Building sustainable neurosurgical capacity: lessons from the Duke Division of Global Neurosurgery and Neurology.

Neurosurgery has long faced significant disparities in access to care in low- and middle-income countries (LMICs), where millions lack access to timely, lifesaving neurosurgical interventions. The Duke Division of Global Neurosurgery and Neurology (DGNN) was established to address these inequities by building sustainable neurosurgical capacity through strategic partnerships, training programs, and service initiatives. DGNN's framework evolved from the initial "3-Ts" approach-technology, twinning, and training-to a broader focus on service, research, and training, prioritizing local ownership of neurosurgical systems. Key challenges, such as resource limitations, cross-cultural collaboration, and the retention of trained professionals, were overcome through collaborative efforts and a commitment to capacity building. The introduction of digitized health records and data systems, along with research projects in epilepsy and traumatic brain injury, contributed to a comprehensive model of growth. Through these initiatives, DGNN has expanded neurosurgical services and increased the number of trained neurosurgeons in Uganda, creating a sustainable model that can be adapted to other countries. This paper outlines DGNN's history, challenges, and strategies with the goal of establishing a framework for other institutions to grow similar initiatives and divisions.