To the Editor: We read with great interest the letters published on "Operationalizing Global Neurosurgery Research in Neurosurgical Journals" and related replies.1-3 The growing interest in global surgery has had a significant impact on neurosurgery with the number of published papers and dedicated conference sessions/webinars increasing over time.4,5 Advocates of global neurosurgery believe that we need to ensure the provision of adequate care to all patients with neurosurgical conditions no matter where they live and that this can be achieved through collaboration between countries with limited resources and high-income countries (HICs). However, why do we need a new "global" section in neurosurgical journals? The very basic knowledge of epidemiological and clinical data from a large part of our globe is limited. Less than 10% of neurosurgical publications are produced by low-income and lower middle-income countries, with 2 countries alone (India and Egypt) contributing 75% of these papers.6 This leads to an inverse relationship between disease burden and number of publications. As an example, in traumatic brain injury, most of the papers originate from North America, Europe, Japan, Australia, and China, whereas trauma is an endemic disease in Africa, South East Asia, and Latin America.7 When examining neurosurgical randomized controlled trials (RCTs), only 9% of the studies are led by low middle-income countries (LMICs).8 Because RCTs usually form the basis of clinical guidelines, most if not all the published guidelines in neurosurgery are produced by HICs for HICs but are then supposed to be applied all over the world. As Galileo Galilei said "misura cio che e' misurabile e rendi misurabile cio' che non lo e" (measure what you can measure and make measurable what is not available). Neurosurgeons and scientists from HICs with expertise in data collection, RCTs, and guideline development need to work together with the large number of surgeons who work, often with limited resources, taking care of a large volume of patients to allow them to answer questions relevant to their practice and develop guidelines relevant to their settings. A good example of such collaborative work is the BOOTStraP (Beyond One Option for Treatment of Traumatic Brain Injury: A Stratified Protocol) project in Colombia, which aims to develop resource-stratified guidelines for managing traumatic brain injury.9 The project is receiving methodological and funding support by the National Institute for Health Research Global Health Research Group on Neurotrauma and from a US institution.10 Nevertheless, this type of collaborative work is currently not available to a large number of surgeons in LMICs.11 This can naturally lead to frustration, and the risk is that one considers the world of neurosurgery as one that is divided in 2 parts without any communication: one part with surgeons/scientists who are highly subspecialised and have time to publish high-quality papers and another part where the sheer volume of clinical work prevents any scientific output. It is worrying to see some of the views expressed by a minority in the largest neurosurgical group in social media arguing that "surgeons only need to learn how to operate and should not spend any time on research". How can we address this perspective, which risks damaging the reputation of neurosurgery, as a discipline which pays equal attention to technical excellence and robust scientific enquiry to improve patient outcomes? When we develop guidelines, we need to consider how they can be used in resource-limited settings. We should be aiming to add because it has already been performed in neurotrauma, a section specific to LMICs.12 Prehospital care, long-term follow up, and rehabilitation are very limited in the largest part of the world. We need to work with local stakeholders to highlight and address their importance but at the same time, we need to consider short-term follow-up as an option for large, multicentre, studies, if this is a scientifically valid option.13 Whenever we publish LMIC data through a collaboration between HIC and LMIC institutions, we need to allow LMIC authors to be in the first and senior author positions, as much as possible. We also need to try and use the data to address the identified problems in patient care. For example, a recent paper about treatment of spinal cord injuries in Tanzania published in collaboration with Cornell University showed how time from injury to surgery can be reduced leading to better outcomes.14 During the Covid pandemic, we had to develop webinars and other online teaching replacing face-to-face meetings. Online teaching cannot fully replace face-to-face meetings but many surgeons and trainees from LMICs found this as a unique opportunity to listen for free to high-quality lectures by some of the most well-known neurosurgeons and could discuss with them during live Q and A sessions.15 This is clearly a positive development and one that we need to preserve in the future, even when the pandemic ends. On a positive note, participation in research seems to be one of the top priorities for young neurosurgeons, and surgeons from LMICs are very keen to collaborate on clinical research studies.16 Technical excellence and robust scientific enquiry are integral facets of modern neurosurgery, no matter where it is being practiced.