The answer was more than 7,500 miles away, and Jerry Tuite, M.D., was eager for the lesson.
Tuite, a pediatric neurosurgeon at Johns Hopkins All Children’s Hospital, has performed hundreds of procedures to treat hydrocephalus, a buildup of cerebral spinal fluid in the cavities—ventricles—deep in the brain. But despite more than two decades of experience, the opportunity to immerse himself to learn and evaluate a newer treatment technique attracted Tuite.
Even if it meant traveling from St. Petersburg, Florida, to Mbale, Uganda.
“It’s the mission of Johns Hopkins All Children’s to provide the best treatment for kids, to innovate, to adopt new techniques and to stay on the cutting edge,” Tuite says. “Hydrocephalus is the most common diagnosis a pediatric neurosurgeon treats. Dr. Benjamin Warf’s technique was new and innovative, and we wanted to go to the place where it was invented and where they perform this procedure nearly 1,000 times a year. We thought it was imperative that we go and learn it so we could offer it to our patients.”
A New Method
Tuite met Warf, then the chief of pediatric neurosurgery at the University of Kentucky, in the mid-1990s. They compared notes, encountered one another at conferences and developed a bond in the small world of pediatric neurosurgery. Tuite considered Warf compassionate, thoughtful and innovative.
In 2000, Warf moved his family to Uganda to become director of a new pediatric hospital started by the Christian non-profit organization CURE International. Uganda and much of sub-Saharan Africa has an acute problem with hydrocephalus. Initially, Warf treated it in the traditional way, inserting a ventriculoperitoneal shunt, a medical device that allows the excess fluid to drain. Shunts can be prone to infection, and the type of hydrocephalus common in Uganda is often the result of infection.
“Shunts are lifesaving, and they’re vitally important for the majority of patients with hydrocephalus,” Tuite says. “But shunts don’t work as well in certain types of hydrocephalus, including those common in Uganda. Shunts are also expensive and prone to infection and blockage, issues that are difficult for patients in the United States and an even greater challenge for patients and caregivers in the countries like Uganda.”
Warf combined two other techniques to create a solution that avoided a shunt. He had great success with his method, and before returning to the United States, he trained African neurosurgeons to continue treating children in Uganda with the method.
Bringing it Home
In 1996, Tuite became the first surgeon at Johns Hopkins All Children’s to use a technique called endoscopic third ventriculostomy (ETV), which essentially acts like an internal shunt by creating an alternative pathway to allow fluid to drain without a mechanical device. He and the other neurosurgeons at the hospital routinely use the technique to treat patients with hydrocephalus in order to avoid placing a permanent shunt.
Warf’s method combines ETV with another technique, choroid plexus cauterization (CPC), which uses an endoscope to burn non-vital tissue in the ventricle, as a way to reduce the production of spinal fluid.
After Warf returned, he resumed his work at Boston Children’s Hospital as a professor of neurosurgery at Harvard Medical School. He and Tuite kept in touch. Warf visited Johns Hopkins All Children’s to learn more about a research project Tuite and his colleagues conducted. Warf showed Tuite the ETV/CPC technique he developed in Uganda. To really get it, though, Warf urged Tuite to visit CURE Children’s Hospital in Mbale, where ETV/CPC is performed more frequently than anywhere else in the world.
In January 2018, Tuite spent a week in Uganda, immersing himself in six to eight surgeries a day.
“Because they were making such an important difference in the lives of so many kids there, I felt compelled to go there and see what they were doing and see if our patients in the United States could benefit from similar techniques,” Tuite says. “I was incredibly inspired by the work CURE International, Dr. Warf and CURE Uganda do. They have a pure and simple mission to help as many kids with hydrocephalus as possible in an environment where they don’t have a fraction of the resources we have. It was inspiring.”
Tuite has performed the ETV/CPC procedure five or six times at Johns Hopkins All Children’s since returning and is happy to have it as an option when the circumstances are right. He remains inspired by the trip.
“That hospital does more treatment for children with hydrocephalus than any other hospital in the world,” Tuite says. “Consider that in the context of resources in Uganda. I was honored and humbled to be part of their team for a week and to have the opportunity to offer our patients at Johns Hopkins All Children’s a new, innovative and potentially life-saving procedure based on what I learned at CURE Uganda.
“This is a model of surgical public health. The entire time I was there, I kept thinking of the following:
Give a man a fish and you feed him for a day.
Teach a man to fish and you feed him for life.
“Dr. Warf not only invented a new technique to help thousands of children with hydrocephalus each year, he established a teaching lineage that stretches across Africa, the rest of the world and right here at Johns Hopkins All Children’s Hospital. We are a link in this chain of education, spreading what we have learned to our neurosurgical residents and other neurosurgeons around the United States.”