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Stigma as a Barrier to Global Health Care

16 Oct, 17 | by Jenny Thomas

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

20 Sep, 17 | by Jenny Thomas

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.

Complementary and Alternative Medicine and Their Effect on Global Health

4 Aug, 17 | by Jenny Thomas

By Nathan Douthit

According to the World Health Organization (WHO), the use of complementary and alternative medicine (CAM) is on the rise. The US National Institute of Health defines complementary medicine as non-mainstream, non-western practice used together with conventional medicine, whereas alternative medicine is defined as the same used instead of conventional medicine. The WHO also offers a definition of traditional medicine (TM) as

 

the sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness

 

Globally, TM and CAM are much more accessible to patients than conventional medicine. Therefore the WHO strategy for TM and CAM revolves around research into these alternative techniques as well as education and training for their practice. However, recent years have seen a surge in popularity for CAM in western countries as well, with many being willing to pay out of pocket for these treatments. Integration of these practices into national health systems can allow them to be regulated and safely practiced along with conventional medicine for the best possible outcomes.

 

Unfortunately, the case report “Consequences of delivery at home in a woman without prenatal care” by Kumar et al reveals the danger associated with lack of education, training and regulation. We are told,

 

The patient denied having any allopathic prenatal care during the current pregnancy. She denied having gestational diabetes testing, blood work or detailed ultrasonography, but she stated that she had undergone regular Doppler and bedside ultrasound scans by her midwife.

 

Despite having had three prior caesarean sections, the woman chose a direct entry midwife, defined as follows.

 

Direct entry midwives are defined as independent practitioners educated in midwifery through self-study, apprenticeship, a mid- wifery school or a university-based programme…. In the USA, licensure and training varies per state, with 50% of states not requiring licensure for direct entry midwives. Most patients are unaware of the difference between [direct entry and certified nurse midwives] and may not receive the necessary guidance to choose the appropriate provider for their needs.

 

This patient’s past medical history puts her at increased risk, and her poor outcome is the result of lack of education, regulation and information in this alternative delivery.

 

BMJ Case Reports invites authors to publish cases regarding the effects both positive and negative of complementary and alternative medicine. Global health case reports can emphasize:

-Successful integration of CAM into national health systems

-Research on CAM that has proved useful in patient care

-Partnerships between practitioners of CAM and practitioners of conventional medicine that have improved patient outcomes

-Use of CAM causing delays in care, inappropriate care or worsening of patient outcomes.

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 CAM at BMJCR:

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

Why tuberculosis control programmes fail? Role of micro level and macro level factors: an analysis from India

Delayed diagnosis of pulmonary tuberculosis in a 13 year old Malawian boy

Selected References on CAM from other sources:

  1. World Health Organization. WHO traditional medicine strategy: 2014–2023. [Internet] WHO; 2016 (cited 07 July 2017). Available from: http://www.who.int/medicines/publications/traditional/trm_ strategy14_23/en/
  2. Complementary, Alternative, or Integrative Health: What’s In a Name? [Internet]. National Center for Complementary and Integrative Health. U.S. Department of Health and Human Services; 2016 [cited 07 July 2017]. Available from: https://nccih.nih.gov/health/integrative-health#role
  3. Abdullahi AA. Trends and challenges of traditional medicine in Africa. Afr J Tradit Complement Altern Med 2011;8(Suppl 5):115–23.
  4. Lee CAL. Alternative Medicine and Global Health [Internet]. Franklin Humanities Institute. Duke University; 2011 [cited 07 July 2017]. Available from: http://www.fhi.duke.edu/blog/my-blog/global-health-and-alternative-medicine.html

Taking Care of Vulnerable Populations as Global Health – Case Reports on Refugees and Migrants

10 Jul, 17 | by Jenny Thomas

By Nathan Douthit

According to the United Nations High Commissioner for Refugees, a refugee is someone who,” owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country .” 1 Globally, the World Health Organization estimates there are 65 million forcibly displaced persons, 86% of whom are in developing countries .2  Implicit in the care of refugees are complex healthcare challenges including language barriers, unfamiliarity with the theory and practice of primary health care, common exposure to violence, torture and warfare, the high prevalence of PTSD, anxiety and depression and anti-immigrant sentiment in their new host country. Access to primary care is an essential facet of refugee care. Low socio-economic status and social isolation complicates the management of chronic non-communicable disease.

 

In the case report  “A Rohingya refugee’s journey in Australia and the barriers to accessing healthcare,” Jiwrajka et al discuss some of these issues.3 The case describes the peculiar challenge of the Rohingya people

 

[o]ver 200000 Rohingya refugees are currently resettled in Bangladesh, a country with already limited health-care for its own citizens as well as a non-signatory country to any of the United Nations Refugee or Stateless Conventions. As a result, refugees are not guaranteed access to basic human rights, including healthcare.

 

Even with a robust translation service freely available in Australia, this patient states the interpreter spoke an “unfamiliar dialect.” She did not understand her prescriptions as a result.  The patient did not feel that her doctors cared about her concerns of infertility, instead she states that “the doctors were more interested in her diabetes.” The low socio-economic status of this patient is linked to her health – the authors write:

 

[T]here is a disproportionate burden of diabetes among minority groups, migrants and the socioeconomically vulnerable. [Socioeconomic status] and social stratification are intrinsically linked to health, in turn creating a social gradient of health. As a result, adverse health outcomes within vulnerable populations, including refugees, transgress beyond the individual to affect whole communities.

 

Due to a variety of factors, most notably the conflict in Syria, the world is in the midst of the largest migration of people since World War II. BMJ Case Reports invites authors to publish cases regarding the health of these vulnerable patients as well as the dilemmas created by migration on national health systems. Global health case reports can emphasize:

-Barriers to access of care due to linguistic, social and cultural differences

-Problems created by lack of cultural competence in healthcare systems

-Discrimination and effects on healthcare for refugees and migrants

-Uncontrolled chronic conditions due to migration or delays in access to healthcare

-Other factors that exacerbate the vulnerability of migrant populations

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 refugee health at BMJCR:

Paired suicide in a young refugee couple on the Thai-Myanmar border

A Syrian man with abdominal pain

Ethiopian-Israeli community

References:

  1. UNHCR. Global Strategy for Public Health: A UNHCR Strategy 2014-2018. United Nations High Commission for Refugees, Geneva. 2014.
  2. WHO. Refugee and migrant health [internet]. World Health Organization 2017 [cited July 6 2017] Available at: http://www.who.int/migrants/en/
  3. A Rohingya refugee’s journey in Australia and the barriers to accessing healthcare. Manasi Jiwrajka, Ahmad Mahmoud, Maneeta Uppal. BMJ Case Reports 2017: published online 9 May 2017, doi:10.1136/bcr-2017-219674.

Selected References on Refugee and Migrant Health from other sources:

-Hunter P. The refugee crisis challenges national health care systems. EMBO reports. 2016 Apr 1;17(4):492-5.

-Onnell C. Healthcare for Syrian refugees. BMJ. 2015 Aug 8:13.

-Jackson JC, Haider M, Owens CW et al. Healthcare Recommendations For Recently Arrived Refugees: Observations from EthnoMed. Harvard Public Health Review. 2016 April;7

 

 

 

What can Global Health Case Reports do for the “Neglected Stepchild of Global Health”?

7 Jun, 17 | by Jenny Thomas

By Nathan Douthit

Access to safe, affordable surgery is an essential aspect of global health. Eight million people are killed or injured every year due to inadequate availability of surgical services. Five billion are at risk due to lack of access to these services. Despite investment in surgery providing a 10:1 benefit:cost ratio for developing economies, surgery remains “the neglected stepchild of global health.”

 

The case report “Penetrating cardiac injury: sustaining health by building team resilience in growing civilian violence” by Pol et al addresses some of these issues. The report includes two cases, both of young men. This represents a demographic at greater risk for perpetrating and being victims of violence. The case report addresses the issue raised by the greater availability of cheap firearms, so called ‘desi-kattas’ in India. Readily available firearms represent a risk for global health in both developed and developing nations. Pol et al discuss the importance of government initiative to curb violence as well as to build multi-disciplinary surgical teams capable of handling the surgical emergencies created by these underlying issues. One third of the global burden of disease is addressed surgically, and without these systems in place, needless death and disability will occur.

 

BMJ Case Reports invites authors to draw more attention to problems created by violence and conflict and the need for surgery in global health as well as the successes in this field. Case reports can expose:

-Increasing prevalence of surgical disease in developing countries

-Complications associated with delayed presentation

-Issues faced by vulnerable populations in the developed and developing world

-Management of surgical care in limited resource settings

-Violence and conflict and their effect on the health of populations

The Lancet Commission on Global Surgery discussed the importance of supporting research in developing countries by partnering with local practitioners in the developing world. This literature can be submitted by students, physicians and other medical professionals and will be necessary in helping to develop solutions to these global health problems.

 

Selected references on conflict, resilience and surgery within BMJ Global Health Case Reports:

Landmines in the Golan Heights: a patient’s perspective

Complications of Dysgerminoma: meeting the health needs of patients in conflict zones

The Tell-Tale Thigh

Rheumatic fever with severe carditis: still prevalent in the South West Pacific

Birth brachial plexus palsy: a race against time

A Syrian Man with Abdominal Pain

For further guidance on how to write for BMJ Case Reports, please see here.

Selected references outside of BMJCR

  1. Ng-Kamstra JS, Greenberg SL, Abdullah F, Amado V, Anderson GA, Cossa M, Costas-Chavarri A, Davies J, Debas HT, Dyer GS, Erdene S. Global Surgery 2030: a roadmap for high income country actors. BMJ Global Health. 2016 Apr 1;1(1):e000011.
  2. Stewart F. Root causes of violent conflict in developing countries. BMJ: British Medical Journal. 2002 Feb 9;324(7333):342
  3. Bruno E, Shrine MG. Surgery: The Neglected Stepchild of Global Health. The New York Times: Opinion. 2016 Apr 20. Accessed online at https://kristof.blogs.nytimes.com/2016/04/20/surgery-the-neglected-stepchild-of-global-health/?_r=0 on 2017 June 4
  4. Weinberger SE. Curbing Firearm Violence: Identifying a Target for Physician Action. Annals of internal medicine. 2016 Aug 2;165(3):221-2.

 

What does it mean to celebrate International Women’s Day in health and medicine?

9 Mar, 17 | by Jenny Thomas

By Manasi Jiwrajka

We look back at some of our case reports:

Gender remains an important determinant of health. For example, in HIV in India: the Jogini culture , we read that female gender ensured a lifestyle that exposed the patient to HIV.1

“The patient never attended school. At menstruation, she awoke to a startling reality as she had her first sexual encounter in her parent’s home.”

Another case from India reports that more women and girls are illiterate compared to men (41.2% and 21.4% respectively).2 Karande states that “maternal illiteracy directly affect[s] health-seeking behaviours,” and in this case, maternal illiteracy as well as maternal undernutrition results in infantile iatrogenic Cushing syndrome.

In this case from the USA, a patient without prenatal care has devastating consequences by attempting to deliver at home. 3

Sometimes, being a female is uncertain in and of itself as in intersex individuals or rare conditions such as female hypospadias, which may be recognised early in the patient’s life or much later.4,5 Some females have had gender reassignment surgery, and were previously males. The surgical intervention to become a female may lead to complications.

Vaginal reconstruction does come with a myriad of complications including rectovaginal fistula, urethral fistula, vaginal stenosis, with loss of either depth or width, urethral stenosis, hair growth in the vaginal canal if scrotal skin is used for construction6

Women’s health is often equated to maternal health or gynaecological health but women’s global health includes cases such as the following:

  1. Mental health in a Dominican, HIV+ woman who was scared of being considered “loca” and promiscuous. The authors write:

“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 fulfil expected gender roles…HIV-positive women are often negatively perceived as sexually promiscuous, which can be considered an insult to their partners’ ‘machismo’ (sense of manliness), and women who disclose their serostatus are at a greater risk of abandonment and abuse by their partners.” 7

  1. Multiple Sclerosis in an anaesthesiologist from Trinidad and Tobago: MS incidence is higher among females, and the burden of the disease is high for any patient especially for someone working in “a medical specialty with a high level of stress and long hours of exposure and night shifts.” The patient, and the doctor, in this case writes:

“For those who read this article, just be part of those who are disclosing this global health problem for the well-being of many.”8

Women around the world are facing significant health issues both as patients and doctors. Some emerging priorities for women’s health globally are well outlined in this paper by Temmerman et al.9

  1. Restricted physical activity among women due to social norms
  2. Tobacco use, maternal smoking and COPD
  3. Women’s cancers such as breast cancer, and cervical cancer
  4. Conditions of older age without adequate treatment
  5. Structural determinants of women’s health

Women in health are also celebrating today that we have come a long way to become anaesthesiologists, surgeons, gynaecologists and urologists.

References:

  1. Borick J. HIV in India: the Jogini culture. BMJ Case Reports. 2014;2014.
  2. Karande S. Consequences of low birth weight, maternal illiteracy and poor access to medical care in rural India: infantile iatrogenic Cushing syndrome. BMJ Case Reports. 2015;2015.
  3. Kumar N, Gilbert L, Ellis T, Krishnan S. Consequences of delivery at home in a woman without prenatal care. BMJ Case Reports. 2017;2017.
  4. Prakash G, Singh M, Goel A, Jhanwar A. Female hypospadias presenting with urinary retention and renal failure in an adolescent: uncommon and late presentation with significant hidden morbidity. BMJ Case Reports. 2016;2016.
  5. D’Cunha AR, Kurian JJ, Jacob TJK. Idiopathic female pseudohermaphroditism with urethral duplication and female hypospadias. BMJ Case Reports. 2016;2016.
  6. Rezwan N, Basit AA, Andrews H. Bilateral ureteric obstruction: an unusual complication of male-to-female gender reassignment surgery. BMJ Case Reports. 2014;2014.
  7. Santoso LF, Erkkinen EE, Deb A, Adon C. HIV-associated dementia in the Dominican Republic: a consequence of stigma, domestic abuse and limited health literacy. BMJ Case Reports. 2016;2016.
  8. Reyes AJ, Ramcharan K, Sharma S. Multiple sclerosis in a postgraduate student of anaesthesia: illness in doctors and fitness to practice. BMJ Case Reports. 2016;2016.
  9. Temmerman M, Khosla R, Laski L, Mathews Z, Say L. Women’s health priorities and interventions. BMJ : British Medical Journal. 2015;351.

Back to Basics with Female Genital Mutilation

6 Feb, 17 | by Jenny Thomas

By Manasi Jiwrajka

The 6th of February marks the International Day of Zero Tolerance to Female Genital Mutilation.

Last year I had the privilege to listen to Khadija Gbla at the Global Health Conference in Newcastle, Australia organised by the Australian Medical Student Association. Khadija is the voice and face of female genital mutilation (FGM) in Australia and worldwide. She addressed an audience of ambitious future doctors interested in global health, and what struck me was the simple message: take a good history and examine the patient.

As junior doctors and medical students, we often forget that we may be closer to patients than anyone else because there is not that white coat barrier between the patient and us. We forget that although we don’t always make major clinical decisions, the information we relay to our seniors is what determines their clinical decision, and as such a thorough history and examination is crucial.

Patients who have had FGM inflicted on them may present with common symptoms such as  incontinence, dysmenorrhea, dyspareunia or all of these. In this case report by Abdulcadir and Dallenbach 1, a 27 -year old female presents with the above symptoms after having consulted a gynaecologist. They write:

“She had been living in Europe for more than 5 years and mentioned having consulted a gynaecologist some years ago, but no treatment had been proposed. She added that she had felt uncomfortable because the physician did not seem familiar with FGM/C. After that experience, she never consulted again in spite of worsening symptoms.”(Abdulcadir and Dällenbach 2013)

One of the key learning points from the case report, as authors write, is “Overactive bladder post female genital mutilation/cutting type III is a very distressing condition, probably under-reported due to shame, poor medical reception and cultural barriers.” We in the medical profession can at least make ourselves aware of FGM and reduce the stigma associated with this.

Khadija’s message to us still holds true. When in doubt, ask. When in doubt, examine.

Here is a video of another one of Khadija’s inspiring talks: https://www.ted.com/talks/khadija_gbla_my_mother_s_strange_definition_of_empowerment

 

References

1 Abdulcadir, J. and P. Dällenbach (2013). “Overactive bladder after female genital mutilation/cutting (FGM/C) type III”. BMJ Case Reports 2013. http://casereports.bmj.com/content/2013/bcr-2012-008155.full (accessed 03.02.2017).

Global Health Workshop, University of Queensland, Brisbane, Australia with Dr Seema Biswas, BMJ Case Reports Editor in Chief

12 Jan, 17 | by Jenny Thomas

By Manasi Jiwrajka

In October, 2016, we conducted a Global Health workshop at the University of Queensland in Brisbane, Australia.

We advertised the event to medical and dental school students, and had an overwhelming interest in the workshop. We had attendees ranging from first year medical students to faculty members at the University of Queensland.

Prof Mieke van Driel, Deputy Head of the School of Medicine and Head of General Practice at the University of Queensland, opened the workshop with her definition of global health, and her experiences working with Medecins Sans Frontier. Her inspirational opening talk paved way for the workshop, and to hear our guest speaker Miss Seema Biswas, EIC of BMJ Case Reports and a war surgeon with the Red Cross.

Miss Biswas said that global health is just health. She also discussed the importance of humanitarian aid and how case reports are crucial in advocating for individuals and their health. One message from Miss Biswas’s talk that resonated with me and other students is that global health is not merely health overseas or abroad, but global in the sense of taking care of all the patients’ issues and addressing the social determinants of our patients’ health.

The workshop involved two breakout sessions. In the first, the attendees wrote on flip charts about the global health projects they have undertaken so far, and what they would like to do in the future.  Students talked about their elective experiences in Haiti, the Philippines, in rural and urban Australia. We discussed where the students see their career in global health.

Miss Biswas also inspired students to write up their own case reports from their daily experiences with patients. It reminded us that any patient we see is a global health case on their own. As such, in the second workshop students used the BMJ Case Reports template to write a case report of their own using their experiences with patients, and we came up with a global health problem list. This was followed by a discussion on how addressing the social determinants of our patients’ health can result in improving health and access to health.

The global health workshop has been a great success, and we have received incredible feedback from the students. During the workshop we created a mailing list, through which the global health discussion continues, and we look forward to many more workshops in Brisbane and around Australia!

A dentist with training wheels

8 Dec, 16 | by Jenny Thomas

By Nandini Sharma

In the United States the third year of dental school serves as the first clinical year of dental education. During this year we are expected to translate our first two years of didactic knowledge into full time patient care. By the end of my second year I was more than eager to get away from the constant barrage of examinations and start to treat patients. I expected the transition from treating a plastic tooth to a real patient to be difficult. What I didn’t expect was to learn was how social determinants of health can affect oral health.

Recently, I admitted a patient who exemplified how these factors influence oral health. She was a 24-year-old African American female who had braces placed at age 14 and has never had them removed. The patient complained of pain in her mouth and said she had recently been to the emergency room because of a dental abscess. The emergency room gave her amoxicillin to treat the infection and recommended finding care at the dental school. In 2014 the Journal of American Dental Association found emergency department visits for dental problems cost almost $3 billion from 2008-2010. The study also found that individuals who are uninsured and live in a low-income area are more likely to visit hospital-based settings for urgent dental care (1).

During her oral examination she presented with heavy calculus on her teeth, missing teeth, root tips, mobile teeth, generalized inflammation, and a chronic abscess on her maxillary palate. An endodontic resident was called in for a consult and used a palatal nerve block before draining the abscess (2). I realized she would need to have all her maxillary teeth extracted for immediate dentures. As a provider it was very difficult for me to tell a 24-year-old patient that she will need dentures. Although complete denture prosthodontics is a routine, inexpensive treatment option, it is a last resort.

As dental students we sink our teeth into clinical practice by treating a diverse, underserved population. This provides us with a unique insight on how social, physical, and behavioral barriers prevent our patients from attaining oral health care (3,4). My patient disclosed that her mother would take her for orthodontic check-ups when she was younger. But at the age of 19 she lost her mother and stopped visiting the dentist. Over time as the status of her oral health deteriorated she no longer felt the need to brush daily. For my patient one of her main deterrents of proper oral health care was psychosocial. Aside from treating dental disease we need to tailor our care based on which determinants are hindering our patients from having good oral health.

 

References:

  1. Allareddy, V., Rampa, S., Lee, M. K., Allareddy, V., & Nalliah, R. P. (2014). Hospital-based emergency department visits involving dental conditions: profile and predictors of poor outcomes and resource utilization. The Journal of the American Dental Association145(4), 331-337.
  1. Fitch, M. T., Manthey, D. E., McGinnis, H. D., Nicks, B. A., & Pariyadath, M. (2007). Abscess incision and drainage. New England Journal of Medicine357(19), e20.
  1. Scheerman, J. F., Loveren, C., Meijel, B., Dusseldorp, E., Wartewig, E., Verrips, G. H., … & Empelen, P. (2016). Psychosocial correlates of oral hygiene behaviour in people aged 9 to 19–a systematic review with meta‐analysis. Community dentistry and oral epidemiology.
  1. Strauss, R. P., Stein, M. B., Edwards, J., & Nies, K. C. (2010). The impact of community-based dental education on students. Journal of Dental Education74(10 suppl), S42-S55.
  1. Greenspan, J. S. (2013). Global health and dental education: a tipping point?. Journal of dental education77(10), 1243-1244.

 

“The Crossroad between Dentistry and Medicine” at ADEE & AMEE

30 Nov, 16 | by Jenny Thomas

By Prof. Rui Amaral Mendes and Dr. Seema Biswas

In August, taking advantage of having our annual meetings in the same city – the beautiful Barcelona – ADEE (the Association for Dental Education in Europe) and its medical counterpart, AMEE (the Association for Medical Education in Europe), convened efforts to hold a joint scientific and business meeting under the topic of: “The crossroad between Dentistry and Medicine”.

More than a mere morning workshop’s theme, this is a major trend worldwide and should be regarded as one of the major challenges pending upon two of the major stakeholders as far as Heathcare providing is concerned.

According to the World Health Organization, Interprofessional Education (IPE) is a necessary step in planning a “collaborative practice-ready” health workforce that is better prepared to respond to local and global health needs. A similar opinion is shared by ADEE’s American colleagues from ADEA.

Still, the important thing is how we, educators, can use a potentially good idea and put in to good use, ensuring that our students get the best possible training, in line with the most recent FDI definition of oral health, as an “integral part of general health and well-being”.

Hence, being, as we are, well-aware and committed to this evolving educational paradigm of Interprofessional Education and Learning and Interprofessional Collaborative Practice (IPCP), one must also consider the prospects of a partnership that makes the best out of each other’s know-how, while keeping in mind that the European Directive 2005/36/EC, issued by the European Parliament and by the Council, establishing the EU legal foundations for the recognition of professional qualifications, makes it even more pertinent, not to say imperative, that both ADEE and AMEE join efforts in a combine approach advocating for new European Directives calling for a competencies-based approach for the education of dentists and physicians.

We often forget that according to the World Health Organisation, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.
Hence, when we think about Dental Education and overall services’s provision, we can not help to feel that we are currently at a crossroad: one that demands us to move “outside the box” of our Dental Schools and Dental offices, while engaging with the needs of our communities at home and vulnerable communities across the world.

Education, even at the undergraduate level, and service provision are, therefore, intricately linked. We have to accept that we need to train dentists who are far more than just competent technicians, but rather health professionals responsible for oral health and health in general. Dentists need to get to know their patients and their communities better if they are to provide truly effective care.

There is a need for those involved in Dental Education to take the lead on incorporating global health into the undergraduate dental curriculum and to boost global health in postgraduate practice. The key focus should be to provide better dental care to patients at home, work on improving access (for free or at low cost) for patients at home and to fill the gap where dentists are scarce.

Due to socio-economic, cultural and political reasons, large segments of the world’s population have limited or no access to regular dental care. Assisting the development of dental services in these areas should be regarded as a win- win strategy for both the developed and developing world as opportunities for training, practice and research lend themselves to twinning established successful programs at home with programmesfor the world’s most vulnerable communities.

It’s within this context, that, as we look through the feedback of the ADEE and AMEE meetings and workshops in global health, it becomes clear the enthusiasm for global health across all the medical disciplines. This enthusiasm seems centred on clinical practice: global health in the workplace, renewed focus on ensuring that the most vulnerable of our patients receive the best of clinical care, setting an example in the workplace to trainees who are going the extra mile to ensure that they address ALL the health needs of their patients and moving forward together to address the determinants of health in our undergraduate teaching programmes.

Thus, as ADEE and AMEE discuss the modern teaching agenda, we remind ourselves that global health is comprehensive healthcare and research. At BMJ Case Reports, we have the opportunity to put together the input of authors from across the world and emphasise priorities in addressing health disparities and access to healthcare. We have case reports from Trinidad in the West Indies (link) to Queensland in Australia (link). What is key is not so much the reach across the globe as the fact that authors are clinicians writing about patients they see locally daily.

As clinicians write about global health issues, we encourage students to do this, too. Global health problems cannot be tackled without a strong evidence base. Our cases are hugely valuable for teaching and to assist students as they begin to write. These case are also a powerful tool in bringing about improvements in health and should be used again and again as we advocate for our patients. There is extensive guidance on our website, and, as editors we are always to eager to engage with authors on how to make BMJ Case Reports more accessible to our readers and promote excellence in research and education.

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