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Global health perspective for an unfortunate injection through a BMJ Case Report

5 May, 16 | by hbedi

by Amy Price

Finding the Balance

Finding the balance between the global health perspective and the individual patient is a challenge worth pursuing1. My first experience in writing from both worlds in one research paper was in our report of “An Unfortunate Injection.2 Working together on this report showed us as a team the struggle between population health and meeting the needs of an individual patient who trusts in our care.

The job of the human being [in the digital age] is to become skilled at locating relevant valid data for their needs. In the sphere of medicine, the required skill is to be able to relate the knowledge generated by the study of groups of patients or populations to that lonely and anxious individual who has come to seek help” (Sir Muir Gray, 2001) 3

Solving the Global Health Problem

This is how we did it. First we unpacked the problem with the patient’s help and with the support of Tabula Rasa a volunteer online network consisting of health professionals, patients and social workers5. We brainstormed for the best solution for this patient and then considered how it could be used for others.

The aim of population-based healthcare is to improve the health and wellbeing of individuals through population based systems accountable to the patient”, (Sir Muir Grey, 2001) 3

The case was about a grave but common error that can come from a simple intramuscular injection to relieve pain. In this case the sciatic nerve in the patient was injured causing irreversible damage, leaving the patient with limited mobility, unremitting pain, the inability to return to work and the need for an orthotic. The indiscriminate use of intramuscular injections for treating common illnesses is frequent and injections are often administered by unlicensed or undertrained practitioners. The only care available to many in low resource countries is through those who do not have adequate training. The simple solution is to train the unlicensed to give the injections. When given incorrectly bad practice accounts for 20% of nerve trauma injury. We found that those responsible for the injection errors did not associate the patient’s trouble with how they gave the injection and in our case report the patient was injured twice. This is malpractice and a serious breach of trust. It is these errors that increase morbidity, destroy public trust and strain existing medical resources.

Keeping it Simple

We produced a simple diagram of how not to give the injection along with what to do instead and a warning of what can happen when the injection is incorrectly given. The next step shows how to find this area easily. The diagrams are superimposed on a human figure seen below so that nothing is lost visually in the translation and the process can be followed even by those with limited literacy. When all can see the relationship between technique and injury in a simple diagram this sets up an internal accountability. The patient can see a large poster of the diagram in the same area where the injection is administered. The patients are also given a brochure with the same diagrams prior to giving their consent for the procedure 2.

Figure-1 Adapted and used by Permission: Shah BS, Yarbrough C, Price A, et al. An unfortunate injection. BMJ Case Rep 2016: bcr2015211127. doi:10.1136/bcr-2015-211127 (accessed April 15, 2016)

Picture1-injection Injection2 (1)

Making it Global

We identified the issue in our individual patient and then we noticed how common this mistake was. We thought about how to help other patients and we devised a plan to train others to carry out the correct procedure safely.

We shared health inequalities that those in India and the world face and we considered how we could narrow the gap to knowledge with the least amount of resources and outside skills. This involved filtering out things that were important to us as a country and culture and sharing the solution to work other places as well. The BMJ Case Report editors and reviewers helped us to negotiate that balance. Our report can be found in the journal BMJ Case Reports or for those without access the lead author has written a blog on the article.

Any intelligent fool can make things bigger, more complex, and more violent. It takes a touch of genius—and a lot of courage to move in the opposite direction,”(EF Schumacher 1973)

Meeting the Challenges

The challenge came in translating the solution so it could be simply used by the world and shared with dignity. We needed to do this without allowing shame, poverty, cultural differences, or health sensationalism to steal the focus and we worked to distil population learning into a local solution that could be used for the world as it is. The world for us all is where the untrained will continue to learn on the job, with minimal oversight because conditions demand it.

Dr Abrahaham Verghese framed this issue in medicine well when he shared “We are all fixing what is broken and it is the task of a lifetime4



1. Price AI, Djulbegovic B, Biswas R, et al. Evidence-based medicine meets person centred care: a collaborative perspective on the relationship. J Eval Clin Pract 2015;:n/a – n/a. doi:10.1111/jep.12434

2. Shah BS, Yarbrough C, Price A, et al. An unfortunate injection. BMJ Case Rep 2016;:bcr2015211127. doi:10.1136/bcr-2015-211127

3. Gray M. The Resourceful Patient. London UK: : eRosetta Press 2001.

4. Verghese A. Cutting for stone : a novel. New York: : Alfred A. Knopf 2009.

5. Purkayastha S, Price A, Biswas R, et al. From Dyadic Ties to Information Infrastructures: Care-Coordination between Patients, Providers, Students and Researchers. IMIA Yearb 2015;10:68–74. doi:10.15265/IY-2015-008

World Immunisation Week 2016

26 Apr, 16 | by hbedi

By Hemali Bedi

“The two public health interventions that have had the greatest impact on the world’s healtposter-largeh are clean water and vaccines.” – The World Health Organization [1]

World Immunisation week takes place each year during last week of April (24-30). Last year, over 180 countries took part in the campaign, which is coordinated by The World Health Organization (WHO). [2] During this time, WHO encourage the uptake of vaccines and highlight need to improve equitable access to immunisations worldwide. [2]

Immunisation prevents between 2 to 3 million deaths each year. [2] The theme of this year’s World Immunisation Week is “Close the immunisation gap”. [2] This is because, despite promising advances in vaccine coverage so far, WHO estimate that 18.7 million infants worldwide (approximately 1 in 5) still do not receive immunisations for preventable diseases, such as diphtheria and tetanus. [2] Furthermore, over 60% of children who do not receive vaccinations live in just 10 countries, including the India, Iraq, the Philippines and South Africa. [2]

Barriers to vaccine uptake include social, political and economical factors [3]. Inequitable access to health care services, a lack of information about vaccines, insufficient political support, and in some areas, an improper supply of vaccines, all contribute [3]. Cost is also an issue, with new vaccines being more expensive. [2] But what can be done to address these challenges? We want to know just that. Leave a comment below, and let us know what you think.

Our global health case reports highlight important global health issues including the lack of access to health services in all parts of the world. With the resurgence of polio and measles in areas of conflict and disaster, we want to hear from you about vulnerable patients and populations.

For more information about global health, the determinants of health and medical anthropology, see our global health toolkit


[1] Public Health England. Information for immunisation practitioners and other health professional, updated 1 April 2016

[2] World Immunization Week 2016: Immunization game-changers should be the norm worldwide. WHO., published 21 April 2016

[3] World Immunization Week 2016: Close the immunization gap. WHO., accessed 25 April 2016

Ottawa 2016 and ANZAHPE Conference

31 Mar, 16 | by hbedi

By Manasi Jiwrajka

The beautiful city of Perth on the Western Coast of Australia hosted the Ottawa 2016 and ANZAHPE conference this year. Delegates from the US, Canada, the UK, Netherlands, Indonesia, Hong Kong, China, South Africa, Australia and many other countries attended this conference. I downloaded the mobile app for this conference prior to my flight from Brisbane to Perth, and got a minute by minute update on the conferedited_IMG_20160322_144637ence.

There were several important medical education themes addressed during this conference from simulation in the context of medical education, OSCEs, peer tutoring, medical scientist, rural health program, global health, and empathy. My poster was titled ‘Why Should Students Write a Global Health Case Report?’, and I presented it to an eclectic audience that thanked me for my enthusiasm! Several educators approached me after the presentation for more information regarding their students writing case reports for the BMJ, and I reminded them of the elective competition that is due on April 30th.

Some of my favourite parts of the conference included (i) a talk on cultural competency, and including patients culture to provide individualised healthcare, (ii) the concept of ‘phenomics’, suggesting that a patient’s environment can affect their health prognosis, (iii) all the focus on feedback for students, (iv) how empathy levels can be altered following a reflection exercise, and is dependent on coping styles, (v) and acquiring loads of free pens!

I am looking forward to the next ANZAHPE conference in Adelaide next year.

Behaviour change: A bitter pill to swallow

29 Mar, 16 | by hbedi

By Kristian Dye

The case reported by Dunton et al comes from a very particular cultural context, and yet it demonstrates things that all practitioners see in almost all healthcare settings.

The patient reported is a 60 year old man with type 2 diabetes, who despite taking his medications, is unable to make the diabetes-592006_1920behaviour change that could impact the course of his disease.

The report looks at the complex nature of this phenomenon, that it is not as simplistic as ‘not wanting to change’, but that there are cultural and sociological issues at play.

The real question for clinicians across the globe for many long-term conditions is no longer how to treat them, but how to support patients to manage their own conditions.

What skills are most important for clinicians to facilitate the self-care that long-term conditions rely upon?

World Tuberculosis Day 2016

24 Mar, 16 | by hbedi

By Hemali Bedi

Tuberculosis (TB) is one of the world’s top global health challenges. [1] It is both ptb-poster-largereventable and curable, yet in 2014, 9.6 million people contracted TB and 1.5 million died from the disease. [1] Currently, over 95% of cases and deaths occur in developing countries. [2]

March 24th marks World TB Day, which aims to increase awareness of the global burden of TB and call for political and social support to tackle the disease. [3] Co-ordinated by the World Health Organization (WHO), this day commemorates Dr Robert Koch’s discovery of the TB bacillus bacteria in 1882. [3] This year, the campaigns focus is “Unite to End TB”. [4]

WHO recognise that tackling this complex disease requires a multifactorial approach – societal, social, economic and medical factors all need to be addressed. [1] This is outlined in WHO’s 2015 Global Tuberculosis Report, which takes an in depth look at the global strategy needed to combat the epidemic.

World TB Day calls for progress in these areas and highlights the need for collaboration across sectors and disciplines to address the medical and social causes of ill health. [4]

If you would like to know more about TB, visit BMJ Case Report’s collection of TB related cases or see our Global Health Collection.


[1] 2015 Global Tuberculosis Report. The World Health Organization. , published 2015

[2] Tuberculosis. The World Health Organization., published October 2015

[3] World TB Day. Stop TB Partnership., accessed 21 March 2016

[4] World TB Day 2016: Unite to End TB. The World Health Organization.
, accessed 18 March 2016

An unfortunate injection

7 Mar, 16 | by hbedi

By Bhavik Shah

Foot drop” due to injured sciatic nerve because of a faulty technique of intramuscular injection is prevalent in developing countries. Some important Global Health issues related to this problem are discussed here.nurse-527622_1280

Indiscriminate use of injections

Oral medications are easier to administer and are equally effective in treating many conditions without causing pain or compromising skin barrier, yet the use of intramuscular injections has increased dramatically in the developing world. Some established facts leading to injection overuse include prescriber misconceptions regarding “strength” of injections, rapid onset of action and desire to meet patient expectations. [1] Such indiscriminate use of injections needs to stop.

Limited training in proper injection technique                 

The most common scenario for sciatic nerve injection injury occurs when the site of needle insertion is located more medial and/or inferior to the recommended site on the upper and outer quadrant of the buttock. [2] As such injuries are easily preventable, proper training to develop an anatomical understanding of the sciatic nerve is essential.

Inequality in access to quality healthcare    

Inadequate access to appropriate healthcare in vulnerable communities is a major constraint for the health of poor and marginalized groups in low and middle-income countries (LMICs). [3] Access to quality healthcare requires improvement in physical infrastructure, appropriate training for rural providers, and assistance to patients accessing care.


  1. Comparison of pharmacokinetics and efficacy of oral and injectable medicine. (2015). [online] Available at: [Accessed 3 Sep. 2015].
  2. Kline DG, Kim D, Midha R, Harsh C, Tiel R. Management and results of sciatic nerve injuries: a 24-year experience. J Neurosurg. 1998 Jul; 89(1):13–23.
  3. Haddad S, Narayana D, Mohindra K. Reducing inequalities in health and access to health care in a rural Indian community: An India-Canada collaborative action research project. BMC Int Health Hum Rights. 2011; 11 Suppl 2: S3.

Rare Disease Day

29 Feb, 16 | by hbedi

By Hemali Bedi

Rare diseases affect one in 2000 people or less; [1] but, rare diseases are more than just a rdd-logo-smallmedical challenge. Together, they present a public health problem that affects approximately 400 million people worldwide. [1]

February 29th marks the ninth annual Rare Disease Day, which is co-ordinated by EURORDIS. [2] With the aim of raising awareness for rare diseases, this day is celebrated by health care professionals, researchers, patients, carers and policy makers in over 80 countries across the world. [2]

People all over the world are affected by rare diseases, which make them an important global health issue. [1] The causes of most rare diseases remain unknown. [1] The challenges of living with a rare disease often include a lack of medical knowledge about the condition, delayed diagnosis and inequitable access to health care. [1] Some of these factors are listed in a recent Global Health case report by Sundram et al, which focuses on a rare congenital disorder known as Cloacal dysgenesis sequence.

At BMJ Case Reports, we are interested in Global Health case reports that focus on all the causes of ill health and access to healthcare services, whether economic, social or political – global health issues as they impact on individual patient’s lives.

With this in mind, what else can be done to raise awareness of rare diseases and promote them as an international public health priority?


[1] The World Health Organization. Priority Medicines for Europe and the World “A Public Health Approach to Innovation” Update on 2004 Background Paper.

[2] What is Rare Disease Day? Rare Disease UK., accessed 22 February 2016

Steps to success

3 Feb, 16 | by hbedi

By Kristian Dye

Frates and Crane report a case that is a little unusual among case reports. The patient had no weird or wonderful signs or symptoms. She had no particular pathology. She was not unwell. Her presentation was all about lifestyle, risk, and the case is all about modification of that risk. walking-711789_1920

The patient in this case is an archetype for many patients seen in primary care. She is overweight, has elevated lipids, has a sedentary lifestyle and has a family history of stroke.

For me, this only really poses two questions:

1. What was different in this case to those who we can convince of the value of risk modification, but who are unable to achieve it?
2. How can we achieve these kinds of results for more of our patients?

Answering these questions could reduce morbidity and premature mortality among our populations much more radically than more glamourous, cutting-edge interventions.


How to write a global health case report

22 Jan, 16 | by hbedi

By Hemali Bedi

Have you come across an interesting case in your medical training so far? Whether you have a patient in mind, are browsing through our online collection, or joining our blog, we’re here to help you submit your own global health case reports. Seema Biswas, Editor in Chief of BMJ Case Reports, guides you through the writing process in a new article featured in The Student BMJ.

Seema Biswas comments, “To make a difference in thstudent-849822_1280e lives of patients we must look at the causes of disease, which are often intrinsically related to the environment individual patients and the wider community live in. The field of global health considers the social, cultural, economic, and political determinants of health of patients with the aim of raising awareness of these causes to achieve equity in health for all people worldwide.”

Key messages in this guidance

  • Always get written consent from your patient before you put pen
    to paper. Not only is this good medical practice, it’s also mandatory if you want to submit to a journal such as BMJ Case Reports.
  • Structure your article logically. BMJ Case Reports has a global health template which you can follow.
  • Don’t forget to ask for the patient’s perspective – they may, or may not want to contribute to your article, but they should have the chance to do so.
  • Remember, global health case reports don’t have to come from abroad. Cases from your part of the world are just as worthy. We should be thinking about the social determinants of health of all our patients, wherever we happen to be working.
  • Visit the BMJ Case Reports website for examples of previously published global health case reports and look at the annotated example.

Read the full article here, join our global health blog and get writing! We look forward to receiving many interesting global health case reports!

The Student Elective Competition – have you entered yet?

31 Dec, 15 | by hbedi

By Hemali Bedi

Travelling far afield for your elective? If so, we want to hear all about it. Write up your experiences into a Global Health case report and not only could you be the lucky winner of a £500 travel bursary, your article could also be included in the 2016 special edition print journal.

We’ve put together a quick guide to tell you everything you need to person with suitcaseknow.

What is a Global Health case report?

Global Health case reports should focus on:

  • the causes of disease
  • the social determinants of health
  • access to healthcare services
  • how Global Health issues affect individual lives

Global Health case reports require a comprehensive review of the relevant literature. This includes related publications published by governments and global organisations, not simply the medical literature. For more information, see our website.

What could I win?

  • A £500 travel bursary to help you attend a medical conference or event related to Global Health.
  • Your article will be published in our 2016 special edition print journal along with three runners-up.

How do I get started?

Before you begin, why not have a browse of our existing Global Health case reports collection? Be sure to check out our Instructions for Authors for guidance on patient consent, the submission process, and formatting issues such as the use of images. If you’ve never written a Global Health case report before, you may find our template useful to help get you writing.

The deadline for entries is 30th April 2016. For more information, visit our competition website or get in touch!

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