Surgical Neurolog

Editorial

The rise of Chinese neurosurgery and neurosurgery in the

developing world, and scientific colonialism

www.surgicalneurology-online.com

In this issue of Surgical Neurology, there are 3 articles

from Chinese neurosurgical groups. The articles are of very

high quality. Ten years ago, we did not receive articles from

China and many of the countries in the developing world.

The articles in this issue are an example of the rise of

neurosurgery and neurosciences in China and in the

developing world. In the past year, Surgical Neurology

received an increase in articles of more than 35% as

compared with the previous year. This trend is occurring in

many medical publications as physicians in the developing

world seek to publish their observations. The trend we are

seeing will continue. In 2006, the Chinese Neurosurgical

Society published its first international neurosurgical journal

as a supplement to Surgical Neurology. Brazil and Taiwan

have done the same. What is happening in China to produce

these changes?

In 1995, my wife and I first went to China to start the first

World Federation of Neurosurgical Courses in the country.

Kintomo Takakura from Japan initiated the contact, and my

teacher, Shelley Chou, a China-born United States–educated

neurosurgeon who had been the chairperson of neurosurgery

at the University of Minnesota and president of the American

Association of Neurosurgical Surgeons, accompanied us. A

number of neurosurgeons from around the world participated

in this first international neurosurgical course in China. Our

talks were communicated by Chinese translators.

At that time, the streets of Beijing were filled with people

on bicycles. There were few cars. Construction was just

beginning on major buildings. We visited the Forbidden

City, home of the emperors of the past, located in the center

of Beijing. Its imposing red walls with many buildings

inside contained what remained of the historically signifi-

cant artistic creations of a 4000-year-old civilization. We

climbed the Great Wall, which was built to connect the far-

distant places in China so that the army could easily access

the troubled spots by an elevated road. One third of the

patients were treated by traditional medicine with acupunc-

ture and herbs; the rest had access to modern medicine and

science. There was little demonstrable poverty, but a

glimpse of it could be seen in the many narrow alleys that

came off the large streets. Few neurosurgeons from the

developing world had been to China at that time.

0090-3019/$ – see front matter D 2007 Published by Elsevier Inc.

doi:10.1016/j.surneu.2007.01.011

I visited a major hospital in Beijing that had one ward of

15 beds filled with patients who had acoustic neurinomas, a

concentrated sample of patients I had not seen anywhere

else. Radiographs were filed under the mattress of each

patient. I saw no patient older than 40 to 50 years. Modern

medicine was only available to the young. With 1 billion

people, the scant resources for health care had to be spent on

those who would be able to contribute to the society for a

long time. The hospitals were simple. There were few

monitoring devices, and each neurosurgical operating room

had a basic microscope and a simple bipolar coagulator. The

volume of surgery performed was larger than in any other

place I had seen in the world, reflecting the country’s

population size of 1 billion and the need to accommodate

large numbers of patients.

Ten years and many visits to cities throughout China

later, we see that major changes have occurred. Construction

cranes now populate the sky in Beijing, Shanghai, and other

cities. Automobiles crowd the streets of the cities, creating

traffic jams. Few people on bicycles are seen. I have seen

modern operating rooms that surpass the best ones I have

seen elsewhere in the world. In Shanghai, a city with many

modern and beautifully designed skyscrapers, Prof Liang-fu

Zhou is head of a neurosurgical service that performs 8000

surgeries a year, mostly cranial, at several hospitals. His

staff numbers 100 neurosurgeons. His department, as other

departments, is actively engaged in basic research. Many

neurosurgeons from outside China visit and present lec-

tures—some without translations—throughout China. There

is growing contact with neurosurgery and medicine all over

the world. Many Chinese neurosurgeons are receiving

additional postgraduate training in other countries. Thus, it

was easy to see that the scientific and medical advances

have been rapid and in step with the country’s economic and

industrial growth. To encourage the people to relocate

inland and reduce the pressure of migration to the big cities

on the coast of China, the government started the

construction of 200 new inland cities, each intended for

1 million people, which will be carried out over the next

20 years. This is the largest relocation of a civilization in

the history of humankind, 200 million people. To reverse

its dependence on oil, a nuclear power plant is being

y 67 (2007) 323–325

Editorial / Surgical Neurology 67 (2007) 323–325324

constructed each month for the next 20 years to provide

energy for this growing industrial power. These are

examples of the magnitude of problems that the government

faces in serving 1 billion people.

We have talked with many Chinese people at all levels of

society and asked about their desires in life. Many have

migrated from the countryside to the city, attracted by the

opportunity to make money and to have a better life than

they would have in the rural communities. Uniformly, the

Chinese want to have a chance to live the life they were

denied for years, to acquire material goods, and to live in

peace. Husbands and wives both usually work to provide

income, part of which they spend to support their parents in

other cities, mostly in the countryside, because there is no

governmental support system for the elderly population.

One year ago, you would not have received health care in

China if you did not have money. Seven hundred million

Chinese, 70% of the population, live in the countryside

outside the big cities and do not have access to health care

because they do not have the money to pay for the services.

In 2006, the government recognized this problem and began

to provide some support for the care of those living outside

the cities. Individuals in the cities who have jobs are able to

receive health care as part of their benefits from working.

Although the government is communist or socialist, it

does not appear to affect the lives of the Chinese directly;

neither does it stop the growth of capitalism and the

development of independent businesses. In our opinion, it

would be virtually impossible for the government to reverse

the course of this country, which is now on the path to

individual freedom that so many Chinese currently enjoy. In

addition, any consideration of involvement in a war would

destroy the lives that many of the 1 billion people now enjoy

and ruin the economy because trade with others would be

stopped. This economy is vital to this huge population that

now wants to have more of the opportunities that life offers.

However, all is not easy. The poor people from the

countryside riot against government corruption and its

denial of services to them, but little of this unrest is known

to the Chinese or to the rest of the world. This example is a

remnant of governmental control of the press. In a country

with 1 billion people, if 10% are unhappy, it means that

100 million people are not happy. No politician can enjoy

that possibility. Therefore, the problems that the government

faces at a time of huge change are very difficult.

Some companies have given money back to doctors and

hospitals that buy their equipment as a reward for their

purchase. The government has attempted to stop this

corruption by passing laws that are very restrictive on the

purchase of new equipment. Corruption is very common in

China as it is in other countries. It involves the government,

the banking system, the business sector, and many aspects

of life. Corruption in most countries is how many survive in

a social system that frustrates opportunity. Part of the reason

for this corruption in medicine is the fact that Chinese

physicians are poorly paid by standards in other countries,

and it is a way for the people to make some extra money. It

was very difficult for Prof Jizong Zhao, head of the Chinese

Neurosurgical Society, to raise enough money for the initial

issue of the Chinese Neurosurgical Supplement. Although

there is great progress in Chinese neurosurgery, doctors

work under difficult circumstances with little pay in taking

care of the large numbers of patients who need care. When I

visited Nanjing in November 2006, the main hospital there

registered 10000 outpatients each day. There is no uniform

standard of training; as such, there is an uneven education

among neurosurgeons in the country, a situation seen in

many countries around the world. However, the Chinese are

also working to correct these problems. The Brazilians, who

have a similar social and economic situation, have been the

most successful in the world in providing standards of care

for the education of neurosurgeons. I met the head of the

Chinese Medical Association. It has 1,500,000 physicians as

members. It has to be the largest medical society in the

world. The numbers in every area one investigates are huge

because of the one billion populations base.

So, when we read an article from China or from other

developing countries, there is a background we must

understand. In many ways, to produce a fine article in a

developing country is extremely difficult because of the

problems that the doctors must overcome to do this extra

kind of work. Nonetheless, there are very bright people all

over the world who have good ideas. The best ideas do not

just come from developed countries. As a matter of fact, I

see a tremendous desire among the Chinese and others from

developing countries to succeed and make a better life that

the government cannot provide. This desire is not present in

some of the developed world because people have taken

their freedom for granted, without an appreciation of how

hard it was to get such freedom. The reason why the

Chinese are succeeding is that they have this tremendous

desire to succeed and have a better life. Why has this same

desire not surfaced in Russia or in many of the Eastern

European countries, in Latin America, and in other places in

the world? Why is it not even seen in the more developed

world? Have the socialistic systems frustrated innovation

and creativity? We see a large number of new articles

coming from Turkey, Taiwan, and Brazil, in addition to

China. Yes, we are also seeing articles from the Middle East

and a few from Africa. What does this emergence of science

in the developing world mean? There are ideas to be

understood coming from bright minds in many places.

I have witnessed bscientific colonialismQ in meetings in

which the scientists from the developed world lecture as if

the developing world audience knows nothing. I have seen

scientific colonialism in the conduct of the scientists from

the developed world who do not select articles from the

developing world for publication because the reviewers or

editors do not think that science in the developing world has

reached bthe developing-world standards.Q The articles are

not even considered. I have seen resident candidates from

the developing world rejected without consideration for the

Editorial / Surgical Neurology 67 (2007) 323–325 325

similar reason—that they cannot be well educated. I have

seen a medical school that supported this kind of thinking.

This attitude has also infected the World Federation of

Neurosurgical Societies (WFNS) in its continued selection

of leadership from the developed world. Are there no

creative and innovative leaders from the developing world?

I witnessed this bias against the developing world when, as

chairperson of the nominating committee of the WFNS, I

was told that those in the developing world were not able to

lead a major organization. Our committee selected a leader

from the developing world as a candidate for president, who

was elected. There is no place for this biased thinking or

philosophy in the scientific world. All people and ideas

should be given fair opportunity for understanding. Some of

the greatest discoveries in neurosurgery and medicine have

come from people working in very difficult circumstances

and in developing countries.

Scientific colonialism or progress? You decide. I have

just described how the Chinese are making huge strides to

surpass those who are complacent. This same phenomenon

of complacency has happened throughout history. It occurs

in academia and in business. The complacent lose, whereas

those who have the desire to win do win. The accompa-

nying editorial in this issue by Miguel Faria is a testimony

to the struggle of one person to rise above his life

circumstances to achieve success. Miguel escaped from

Cuba with his family to come to the United States, where

he became a physician, a neurosurgeon, and eventually a

leader of a very proindependence antisocialist medical

society. He became editor of its national publication.

Miguel, the Chinese, and others are overcoming huge

obstacles to succeed in this world.

Are the rest of us becoming complacent? I have told the

residents I teach that their competition is not the person

next door but the best in the world. There is always

someone who wants to succeed and who will make great

sacrifices to do so. Are the rest of us willing to do that?

That is the attitude that separates the victorious from the

defeated.

James I. Ausman, MD, PhD

E-mail address: surgicalneurology@dc.rr.com