Letter: Importance of Neurosurgeons at Earthquake-Prone Countries—Learning After Earthquakes at Syria and Turkey and Correspondence on Urgent Call for Actions

Dear Editor,

I am writing to emphasize the critical importance of addressing the shortage of neurosurgeons in Turkey and Syria, particularly in the current earthquake situation. There has been a sequence of immense earthquakes that took place on February 6, 2023, in the southeastern region of Turkey, close to the border with Syria. These powerful earthquakes, along with numerous aftershocks, resulted in significant destruction and devastation on both sides of the border. Thousands of lives were tragically lost in both countries and vital infrastructure, including healthcare facilities, was extensively damaged or completely destroyed. These earthquakes were among the most forceful ones witnessed in the region within the last hundred years. ¹ With the already devasted healthcare system in war-torn Syria, the recent Turkey-Syria earthquake is another blow to the entire Syrian healthcare system, which is already on the verge of collapse. As of February 20, 2023, at least 41 020 and 5800 have lost their lives in Turkey and Syria respectively and thousands are injured. ² Severe economic losses have also been faced by these 2 countries. ³ There are approximately 1200 neurosurgeons present in Turkey and the total population of Turkey is 84.3 million (2021). So, it is important to create more neurosurgeons in Turkey and Syria. Brain drain is a big issue. Many doctors are leaving Turkey and settling abroad. ⁴ Reduction in brain drain is very much crucial at this stage. In this scenario, we want to seek the attention of the various neurosurgical interest groups worldwide.

Neurosurgeons are vital in disaster medicine, especially in regions hit by earthquakes like Turkey and Syria. However, there is a shortage of neurosurgical workforce. The neurosurgeon-to-population ratio in Syria is very low, about 0.2 per 100 000 and the impact of this workforce paucity is intensified by the need for excess neurosurgical trauma care due to the war. ⁵ Earthquakes can cause serious damage, resulting in numerous casualties and injuries, the most significant of them being neurological complications. In such situations, the skills and expertise of neurosurgeons are essential in providing immediate medical care, performing life-saving surgeries, and managing the long-term consequences of neurological trauma. A press release by the Disasters Emergency Committee (DEC) stated that the surgeons involved in treating victims of the Turkey-Syria earthquake felt a lack in various areas. It included a lack of trauma kits, antibiotics, analgesics, and anesthetics to treat the crush injuries sustained over the limbs and head. Also, the lack of specialists and special equipment is a major challenge in treating head injuries. ⁶

World is not only facing earthquakes, but also facing different war situations and other global problems. It is also important to increase the amount of trained neurosurgeons in the war prone areas. A beautiful article written by GJ Rainone has beautifully described the close relation between wars and development of neurosurgery. ⁷

It was the Great East Japan earthquake, that revealed the importance of neurosurgeons in disaster medical management, and further improvement and strengthening of the medical system to prevent damage to the victims’ medium to long-term health. ⁸ A study showed that neurosurgical head trauma ranks third among all earthquake-related injuries. ⁹ Therefore, trained neurosurgeons are indispensable in earthquake-prone regions to provide immediate and effective medical care to those in need. Neurosurgeons may encounter various neurological injuries during earthquake relief efforts, including severe head injuries, spinal cord trauma, and peripheral neuropathies. Crush injuries to limbs after being trapped by falling debris can lead to severe neuropathic pain, which is an important sequelae of crush injury. The most frequently injured sites are the ankle-foot and hand-wrist. Extremity fractures account for most injuries, especially 3 days after an earthquake. Soft tissue injuries cannot be neglected. Traumatic injuries are widespread, and various surgical procedures, especially orthopedic and neurosurgery, are the domain of treatment modalities.^{10 -13}

However, there is a significant shortage of neurosurgical workforce in this region is further amplified by the extra demands of neurosurgical trauma care due to the war. ⁵ In addition to this, the recent Turkey-Syria earthquake is another blow to the Syrian health system which is already on the verge of collapse. In this scenario, we want to seek the attention of the various neurosurgical interest groups worldwide. The neurosurgical residents of Syria are challenged from all corners, from being morally obliged to take up cases beyond their level of expertise to enduring physical and mental assaults and kidnappings, and murders of their own colleagues. ¹⁴ They are displaying tremendous courage and dedication to preserve the specialty and continue providing patient care, as most of the senior neurosurgeons have left the country. Thus, it is crucial for the healthcare systems in Turkey and Syria to recognize and prioritize the importance of neurosurgeons in earthquake preparedness and response plans. This includes adequate training, resources, and infrastructure to support emergency neurosurgical interventions. Additionally, investing in research and advancements in neurosurgical techniques can further enhance the capabilities of neurosurgeons in managing earthquake-related neurological injuries. Public awareness and education regarding the role of neurosurgeons in earthquake situations are also essential. Empowering communities with knowledge about immediate response actions and when to seek specialized care can contribute to better outcomes for individuals affected by earthquakes.

In light of these challenges, we urge neurosurgical interest groups worldwide to play a significant role in supporting Turkey and Syria. Also, the Turkish and Syrian Governments should give more focus on preparing more neurosurgeons. For this proper motivation is important. All hospitals should start their Neurosurgery departments. Gradually with proper fundings, the department will be more developed. Other countries should also follow the same procedure. In India, Nepal, Pakistan, and other high population density countries, neurosurgery departments are present in the cities mostly, so it is important to start a neurosurgery department in the peripheral medical colleges also. Then more young doctors can per sue neurosurgery residency. In post earthquake situations, different NGOs can build different teams with these trained neurosurgeons. Then more neurosurgeons can combat the situation at a same time. For this, preparing more and more neurosurgeons is crucial. Senior neurosurgeons should motivate young surgeons and medical students, Trainees and young neurosurgeons face different problems in developing countries, like less advanced infrastructures. They should attend foreign fellowships, training workshops, and conferences. Senior neurosurgeons, the government should support them. Different scholarships could be started for this. While directly deploying a skilled workforce may not be feasible, alternative approaches can make a meaningful impact. Advocacy and awareness campaigns, training and education programs, telemedicine consultations, research collaborations, and humanitarian support are avenues through which international neurosurgical communities can extend their assistance. Different NGOs can help. NGOs help a lot in these scenarios. Young doctors from different specialties should join different NGOs. More similar NGOs can be started in different region to combat similar situations. NGOs can help in training procedure and equipment. Different philanthropists and politicians can fund the NGOs. Setting up a neurosurgery department is costly. Proper funding will develop the unit easily. By uniting our efforts, we can bring attention to the critical need for neurosurgical care in these regions and work toward sustainable solutions. Internationally a neurosurgeon group can be created to provide enthusiastic neurosurgeons in disaster areas. Regular training programs can be held. Also, it’s important to inspire new medical students to become a neurosurgeon. For them, workshops, teaching, and live surgery classes could be arranged. So that, the scarcity could be filled in the future. Together, we can provide hope and support to neurosurgical residents, ensuring that the people of Turkey and Syria receive the essential care they need during these challenging times. Also, we should learn from this incident and prior preparation and strategies are essential to combat a similar situation in the future.