In Reply: The Low-Income and Middle-Income Countries' Perspective on Global Neurosurgery Collaborations

To the Editor: We sincerely appreciate the insightful comments and positive inputs from Glover et al regarding our recently published article, “The Low-Income and Middle-Income Countries' Perspective on Global Neurosurgery Collaborations.”1,2 The Letter is well-received, as the thoughtful analysis highlights critical challenges and additional areas in global neurosurgery (GN) in need of attention. We welcome the discussion on these issues and take this opportunity to further elaborate on key points raised. One of the concerns highlighted in the Letter is the limited representation of respondents from low-income countries in our study. As the authors rightly point out, low-income country perspectives are crucial to understanding the specific challenges of resource-constrained settings. This underrepresentation likely reflects broader systemic barriers, including limited access to international professional networks, internet connectivity challenges, and language barriers. We therefore agree that future research should use targeted strategies to enhance participation from these underrepresented groups, including multilingual surveys, partnerships with local institutions, and alternative data collection methods. Aligned with the previous consideration, the Letter further emphasizes the importance of neurosurgical registries in low- and middle-income countries (LMICs) to support data-driven policy and funding initiatives. We strongly agree that large-scale, systematically maintained neurosurgical registries are vital for assessing injury patterns, resource allocation, and clinical outcomes. The absence of such databases in many LMICs poses a significant challenge in advocating for healthcare policy changes and securing sustainable funding. Encouragingly, existing initiatives, such as the World Health Organization Clinical registry or region-specific trauma registries, provide promising models for expansion.3-5 A concerted effort is required to integrate these initiatives with local healthcare systems, ensuring that data collection is sustainable and beneficial to both local and international stakeholders. Our findings align with the perspective on the need for sustainable programs to overcome financial and institutional barriers to GN collaborations. Expanding programs similar to the one reported by Glover et al can play a crucial role in capacity building for LMIC neurosurgeons. We welcome and encourage further discussions on how high-income country (HIC) institutions can best support and scale up such initiatives while ensuring that local needs and priorities guide these efforts. The Letter also raises appropriate concerns regarding selection bias in GN research and the potential exclusion of neurosurgeons not currently engaged in international collaborations. This is indeed a limitation of many GN studies, as respondents often represent those with existing global connections rather than the broader community of neurosurgeons in LMICs. We agree that future efforts should address this by exploring alternative outreach methods to reach a more diverse but representative cohort. Another critical issue highlighted is the role of power dynamics in GN collaborations, particularly concerning mentorship, authorship, and decision making, and we agree that addressing these imbalances is crucial for fostering equitable partnerships. Establishing clear guidelines for ethical and collaborative research, promoting LMIC-led initiatives, and ensuring that local experts have a central role in shaping research priorities can become important steps forward.6,7 Moreover, mentorship programs should empower LMIC colleagues to take leadership roles in academic and institutional decision-making processes, beyond technical and research skills development. Finally, the Letter underscores the broader governance challenges affecting neurosurgical capacity in LMICs. These systemic issues undoubtedly influence the effectiveness of GN initiatives and undoubtedly deserve a deeper exploration that was beyond the aims of our study, which was primarily focused on individual perspectives. Future efforts should focus on exploring and understanding these barriers. Beyond these challenges, we want to emphasize the significant opportunities that collaborative neurosurgical partnerships present for both LMIC and HIC stakeholders. Although LMIC participants benefit from advanced training, resource sharing, and research collaborations, HIC neurosurgeons may gain invaluable exposure to diverse pathologies, innovative problem solving in resource-limited environments, and an enhanced understanding of global health disparities. Such experiences cultivate a broader, more adaptable skill set and contribute to professional and ethical growth. Moreover, GN initiatives foster long-term professional networks, encouraging sustained exchange and joint advocacy efforts for neurosurgical equity. In conclusion, we deeply appreciate the commentary on our work and the opportunity to engage in this important discussion. We hope that our study, along with the ongoing discourse, contributes to meaningful progress in addressing the neurosurgical needs in underserved areas, prioritizing an accessible, sustainable and ethical GN commitment.