hospitals; however, at Veteran's General Hospital in Taipei one of the staff members is devoted to the treat- ment of pediatric cases. There are 13 beds and another 2 in the PICU. In Taiwan, there are no special programs devoted to training in pediatric neurosurgery. I f physicians want to

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be pediatric neurosurgeons after finishing their 6-year neu- rosurgical training, they must be trained as a clinical fellow or a resident in Europe or Nor th America. There is no special meeting for the specialty o f pediatric neurosurgery, but they hold monthly case conferences in Taipei. I t is possi- ble that another two or three medical centers will be ready to set up pediatric neurosurgical care units in the next few years. There is interest in setting up a special program devoted to training in pediatric neurosurgery.

Thailand (territory: 514,000 km 2)

There are some 50 neurosurgeons in Thailand and most o f them do both adult and pediatric neurosurgery. Yet a few take special interest in pediatric neurosurgery and may spend their time, up to 40% to 50%, in handling pediatric cases. In general, however, they are too busy to cope with general neurosurgical cases, particularly t rauma cases. In the future, some will certainly want to do solely pediatric work.

far as the training system is concerned, residents spend 6 months in pediatric neurosurgery, they hold a pediatric section, but this subspeciality is still a part of general surgery in this country.

Conclusions

In summary, in most of the Asian countries the number of children's hospitals is still not sufficient, and in some coun- tries there are no such facilities available. In addition, in some children's hospitals they have no separate division for neurosurgery - mainly due to the lack of neurosurgeons.

Pediatric neurosurgery as a subspecialty is well recog- nized in some nations; however, the beds available for pediatric care are undoubtedly few in number. There are few full-time pediatric neurosurgeons, if any, in most o f these countries. Specialty meetings, are infrequently held in many places. In conclusion, in most Asian countries pediatric neu- rosurgery is still on the drawing board, only a tiny speck on the horizon, but in some nations it is certainly almost there.

Turkey (territory: 780,576 km 2)

There are seven children's hospitals in this nation and 150-200 beds are available for pediatric neurosurgery. As

Acknowledgements. Gratitude is expressed to those who responded and answered the questionnaire so thoroughly and made the survey possible. The effort they made is indeed invaluable.