Why should students write a global health case report?

Manasi Jiwrajka, Dr Seema Biswas


Manasi Jiwrajka
Final Year Medicine (Graduate)
University of Queensland

Dr Seema Biswas
General surgeon and editor in chief of BMJ Case Reports

Manasi is a student editor for BMJ Case Reports, studying medicine at the University of Queensland. She is also pursuing a concurrent MPhil at the Queensland Institute of Medical Research, studying glioblastoma multiforme. She has a previous degree in neuroscience from Vassar College in the US, and spent a year at University College London pursuing biomedical science and international health. She is interested in gliomas, global health, medical ethics, writing, and travelling.

Dr Seema Biswas studied medicine in London and trained in surgery in the UK and South Africa. She works as a field surgeon for the International Committee of the Red Cross and teaches surgery and global health. The global health case report was developed by the editorial team at BMJ Case Reports and has been validated as an educational tool in undergraduate medical education.


We often see a case report about something absolutely fascinating – that one condition found on that page of Robbins [1] that we vaguely remember – but we don’t often hear about a global health case report. In this short piece, we offer a tangible definition of global health, discuss the concept of a global health case report, [2] and make the case for why we, as medical students, should be writing these.

Defining Global Health

Most medical students find global health quite nebulous and so overarching that it does not necessarily fit with our idea of treating the individual patient in front of us. Global health seems to be for health policy makers rather than doctors. It seems far-fetched that as medical students we could have any effect on how patients live and the determinants of health, especially when we hear that global health concerns only low-income countries. There are two main reasons for this perception: one, a single definition of global health is not universally accepted; and two, worldwide, there remain profound differences in global health education. [3,4]

We propose that the ‘global’ in global health does not refer so much to ‘overseas’ or ‘over there’, as it refers to ‘over here’; indeed, the real definition of ‘global’ in global health is ‘health everywhere’. Even if a doctor, or any health professional, trains and works in their home town, never travelling beyond the limits of what they see every day, they will inexorably meet and treat someone of a different socioeconomic group, ethnicity, religion, race or language. Dealing at an individual level with patients who have become ill because they do not have a safe and clean environment in which to live, have nowhere to sleep, are exploited at work, or vulnerable at home means that those international problems over there for doctors without borders who travel all over the world, are right here for all doctors whose routine practice is right at home. Global health has much in common with public health in that aspects of global health address populations and changes may be implemented at population levels through local, national, and international governments. However, ‘global’ also refers to all aspects of health, i.e. a holistic approach essential to exploring and taking on the real causes of disease, the social determinants of health. This focuses our attention and intervention on the patient in front of us and what we need to do to prevent them from becoming ill again. [5] Global health is, therefore, health that affects every patient we treat, and their families, at a very personal and individual level.

The British Medical Journal Case Reports has published several global health case reports. Here we summarise two examples. In one case, a 2 year-old boy with 40% burns to his head and arms presented to an eye clinic in Turkey one month after his injury. By then, he was blind. [6] The author was moved to write because of the severity of the burns, the preventable causes of house fires, the dire need for equitable access to medical care, and the devastating consequences for the child. Perhaps on their own, each of these global health problems is too large to contemplate and tempting to ignore, but no one can ignore the clinical history of this child, and the authors were moved to investigate the lack of health resources and the social circumstances responsible for this lamentable outcome. The authors offer solutions in healthcare that seem very practical. Certainly, they provide the evidence that these changes are necessary.

Another case report explores the link between HIV/AIDS and Jogini culture of sexual exploitation. [7] The case is of a 32 year-old woman who, since the age of seven, has worked as a Jogini. It’s a powerful story. We read of her first sexual encounter, teenage pregnancy, and total isolation. The global health issues discussed by the authors include the consequences to health of profound social inequalities, gender inequality, criminal prostitution, and the scourge of HIV/AIDS amongst the most vulnerable of society. The author remains focussed on the patient’s life and we read with dismay about her relationship with her son and the likelihood that his life will also be in poverty, without the education or opportunities to change a course that seems bitterly unfair. These global health problems, overwhelming and pervasive, are poignantly real and move us to act. The doctors and medical students submitting global health case reports are describing the lives of patients they see every day, and are moved to write because tackling these problems head-on is essential to making their patients healthy again, keeping them healthy, and helping people just like them.  Enormous, ethereal global health problems are now individual and personal; indeed, they are tangible and very much inside our consulting room or hospital ward.

Why are these case reports useful? Why should we write these?

  1. To look at the root causes of the illness. Let’s think about why our patient is really ill. While a discussion of the social determinants of health may switch off an audience overawed by the magnitude of these issues, with a patient in front of them no doctor or medical student can ignore the causes of illness and the factors limiting the effectiveness of medical therapy for that patient.
  2. To learn about society, economics, politics, cultures, and how they affect our patients. These help us understand our patients better and facilitate all contact with them. These case reports show how individuals deal with illness, how they seek out medical assistance, and what is available for them. By writing these case reports, we also understand better how healthcare priorities are set and decided.
  3. Global health is an in depth analysis of the causes of ill-health, perceptions of health and disease and how healthcare is provided. This is relevant not simply to general practice or public health, but to all medical specialties.
  4. To learn global health. Global health case reports help both the students and faculty discover together the global burdens of disease, the social determinants of health, and factors essential to equity in access to healthcare.
  5. To publish and share patient cases. Publishing an excellent piece of work that speaks for your patient and the general society, and promotes peer discussion of these issues.
  6. To create an evidence base. Every time a global health case is published, we provide more evidence of what our patients need, the reality of their lives, and the care that they received. No one is closer to patients than we are in the medical profession [3]; we have a responsibility to advocate for our patients, and we can do this by writing their stories. This builds evidence that these problems are real and that they cannot be neglected.
  7. To create change. We publish and keep publishing in order for the medical community and the public to read and demand change. Change is possible – doctors are responsible for seat-belts, helmets, and much legislation that has saved millions of lives. [8, 9]

For the audience reading these case reports, global health becomes personal and individual. The case reports are a call to action to work for our patients, and an inspiration to look beyond a pharmacological prescription to the underlying social determinants of health and disease. Ultimately, we must look through the global health lens because, as Virchow famously said:

Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution. [10]

References

[1] Robbins SL, Kumar V, Abbas AK, Fausto N, Cotran RS. Robbins and Cotran pathologic basis of disease. Philadelphia: Elsevier Saunders; 2005.

[2] BMJ case reports; (Journal, Electronic). http://www.bmjcasereports.com

[3] Liu Y, Zhang Y, Liu Z, Wang J. Gaps in studies of global health education: an empirical literature review. Glob Health Action 2015;8(1):25709.

[4] Rowson M, Willott C, Hughes R, Maini A, Martin S, Miranda JJ, et al. Conceptualising global health: theoretical issues and their relevance for teaching. Global Health. 2012;8(36).

[5] Marmot MG. Status syndrome: a challenge to medicine. JAMA. 2006;295(11):1304-7.

[6] Istek, Ş. The devastating effects a fire burn in a child. BMJ Case Rep. 2015 Jun 8;2015. doi: 10.1136/bcr-2014-206663

[7] Borick J. HIV in India: the Jogini culture. BMJ Case Rep. 2014 Jul 11;2014. doi: 10.1136/bcr-2014-204635

[8] Bike helmets a no-brainer, say surgeons. The Australian Doctor [Internet]. 2015 Aug 13 [cited 2015 Oct 09]; Available from: http://www.australiandoctor.com.au/news/latest-news/bike-helmets-a-no-brainer-say-surgeons.

[9] Children’s doctors urge national 20mph limit in built-up areas. The Guardian [Internet]. 2014 Nov 19 [cited 2015 Oct 09]; Available from: http://www.theguardian.com/uk-news/2014/nov/18/children-doctors-20mph-speed-limit.

[10] Virchow R. Die medizinische reform 2. Medicine and Human Welfare. 1949.