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Global Health

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.


  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:



1 Abdulcadir, J. and P. Dällenbach (2013). “Overactive bladder after female genital mutilation/cutting (FGM/C) type III”. BMJ Case Reports 2013. (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!

“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.

World Health Summit

17 Oct, 16 | by Jenny Thomas

By Seema Biswas

The World Health Summit was held in Berlin last week. Leaders in Global Health from universities, health services, policy institutes and the humanitarian sector came together to discuss the health of populations, including some of the world’s most vulnerable communities affected by conflict and disaster. The topics for discussion were timely. No one could have escaped news of the tragedy of the civil war in Yemen, South Sudan and Syria, the challenges to peace, security and development in Afghanistan and Iraq, the effects of climate change as Haiti is once again struck by disaster, and the daunting work ahead on the United Nation’s Sustainable Development Goals. What was heart-warming was the number of students taking part: medical students, students studying health policy, politics, the social sciences and information technology.

It is only by working together that we can make meaningful progress on health disparities, in serving the health needs of mothers and children, people with chronic disease, populations fleeing conflict and trapped in war zones and underserved communities across the world.

Discussion focussed on addressing the social determinants of health and socioeconomic disparities for global security, universal access to healthcare, and advocacy that is mindful of people as individuals with their own histories and identities.

A call was sent out to build an evidence base that can be used to inform policy. At BMJ Case Reports, our global health case reports highlight the determinants of health that affect individuals and the challenges they face in accessing quality healthcare. Read through our online collection and submit your cases. Together we can advocate for needs of our patients.

Empowering women; Gender Equality and Healthcare

22 Aug, 16 | by Hemali Bedi

By Catrin Morgan

‘There is no tool for development more effective than the empowerment of women’ – Kofi Annan

The leading cause of death worldwide for a young woman is HIV. (1) The literature shows that teenage girls and young women are twice as likely to be at risk of HIV infection than teenage boys and young men.  In some countries the prevalence of HIV in adolescent girls is up to seven times greater than that of adolescent boys. (2)

The utilisation of healthcare services is also important when it comes to gender inequality. Studies have shown that gender inequality can affect the use of maternal health care services especially in rural areas. Women who live in areas of rural Africa, where gender norms include tolerance to violence against women are less likely to attend antenatal care and use birthing facilities. (3)

In context

The case report ‘Pregnancy complicated by haemorrhagic ascites in a woman with newly diagnosed HIV’ tells the story of a Zambian woman of low socioeconomic status and the healthcare inequalities she faced. (4) This pregnant 24-year-old presented to Lusaka, Zambia’s capital having traveled on the public bus for over eight hours from a rural region of Zambia.  She was 15 weeks pregnant and presented with a gross ascites that she had noticed for over a month.  This was her third pregnancy and she had received no antenatal care. On routine testing she was found to be HIV positive and was unaware of this diagnosis.  This woman was unemployed, illiterate and could only speak her local dialect.  She then went on to have surgery where a giant haemangioma measuring 21cm was excised.

This woman’s story demonstrates the barriers to healthcare millions of women in developing countries face every day.  The combination of gender discrimination, lack of education and low socioeconomic status results in these women presenting at a later stage of illness, less likely to access routine healthcare and at a greater risk of contracting HIV infection.


Figure 1: An image showing the excised specimen taken from: Morgan C, Nicholls K, Gangat N, et al. Pregnancy complicated by haemorrhagic ascites in a woman with newly diagnosed HIV. BMJ Case Rep. 2016 Jul 29;2016:10.1136/bcr,2016-216346.

What can be done?

With the emergence of many powerful female leaders over the past few years, now is the time to empower young women and girls across the world and to put a stop to gender inequality, that our patient faced in this case report. This could have a huge impact on healthcare across the world with the reduction of infections such as HIV and ultimately putting an end to AIDS epidemic across Africa. 


  1. World Health Organisation. Women’s Health [Internet].
  2. Ramjee G, Daniels B. Women and HIV in sub-saharan africa. AIDS Res Ther [Internet]. 2013 Dec 13;10(1):30,6405-10-30.
  3. Adjiwanou V, LeGrand T. Gender inequality and the use of maternal healthcare services in rural sub-saharan africa. Health Place [Internet]. 2014 Sep;29:67-78.
  4. Morgan C, Nicholls K, Gangat N, Sansome S. Pregnancy complicated by haemorrhagic ascites in a woman with newly diagnosed HIV. BMJ Case Rep [Internet]. 2016 Jul 29;2016:10.1136/bcr,2016-216346.

World Humanitarian Day 2016

19 Aug, 16 | by Hemali Bedi

Events are to be held all over the world today as we mark World Humanitarian Day.

At BMJ Case Reports we look back at our Global Health case reports and thousands of clinical cases from across the globe that remind us of the place of Medicine in the alleviation of suffering, advocacy for human rights and rights to health for the world’s most vulnerable communities.


From mental health in Ethiopia to rural medicine in Trinidad, from appendicitis in Greenland to dementia in the Dominican Republic, we are reminded of the enormous investment of resources necessary to bring essential care to our patients. Sir Michael Marmot writes “most racial/ethnic inequalities in health can be attributed to social determinants of health, as can socioeconomic inequalities”and “given that the causes of disease and violence are likely to be the same wherever we find them, it follows that the remedies should be similar”. He lists the solutions: “early child development, education and lifelong learning, employment and working conditions, minimum income for healthy living, healthy and sustainable communities, and social determinants approach to prevention” [1]

BMJ Case Reports is a world renowned resource for the management of complex or challenging medical conditions but we are also documenting efforts to tackle the social determinants of health and assist communities in meeting their health needs. We celebrate the tireless work of our colleagues today as we focus our attention again on the plight of people in need of the most basic and compassionate care.

BMJ Case Reports is launching a call for Global Health Associate Editors. We are looking for medical students and junior doctors in their internship years to join our Editorial Team. For more information, see our website or get in touch:


[1]  Michael G. Marmot.  Empowering Communities. American Journal of Public Health: February 2016, Vol. 106, No. 2, pp. 230-231. doi: 10.2105/AJPH.2015.302991

The 2015 Student Elective Competition: And the winners are…

16 Aug, 16 | by Hemali Bedi

By Hemali Bedi

It is with great pleasure that we announce the winners of the 2015 BMJ Case Reports Student Elective Competition! Each entry has been carefully reviewed and judged by our expert Editorial Team. It was a difficult task to judge all of our excellent entries, and the Editorial Team thoroughly enjoyed reading each case.

The winners are:

1st Place:
Social Determinants of Health: Poverty, National Infrastructure and Investment

F1.large (11)

Our grand prize winner will receive a £500 travel bursary to be used toward the cost of attending a global health conference or event of their choice. In addition, all of our winners will be featured in our special BMJ Case Reports 2016 print edition.

Congratulations to all our winners. We want to say a big thank you to everyone who participated in our competition and helped make it a success.

Student Elective Competition 2016: A call for entries

We are now launching thCapture3e 2016 competition for students and interns. Write up your experiences as a global health case report and you could be the winner of a position as a Global Health Associate Editor for BMJ Case Reports. Your case report will also be included in the 2017 special edition print journal.

All authors must be students or interns at the time of submission. Your entry will undergo the same treatment that all our journal submissions do, including the peer review process, so be sure to check out our Instructions for Authors for guidance before you start writing. If you’ve never written a global health case report before, you may find our template useful to help you get started.

Winners will be selected for interview to become a Global Health Associate Editor. We welcome submissions from all over the world. Patients may be anyone seen on the ward or at home, in medical school or on elective. Winners will be announced in September 2017.

If you’re interested in writing a global health case report, we’re here to help. Seema Biswas, Editor in Chief of BMJ Case Reports, guides you through the writing process in a recent article featured in The Student BMJ. You can also visit the BMJ Case Reports website for examples of previously published global health case reports and look at the annotated example.

Read our guidance, join our global health blog and get writing! We look forward to receiving many interesting global health case reports.

Urban violence in Honduras: a global health challenge

5 Aug, 16 | by Hemali Bedi

By Hemali Bedi

Honduras has had one of the highest rates of urban violence in the world since 2010. [1] With an average of one violent death per hour in 2013, rates of lethal violence exceed those in many war-affected countries. [2] As well as having humanitarian implications, the violence in Honduras also presents a critical public health problem.

Seema Biswas, Editor in Chief of BMJ Case Reports, discusses her experience of being deployed as a British Red Cross surgeon working with the International Committee of the Red Cross (ICRC) in Honduras in a new article published in the Guardian.

Seema Biswas comments: “Local doctors and nurses keep working. They are well organised, well informed, resourceful and committed to dealing with the continuous emergency of an overburdened health service. They are not silent, but they are considerate in their thoughts and measured in their comments. They explain the situation to me: there are complex problems here. The most vulnerable are the poor. To address their health, communities need to be safe and they need access to education and employment that pays a regular salary sufficient to feed their families.” [3]

Many factors are thought to contribute to the growing violence in Honduras, including political instability, corruption, inequality, organised crime and gang related activity. [2] Universal strategies to reduce violence in Latin  America are featured in the United Nations’ 2030 Agenda for Sustainable Development [4]. The top 10 recommendations to improve safety in Latin America are: [4]

1. Align national efforts to reduce crime and violence, based on existing experiences and lessons learned.
2. Prevent crime and violence, promoting inclusive, fair and equitable.
3. Reduce impunity by strengthening security and justice institutions while respecting human rights.
4. Generate public policies oriented to protect the people most affected by violence and crime.
5. Promote the active participation of society, especially in local communities, to build citizen security.
6. Increase real opportunities of human development for young people.
7. Comprehensively address and prevent gender violence within the home and in public environments.
8. Actively safeguard the rights of victims.
9. Regulate and reduce “triggers” of crime such as alcohol, drugs and firearms, from a comprehensive, public health perspective.
10. Strengthen mechanisms of coordination and assessment of international cooperation.

What are your thoughts?  For more information about global health and the social determinants of health, browse through our global health case reports, which focus the causes of ill health and access to healthcare services in all parts of the world.



[1] OSAC. Honduras 2016 Crime & Safety Report., published online March 2013
[2] B-Lajoie M, et al. The need for data in the world’s most violent country Bulletin of the World Health Organization 2014;92:698. doi:
[3] Biswas S. Field post: ‘Honduras has one of the world’s highest rates of urban violence’., published online 27 July 2016
[4] United Nations Development Programme (UNDP) (2013) Citizen security with a human face: evidence and proposals for Latin America. Human development report for Latin America. UNDP, New York., published 2013

Why should students write a global health case report?

11 Jul, 16 | by Hemali Bedi

By Manasi Jiwrajka

Recently we published a paper on the reasons for medical students to write a Global Health  case report. We don’t often hear about a Global Health case report, and usually it is about something weird and wonderful that we have read in a Pathology text book.

Medical students find Global Health overarching

We, as students, often think that Global Health is a phenomenon that exists only in low-income countries. It also seems that our ‘I-am-just-a-med-student’ attitude stops us from realising that we may actually have an effect on how patients live and their determinants of health.


Perhaps this perception is because there is no universally accepted definition of Global Health and two, worldwide, there remain profound differences in Global Health education.


How can we define Global Health?

“We propose that the ‘global’ in Global Health does not refer so much to ‘overseas’ or ‘over there’, as it refers to ‘over here;’ the real definition of ‘global’ in Global Health is ‘health everywhere’. ‘Global’ also refers to ‘all’ aspects of health i.e. a holistic approach, essential to exploring and taking on the real causes of disease, the social determinants of health. This focuses our attention on the patient in front of us and what we need to do to prevent them from becoming ill again.” [1]

Why are Global Health case reports useful? Why should medical students write a Global Health case report?

  1. To look at the root causes of the illness
  2. To learn about society, economics, politics, cultures, and how they affect our patients
  3. Importance in every field
  4. Learn Global Health
  5. Publish and share these cases
  6. Create an evidence base
  7. Create change


[1] Jiwrajka M, Biswas S. Why should students write a global health case report? AMSJ 2016, Vol. 7(1)

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