Author Archive

Making a Difference in Conflict Zones

Monday, February 26th, 2018

By Nathan Douthit

Large-scale destruction of health services is a feature of modern warfare which today tends to be intrastate (civil war) rather than interstate. Whereas at the time of the World War I 90% of the injured were combatants, by the end of the last century 90% of casualties were civilian. The demand on in-country health services is, therefore, profound, and the destruction of these services a humanitarian disaster, as delivery of the most basic in emergency care becomes a challenge.

            Conflict is a major source of humanitarian emergencies. As mentioned above, it has the potential to devastate the public health systems and primary health systems of a country. It can encourage emigration of health professionals, destroy necessary infrastructure, and threaten the security of providers and patients.[1][2] This tends to effect the most vulnerable populations, including, “pregnant women, children, the elderly and patients with chronic health conditions[, who] are among the first to be deprived of the essential healthcare, including vaccines and essential drugs.

According to the International Federation of the Red Cross, “[H]ealth care is most needed where it is most difficult to deliver.”[3] Health care can be imported into these difficult situations, but this intervention is often accompanied by force, which can create its own political and ethical problems.[4] Healthcare professionals must be engaged in finding creative ways to meet the needs of vulnerable populations in areas fraught with conflict.

While the rebuilding of the infrastructure of these countries is the most appropriate intervention, this cannot be done in the midst of an acute conflict. In, “Complications of dysgerminoma: meeting the health needs of patients in conflict zones,” Hayari et al describe how one young patient was treated appropriately despite her home being destroyed by conflict.

            “The treatment of the war wounded in neighbouring countries, not formally engaged in conflict, is not new…. [T]he ICRC operated through field hospitals in Pakistan during conflict in Afghanistan. Turkey, Lebanon and Jordan have received over two million Syrian refugees in need of acute medical attention; the prevention and treatment of infectious diseases and treatment of chronic conditions poses a prohibitive challenge to the healthcare services of these nations…. The potential to offer high-quality care to a most vulnerable population across national borders warrants further examination as the international community seeks solutions to meeting healthcare needs in conflict zones and postconflict zones begin to reconstruct their cancer care facilities.

Healthcare professionals can make a difference in conflict zones by meeting the needs of patients by innovative solutions. BMJ Case Reports invites authors to publish cases regarding healthcare delivery in conflict zones. Global health case reports can emphasize:

-The methods of identifying and triaging patients in difficult to reach areas.

-Training methods local pracitioners in conflict areas

-Disease spread or exacerbation as a result of conflict

-Successes in healthcare delivery through conflict zones

Manuscripts may be submitted by students, physicians, nurses or other medical professionals to BMJ Case Reports. For more information, review the blog on how to write a global health case report.

Read more about conflict, refugee health and innovative solutions on BMJ Case Reports

Illegal immigration: the puzzling role of several risk factors for rhabdomyolysis

Social determinants of health: poverty, national infrastructure and investment

A Rohingya refugee’s journey in Australia and the barriers to accessing healthcare

Read more about conflict, refugee health and innovative solutions from other sources:

[1] Hoeffler A, Reynal-Querol M. Measuring the costs of conflict. Washington, DC: World Bank. 2003 Apr.

[2] Acerra JR, Iskyan K, Qureshi ZA, et al. Rebuilding the health care system in Afghanistan: an overview of primary care and emergency services. Int J Emerg Med 2009;(2):77–82.

[3] Coupland R, Breitegger A, Nathanson V, et al. Health Care in Danger: The responsibilities of health-care personnel working in armed conflicts and other emergencies. International Committee of the Red Cross. Geneva, 2012

[4] Weissman F, editor.  Introduction: the sacrificial international order and humanitarian action. In: In the shadow of ‘just wars’: violence, politics, and humanitarian action. Cornell University Press; 2004.

Competing Interests

None Declared

Making a difference in the developing world

Thursday, February 1st, 2018

By Marcus Chong

In 2016, while conducting medical research in a rural village of Northern Samar, the Philippines, Professor Allen Ross and his global health research team met a patient with severe electrical burns. He was a construction worker who had suffered an electrical burn at work from an overhanging high voltage electrical wire carrying 20,000 Volts. He had sustained burns to 25% of his body with significant scarring on the skin under the armpits and the amputation of all four limbs.

After the accident, he was transported to a local hospital by a family member; he remained there without medical treatment for eight hours. Public hospitals in Metro Manila are typically overwhelmed – with a lack of physicians available to treat emergency patients. Approximately eight hours later an ambulance was found to transport the patient to a local burns centre. By then his untreated injuries had resulted in thromboses requiring amputations of all four limbs. His relative in Manila sold their company truck in order to pay for his surgical procedures and hospital care. He remained in hospital for a few weeks after the operation. At this point his family had used up all their savings. He was discharged in a wheelchair as physiotherapy, prostheses and rehabilitation were prohibitively expensive. He returned to his home village in Simora Palapag, Northern Samar (Image, left).

The published BMJ case report that resulted can be found here.

In 2017, with the patient and family’s consent, Thao Ross (Allen’s wife) organised crowd funding on a Go-fund-me website. Funds came from people of all walks of life. It took several months to raise the required funds for four prosthetic limbs.

We were able to buy prostheses made of aluminium and coated with an alloy that made them durable and water-proof in Manila, from the prosthetic limb company Ottobock. There were also sufficient funds to provide the patient with rehabilitation and prosthetic fitting services. The prostheses provided by the company for the lower limbs can be seen in the above image (right) and the patient is currently (2018) having his upper limbs custom made and fitted. The patient was able to walk again after a few weeks of physiotherapy and rehabilitation. The patient waited almost seven years to walk again and we are very happy to have made this possible!

Competing Interests

None Declared

Making a Difference

Tuesday, January 9th, 2018

By Nathan Douthit

Global Health Case Reports (GHCR) at BMJ Case Reports can help practitioners of global health in all settings, cultures and situations. These practitioners are doctors, nurses, social workers, students, dentists and others who care about those missed by more traditional healthcare models. They seek to treat the patient but also to change the true causes of their disease—the social determinants of health.

Global Health has three core facets. Global health is global in scope; it crosses international and local barriers. Global health is global in focus; it addresses the whole patient’s well-being physically, socially, mentally, and environmentally. Global health is global in approach; it requires interventions from teams composed of multiple disciplines in order to address the issues faced by individuals and communities.

GHCRs address the scope of global health. They can address the barriers of conflict as in “Complications of dysgerminoma: meeting the health needs of patients in conflict zones,” as well as opportunities and models for overcoming these barriers. In this case, a young woman from a country torn by conflict is treated in a neighboring country. Due to concern that she would not receive appropriate care due the devastation of her country’s infrastructure, “it was agreed that the patient remain in this hospital for chemotherapy as it was unlikely that treatment would have been possible in her home country.” The doctors and hospital administrators went above and beyond to ensure that the patient received appropriate treatment.

The focus of global health can be seen in GHCRs. As “HIV in India: the Jogini culture” shows, patients require more than healthcare to improve their social standing; access to education and economic viability are also essential. The Non-governmental organisation that brought her to the hospital for medical care also, “advocated for her to the government and helped her to understand her rights to a pension and a home as legal entitlements of all former Jogini.” They had to address the determinants of her health in order to ensure that she would not return to the same conditions that made her ill in the first place.

To be successful in global health, a multidisciplinary approach is necessary. Excellent examples of these approaches can be seen in GHCRs. “Family as the primary caregiver: palliative care in the Golan Heights” describes the need for a community to gather around the patient to equip them to meet their needs. Input is needed from many disciplines to have a successful outcome. The physicians went above and beyond to ensure that the father was trained to care for the patient; in addition to weekly visits they made themselves, “available for contact at any time, in case of emergency.” Nursing staff visited the family 2 times per week, and, “a social worker was available to the family to aid with non-medical and bureaucratic issues.” This commitment to the patient enabled the healthcare staff to facilitate, “emotional healing of the family and the village in a way that could not have been accomplished far from home, in the halls of the closest hospital.”

In 2018, BMJ Case Reports has chosen the theme of “Making a Difference.” For GHCRs, this theme will be emphasized to show how global health case reports can change the lives of patients and practitioners. Global healthcare providers advocate for change, educate patients and practitioners, and most importantly are willing to go above and beyond the ordinary limits of medical practice in order to make a difference in the lives of their patients. We will be highlighting the ways these practitioners make a difference through global health in the coming year. Check the blog frequently for more updates on this theme, join us by writing a case report for a global health patient, and follow our social media accounts for more information.

Competing Interests

None Declared

Self-medication and access to care in Global Health

Friday, December 15th, 2017

By Nathan Douthit

I am a local village doctor. I came to the eye hospital escorted by two people in view of my severe eye condition and blindness. Fortunately, I was immediately relieved of my symptoms and my vision was restored after treatment. I am now completely aware of the ill effects of using home remedies. I will spread awareness about these ill effects to all people in my village. I will also bring other blind people from my village for eye treatment.           

            Above is the case “Self-medication complicating pseudo membranous conjunctivitis” by Singh et al described in the words of the patient. The patient had an episode of conjunctivitis 20 days prior to presentation, “for which he had instilled ghee (clarified butter) as well as goat’s milk in his eyes as a remedial measure. Also, he had instilled some antibiotic–steroid combination drops.” His condition had worsened to the point of near blindness before he sought out care at a medical center, where he was diagnosed with pseudo-membranous conjunctivitis and treated appropriately.

One aspect of this problem is Non-Degree Allopathic Practitioners (NDAPs). These practitioners practice allopathy, however very few have any formal allopathic training and by definition, none have allopathic degrees. Some are trained in traditional medicine (for example, the AYUSH practitioners—Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy) while some lack formal training entirely. For many rural residents in India and other countries, these are the first point of contact for acute illnesses.[1] This is likely secondary to the inadequate access to appropriate care, particularly in rural areas, with several other confounding factors including illiteracy, insufficient women’s rights, food insecurity and other variables.

This is especially a problem with ophthalmologic problems.[2] While traditional medicine and traditional practitioners certainly play a role in global health, these delays in presentation can prove costly to the patient and their local community.[3] It can lead to decreased public health and long-term morbidity and mortality from treatable illness.

Education and proper care play a key role in scenarios like this. Since this patient had a high status in the local community, he is using his experience to help educate others:           

            Being a local village doctor, he has better access and hold over the local populace, and now, following positive outcomes of eye treatment based on the principles of mainstream medicine, he wants to extend the same advantage to others who require help—particularly the blind and the visually impaired in his locality—by bringing them to our secondary eye care centre for treatment and vision rehabilitation. He is now voluntarily spreading awareness among people and of his own accord discouraging the use of home-made remedies for different ailments, especially of the eyes.

BMJ Case Reports invites authors to publish cases regarding self-medication, delays in care, and inadequate access to care. Global health case reports can emphasize:

-The effects of educational interventions for patients and providers

-Training methods for non-degree allopathic practitioners, and how to incorporate them into the local healthcare system

-Disease spread or exacerbation as a result of self medication

-Successes in treating cases complicated by early inadequate intervention.

Manuscripts may be submitted by students, physicians, nurses or other medical professionals to BMJ Case Reports. For more information, review the blog on how to write a global health case report.

Read more about cultural competence and humility at BMJCR

Consequences of low birth weight, maternal illiteracy and poor access to medical care in rural India: infantile iatrogenic Cushing syndrome

Factors affecting illness in the developing world: chronic disease, mental health and traditional medicine cures

Why tuberculosis control programmes fail? Role of microlevel and macrolevel factors: an analysis from India.

Read more about cultural competence and humility from other sources

-May C, Roth K, Panda P. Non-degree allopathic practitioners as first contact points for acute illness episodes: insights from a qualitative study in rural northern India. BMC health services research. 2014 Apr 23;14(1):182.

-Carvalho RS, Kara-José N, Temporini ER, Kara-Junior N, Noma-Campos R. Self-medication: initial treatments used by patients seen in an ophthalmologic emergency room. Clinics. 2009;64(8):735-41.

-Cambanis A, Yassin MA, Ramsay A, Bertel Squire S, Arbide I, Cuevas LE. Rural poverty and delayed presentation to tuberculosis services in Ethiopia. Tropical Medicine & International Health. 2005 Apr 1;10(4):330-5.

 

[1] May C, Roth K, Panda P. Non-degree allopathic practitioners as first contact points for acute illness episodes: insights from a qualitative study in rural northern India. BMC health services research. 2014 Apr 23;14(1):182

[2] Carvalho RS, Kara-José N, Temporini ER, Kara-Junior N, Noma-Campos R. Self-medication: initial treatments used by patients seen in an ophthalmologic emergency room. Clinics. 2009;64(8):735-41.

[3] Cambanis A, Yassin MA, Ramsay A, Bertel Squire S, Arbide I, Cuevas LE. Rural poverty and delayed presentation to tuberculosis services in Ethiopia. Tropical Medicine & International Health. 2005 Apr 1;10(4):330-5.

Competing Interests

None Declared

15,000 Cases Reports Published

Wednesday, December 13th, 2017

By Nathan Douthit

BMJ Case reports published its 15,000th case earlier this year. This milestone represents innumerable hours of patient interaction, research, writing, and editing. These cases have given a forum for health professionals and students to discuss difficult and interesting cases of high educational value and to use their patient experiences as a means to teach others.

Of particular importance is the 70+ global health cases published by BMJ Case Reports. While a small number in volume, these cases have helped bring to light issues faced by practitioners around the globe in a variety of settings, and established a formidable base of literature in their texts and references regarding the true causes of disease—the social determinants of health. As an author privileged to publish two of these cases with the journal, I can attest that they have been a formative part of my education in global health. As I encountered patients with avoidable negative outcomes, I reviewed the relevant literature on global health and social determinants in order to understand why these patients had been ill, had delayed presentation to care, and had so much pain wrought in their lives and the lives of their families. This helped me to suggest alternatives and solutions to the current state of affairs in these areas, and to learn innovative ways of dealing with difficult patient populations in low-resource settings.

As a global health associate editor I have reviewed all of these global health cases and am continually learning. Whether this includes the plight of Syrian refugees and their fear of losing their belongings, rare presentations of tuberculosis, the ill effects of complementary and alternative medicine in the USA and in Africa, or the common desire to die a death in accordance with local customs regardless of culture and medical history, there is something to be gleaned from every case. Paul Farmer, American Anthropologist and Physician wrote: “Human rights can and should be declared universal, but the risk of having one’s rights violated is not universal.”[1] Sadly, many of these situations are avoidable, and these case reports motivate all who read them to advocate for their patients in local, national and global settings. It is our hope that these cases will be used to educate practitioners and students about global health, so they can contribute to the solution to these complicated problems as they advance in their own careers.

The first 15,000 cases is truly something to be celebrated. Hopefully the next 15,000 will continue the work begun here by BMJ Case Reports. This literature base will be of great use to future clinicians as they attempt to change the world, one patient case at a time.

[1] Farmer P. Pathologies of power: Health, human rights, and the new war on the poor. Univ of California Press; 2004 Nov

 

A large force of health system- the medical students: have they been utilized adequately?

Tuesday, December 12th, 2017
BMJ Elective: A new experience leading a newer perspective….The Patient-centered learning.

By Vivek Podder

Currently, undergraduate medical education is largely limited to the lectures or textbooks based teaching-learning approach rather than a patient-centered learning in various parts of the world. Lack of formal training for students in medical school as well as lack of future incentives and motivation are not enabling a graduate doctor with necessary basic skills for critical appraisal of available evidence to make best clinical decision in their practice. [1] We may need to revisit the aspects of traditional medical education system that need to be optimized in order to build different mechanisms that can help student critically think, provide a patient-centered learning experience, equip with a platform where medical student can improve knowledge through conversational learning- a process keeps one involved, the facts learned to stay longer than those learned directly from the book, basic mandatory skills for critical appraisal of new evidence and by closely working with patients one can learn to build better doctor-patient relationship and thus build confidence in clinical decision through proper clinical reasoning and better clinical problem solving. I am sharing my experience of a BMJ Elective program wherein I have experienced medical education in a different way.

BMJ Elective Experience: (Pros and Cons)

 Pros:

BMJ elective was one of the best experience I went through which transformed my thinking from traditional medical learning system to a new blended offline-online learning system offered through BMJ Case reports under the supervision of Professor Rakesh Biswas (editorial board member, BMJ Case reports).

It was a patient-centered learning experience where through face-face interactions with the patients in the ward, ICU, SICU, HDU and outpatient department, I was collecting data (bedside clinical evaluation as well as imaging and labs) followed by sharing the de-identified raw data to web-based medical record (blog after taking consent), processing the clinical data through an online discussion in various web-based network of medical professionals providing clinical output (patients management) to our primary beneficiaries of medical education-the patients, chiefly by the supervising doctor to tailor them to match available resources where I can experience and reflect upon the consequences and causation of health disadvantage and share them with our team in the form of written text in our online forum. We were using three online platforms- WhatsApp, Tabula rasa (Facebook) and Email wherein doctors from various disciplines like internal medicine, cardiology, endocrinology, pulmonology, critical care medicine, orthopedics, oncology, hematology, radiology, pathology, microbiology, pharmacology, epidemiology etc. were involved in the discussion providing their collective patient-centered feedback through asynchronous communication. Often I needed to visit microbiology, pathology labs, radiology departments and cath labs to discuss patients’ laboratory findings with faculty doctors. I also used to make home visit for the patients previously admitted or came to our OPD and was evaluating their history and clinical progress while guiding them in various home procedures they were advised to e.g. medicine compliance, blood glucose monitoring, diet plan, temperature record in graphs (which would tell the pattern of fever) etc., and educating them about their diseases and updating their case records so that any further management plan can be applied after further discussion.

I was formatively assessed as well as supervised through our online community where all our cases are discussed regularly (and an online learning-portfolio for the student can be made from the learning interactions). I was encouraged to critically appraise the literatures using CASP check-list from PubMed [2], share searches on the recent evidences from UpToDate as well as reflections, and thoughts on each case with a larger community so that my inputs can actually benefit the patient in terms of generating interest and quality care from all those involved with the patient (offline and online). During this elective, I had involved 50-60 medical students from the same institution to go through the same experience and with involvement of all the stakeholders the patient was getting integrated evidence-based management and much better care even at a low resource setting which also allowed students to develop confidence in clinical decision-making process especially with the joy of knowing that their management strategy can be used effectively in an actual setting. The primary objective for which I had started this elective was initially to make case reports for BMJ and through this excellent learning experience I did make one case report which is under review and three case reports are in the pipeline for submission to BMJ Case Reports. Another global case report which I am working on to raise an issue of unnecessary coronary interventions across the globe.

Cons:

In spite of many learning opportunities it gives, lack of like-minded academic peer groups during the rotation, lack of academic credit (that makes it difficult to get medical school permission), overwhelming tasks (partly due to lack of more elective students), can be improved for optimization of this elective experience.

While the shortage of doctors is of prime concern in a health system, a large force of health system, the medical students have not been utilized better in patient care in a more patient-centered way. If the way I have been involved in the patient-centered learning can also be done by all the medical students then how greatly patient care could be improved and during the process medical student could become much more confident and skillful in critical appraisal of literature, clinical problem solving, and a better empathetic doctor.

A system I expect where the mental presence will be given priority over the physical presence. 

 

1. Kaustav Bera, Bhavna Seth, Rakesh Biswas. Conversational learning among medical students: harnessing the power of web 2.0 through user driven healthcare. Ann Neurosci. 2013; 20(2): 37–38.

2. http://casp-uk.net/

Cultural Competence in Global Health

Tuesday, November 7th, 2017

By Nathan Douthit

[I]n the…aim to produce cultural competence, one dimension to be avoided is… narrowly defining competence… in its traditional sense: an easily demonstrable mastery of a finite body of knowledge. Rather, cultural competence…is best described… as a commitment and active engagement in a lifelong process that individuals enter into on an ongoing basis with patients, communities, colleagues, and with themselves.[1]

            Dunton et al describe the importance of cultural competence in taking care of patients in minority communities in “Navigating care for Bedouin patients with diabetes.” They describe the case of a patient with a 30 year history of diabetes. Despite his best efforts, the doctor’s success when, “encouraging the patient to make lifestyle changes… proved virtually impossible.” He developed End Stage Renal Disease as a result, and then suddenly passed away, likely secondary to “a heart attack due to complications from chronic diabetes.”

            In light of the rise of chronic disease, specifically as demonstrated in a “minority culture within a larger Western society,” the training of culturally competent physicians is essential. In this case, fatalism plays a key role. The eldest son writes,

            “During my father’s disease, his socioeconomic situation was good…. He could go to the experts…. [But] he didn’t consider diabetes a major threat. He was shocked when he was told he needed dialysis. He initially refused treatment for a few weeks before we convinced him with the help of his doctor…. We were sorry that he died. But in our society, we believe in God and see this as the will of God. We can’t do anything about it.”

            Addressing fatalism, a “main obstacle in educating and motivating patients,” requires a culturally sensitive dialogue. The authors recommend focusing on quality of life rather than threat of death. Having patients “consider how changes in lifestyle will help in remaining strong and active until the prewritten day of death,” may help in addressing this issue.

            According to the authors, “the link between trust and the adherence to treatment regimens is found within many communities.” Training culturally competent physicians must focus on having knowledge, skills, and respect and being able to implement these effectively in cross cultural situations.[2] “Culturally appropriate intervention channels” are key to reducing stigma and raising patient awareness of available resources.

            Cultural competence has been shown to improve many health behaviors, specifically related to nutrition, exercise and substance use habits.[3] Culturally competent physicians must be willing to partner with local leaders. As the authors write, “if community and leaders could establish the importance of diet as something on par with the importance of vaccinations, it would contribute to changing the culture positively.”

BMJ Case Reports invites authors to publish cases regarding cultural competence and humility in training global health practitioners. Global health case reports can emphasize:

            -The effects of culturally appropriate health interventions

            -Training methods for culturally competent global health practitioners

            -Disease spread or exacerbation as a result of cultural incompetence

            -Innovation in culturally appropriate interventions

Manuscripts may be submitted by students, physicians, nurses or other medical professionals to BMJ Case Reports. For more information, review the blog on how to write a global health case report.

Read more about cultural competence and humility in the interaction of clinicians with patients at BMJ Case Reports

            –A Rohingya refugee’s journey in Australia and the barriers to accessing healthcare

            –Ethiopian-Israeli community

            –Analysis of the psychosocial impact of caretaking on the parents of an infant with severe congenital heart defect.

Read more about cultural competence and humility from other sources

            -Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Journal of health care for the poor and underserved. 1998;9(2):117-25.

            -Brach C, Fraserirector I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Medical Care Research and Review. 2000 Nov;57(1_suppl):181-217

            -Goode TD, Dunne MC, Bronheim S. The evidence base for cultural and linguistic competency in health care. New York^ eNY NY: Commonwealth Fund; 2006 Oct.

[1] Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Journal of health care for the poor and underserved. 1998;9(2):117-25.

[2] Brach C, Fraserirector I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Medical Care Research and Review. 2000 Nov;57(1_suppl):181-217.

[3] Goode TD, Dunne MC, Bronheim S. The evidence base for cultural and linguistic competency in health care. New York^ eNY NY: Commonwealth Fund; 2006 Oct.

15,000 Case Reports Published

Monday, October 30th, 2017

We are pleased to announce BMJ Case Reports has now published over 15,000 cases online. BMJ Case Reports is an important educational resource offering a high volume of cases in all disciplines so that healthcare professionals, researchers and others can easily find clinically important information on common and rare conditions.

Seema Biswas, Editor in Chief of BMJ Case Reports, says, “Publishing our 15 000th case report has been a remarkable achievement. We would like to thank our authors and reviewers as we celebrate the largest repository of case reports in the world. These cases are ideal for case-based learning. Our cases are free to download to use as teaching materials for all our fellows..”

Amongst our 15,000 cases, we have published over 3,316 Images In… and 70 Global Health cases, and received submissions from 119 countries. Since introducing an additional Open Access option upon acceptance in 2016, we have also published 96 Open Access articles in the past 12 months, making them freely available to view online.

Please visit our website to browse our archive of published articles, view our FAQs and find instructions on how to submit your case report.

We would like to take this opportunity to thank all of our authors, editors and reviewers for their contributions to the journal, and look forward to further expanding our collection of case reports.

Stigma as a Barrier to Global Health Care

Monday, October 16th, 2017

By Nathan Douthit

“People who are excluded…are not ‘just like’ the rest of the poor, only poorer. They are also disadvantaged by who they are or where they live, and as a result, are locked out of the benefits of development.”[1]

In ‘HIV-associated dementia in the Dominican Republic: a consequence of stigma, domestic abuse and limited health literacy,’ Santoso et al describe the case of a woman living with uncontrolled HIV for 14 years. She did not report it for fear of abuse and stigmatization in society. She also was found to have significant psychiatric disease, but when referred to a specialist, “She insisted that she was not ‘crazy’.”

Stigma can be a major factor in the progression of disease and the decision to seek care. The authors of this case describe the barriers to HIV care,

People living with HIV/AIDS in the Dominican Republic experience social devaluing as their illness is commonly associated with marginalised groups such as sex workers, the lesbian, gay, bisexual, and transgender (LGBT) community and drug users. Additionally, they are subjected to institutionalised discrimination, including denial of medical services or jobs. Fear of discrimination likely played a significant role in this patient’s avoidance of treatment.”

And the reluctance to receive treatment for her psychiatric problems with,

Although the patient voiced suicidal intent, she was reluctant to see the psychologist for fear of being labelled as a ‘loca’ (crazy person). Locas are rejected in Dominican society for being perceived as being out-of-control, unpredictable and unable to fulfill expected gender roles.

Stigma from mental health can have, “significant social and economic deprivation…as a consequence.”[2] This problem is not only neglected but, in some ways, exacerbated by the global health community. While the burden of depression exceeds malaria in low-income countries, the amount of awareness, fundraising and innovative treatments for the latter far exceed the former. It has been shown that physicians educated in low-income countries may worsen stigma by attributing mental illness to supernatural forces; a problem that persists even after psychiatric training.[3]

Stigma from HIV is well described by the authors above. In many countries, there is legislation in place that enforces stigma and economic deprivation for those infected by HIV. The social stigma in place also effects the livelihood of patients.[4]

Global health professionals engaged in the care of individual patients must work to ensure that discrimination and stigma are eliminated as barriers to care. This can be done by intentionally working with high-risk or stigmatised groups, education of local communities and advocacy for change in harmful policies. All stake-holders must realize that disease stigma causes increased morbidity and mortality and has no place in society.

In light of this, BMJ Case Reports invites authors to publish cases regarding stigma in global health and methods used to overcome this barrier. Global health case reports can emphasize:

-the devastating effects of stigma worsening disease

-diseases that are uniquely stigmatised in individual cultures

-innovative methods to overcome stigma

-the stigma created and perpetuated by the healthcare system

Manuscripts may be submitted by students, physicians, nurses or other medical professionals to BMJ Case Reports. For more information, review the blog on how to write a global health case report.

Read more about stigma and disease at BMJCR:

Stigma kills! The psychological effects of emotional abuse and discrimination towards a patient with HIV in Uganda

Factors affecting illness in the developing world: chronic disease, mental health and traditional medicine cures

Myxoedema in a patient with achondroplasia in rural area of Guatemala

Read more about stigma and disease from other sources:

-World Health Organization. Mental health and development: targeting people with mental health conditions as a vulnerable group. World Health Organization; 2010.

-Ngui EM, Khasakhala L, Ndetei D, Roberts LW. Mental disorders, health inequalities and ethics: a global perspective. International Review of Psychiatry. 2010 Jun 1;22(3):235-44.

-Joint United Nations Programme on HIV/AIDS. Global AIDS update 2016. Geneva: UNAIDS. 2016.

 

References:

[1] Reducing poverty by tackling social exclusion: a DFID policy paper. United Kingdom, Department for International Development, September 2005 (http://www.d d.gov.uk/Documents/publications/ social-exclusion.pdf, accessed 29 December 2009).

[2] World Health Organization. Mental health and development: targeting people with mental health conditions as a vulnerable group. World Health Organization; 2010.

[3] Ngui EM, Khasakhala L, Ndetei D, Roberts LW. Mental disorders, health inequalities and ethics: a global perspective. International Review of Psychiatry. 2010 Jun 1;22(3):235-44.

[4] Joint United Nations Programme on HIV/AIDS. Global AIDS update 2016. Geneva: UNAIDS. 2016.

Use of Telemedicine to Deliver Global Medical Care

Wednesday, September 20th, 2017

By Nathan Douthit

Telemedicine is an important developing field for global health. Its use has been endorsed by the World Health Organization (WHO), Medecins Sans Frontieres and multiple other national health services and Non-Governmental Organizations (NGOs). Telemedicine has multiple definitions, but the one endorsed by the WHO is:

The delivery of health care services, where distance is a critical factor, by all health care profes- sionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities”. 1

One of the earliest recorded instances of telemedicine was the transmission of an electrocardiograph in 1906. However, recent applications include sharing of data for specialist assistance in diagnosis and management, education of healthcare professionals and patients, research on difficult to reach populations and even screening services for health monitoring and maintenance. Telemedicine certainly has applications in the developed world and in urban centres. However, the effective delivery of telemedicine can make an unprecedented impact in developing countries and rural areas.

In the case report, “Remote care of a patient with stroke in rural Trinidad: use of telemedicine to optimize global neurological care,” Reyes and Ramcharan describe “The use of… [telemedicine] for low-income countries to provide support for high-risk patients.” Their case specifically focuses on the application of teleneurology, or remote access to specialists in neurology. The patient described was seen in hospital by a neurologist, but on discharge home it was noted that the “patient’s home was located in a low income village 60 km away from the GP[general practitioner’s] office.” In order to continue monitoring the patient for improvement, the patient’s 24 hour caregiver

“[W]as initially trained by the GP to collect, process and transmit the patient’s data by the use of a smart phone and a laptop with internet access. The GP and the neurologist also used similar technology.

This allowed medical care to be provided to the patient in a timely fashion. The caregiver was educated to recognize seizures, falls, neurogenic bladder, and dysphasia.

Once the event was recognised, the caregiver called on the GP assistance over a phone call and/or via email. The GP instructed the caregiver on first aid actions for the… event in order to prevent further complication… [and, if necessary, arranged] transportation of the patient to the nearest health facility available. Concurrently, the GP called on the senior neurologist for remote assistance…. The GP coordinated initial management of the complicated patient with the caregiver, paramedics and other doctors remotely…. The GP saw the patient directly to verify all instructions were carried out correctly, but there was no need for the neurologist to examine the patient for those reasons.

The authors conclude that this treatment model, “[S]uggest[s] that improved access to primary, secondary and tertiary levels of neurological care in remote and underserved regions of the world is a feasible way forward.” They also correctly remind us that, “This is a global issue that requires urgent consensus and actions by stakeholders.

In light of this, BMJ Case Reports invites authors to publish cases regarding the trials and successes of telemedicine in delivering medicine in difficult to reach areas. Global health case reports can emphasize:

-successful models of management, such as the one above

-difficulties in implementing telemedicine due to cultural, geographical or technical constraints

-innovative uses of telemedicine

-the use of telemedicine across linguistic, cultural, ethnic and geopolitical barriers

Manuscripts may be submitted by students, physicians, nurses or other medical professionals to BMJ Case Reports. For more information, review the blog on how to write a global health case report.

Read more about telemedicine at BMJCR:

Gestational trophoblastic disease in a Greenlandic Inuit: diagnosis and treatment in a remote area.

Selected References on telemedicine from other sources:

  1. World Health Organization. Telemedicine: opportunities and developments in member states. Report on the second global survey on eHealth. World Health Organization:Geneva ; 2010.

-Medecins Sans Frontieres. MSF Telemedicine Brings Care to Patients in Remote Areas [Internet]. MSF USA: New York; 2016 June [cited Aug 10 2017]. Available from: http://www.doctorswithoutborders.org/article/msf-telemedicine-brings-care-patients-remote-areas

-Kasemsap K. The importance of telemedicine in global health care. InHandbook of research on healthcare administration and management 2017 (pp. 157-177). IGI Global.

-Silva BM, Rodrigues JJ, de la Torre Díez I, López-Coronado M, Saleem K. Mobile-health: A review of current state in 2015. Journal of biomedical informatics. 2015 Aug 31;56:265-72.

-Gornall J. Does telemedicine deserve the Green light? BMJ 2012;345:e4622.