You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

Student editor

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


  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:
  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 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.


  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!

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.



  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.


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)

Ottawa 2016 and ANZAHPE Conference

31 Mar, 16 | by Hemali Bedi

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 Hemali Bedi

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?

Steps to success

3 Feb, 16 | by Hemali Bedi

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.


BMJ Case Reports: publishing, sharing and learning through experience

BMJ Case Reports

Publishing, sharing and learning through experience Visit site

Creative Comms logo

Most recent cases

Most recent cases