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.

Palliative care conundrums in an Ebola treatment centre

21 Dec, 15 | by Hemali Bedi

By Kristian Dye

Dhillon et al. present a case discussing the care of a patient with Ebola, which demonstrates in a micromedical-563427_1280cosm some of the biggest issues facing healthcare providers in patients with palliative or terminal care needs – albeit in a particular extreme care environment.

In the case, the patient is declared palliative and restarted on active management, before being considered palliative once again and passing away.

These are issues which perplex physicians in all care settings.

  1. When do we consider a patient for palliative
    care only?
  2. How can we reconcile differing beliefs and values within the team to deliver the best care for patients?

Deciding a patient is palliative

This is an issue that continues to vex physicians the world over. Cardona-Morrell and Hillman identify no less than 18 different scales and assessment tools available to attempt to guide these decisions, none of which are perfect.

Rightly, much of this effort is focused on identifying those within the population who are entering the end of life, and for whom discussions and decisions surrounding palliative care can help them to avoid invasive and unpleasant interventions – in the UK the Gold Standard Framework is the current tool used in community settings.

The difficulty with many of these tools is that they are not well-suited to the kind of case presented here. The ‘normally fit but acutely unwell’ patient presents a real problem for prognostication – where patients in similar situations receive the same care, some will still die, others stage recoveries that would make Lazarus jealous. In these situations, how can we make clinical judgement without losing the patient in the interest of treating clinical indicators?

Team-based approaches in palliative care

Palliative care is one of the areas of medical practice where personal values can have the biggest impact on the judgements physicians make. We all bring with us a multiple of baggage – emotional, cultural and religious – that colour our views.

A helpful summary of religious views on palliative care, by Steinberg, demonstrates the breadth of both agreement and disagreement between major religions on this topic.

Alongside this, our practice has to be informed by the ethical principles underpinning medical care. Respect for autonomy, the duty to act in the patient’s best interest and the duty not to harm our patients are all critical to decisions around palliation of the dying patient – and all are open to interpretation by the practitioner.

What approaches can we take to ensure that judgement are taken by consensus, objectively, and within the context of the individual patient?

Introducing BMJ Case Reports 10,000 cases special edition booklet

14 Dec, 15 | by Hemali Bedi

By Hemali Bedi

We are pleased to announce that BMJ Case Reports has published over 10,000 online cases. And what better way to celebrate this massive milestone than by sharing our second print edition – the 10,000 cases special edition booklet.

Seema Biswas, Editor in Chief of BMJ Case Reports, comments, “As we enter this new phase, we want to highlight Global Health: improvement in health and access to healthcare for all; and to make sure that all our case reports, clinical or Global Health, include the patient’s perspective.”

Our aim is to publish cases with valuable clinical lessons, with the advantage being that we learn from real cases. We hope that this special collection of case reports will serve as a useful educational resource that supports both learning and teaching. Why not have a look and let us know what you think? We’d love to hear your feedback.

We would like to thank all of our authors and contributors, and we look forward to welcoming many more cases in the days to come.

Malpositioned IUCD: the menace of postpartum IUCD insertion

1 Dec, 15 | by Hemali Bedi

By Manasi Jiwrajka

The three cases presented by Nigam et al outline the malposition of an intra-uterine contraceptive device (IUCD) in young women who had given birth in the previous 1-2 years.

Some significant global health problems in this report are:

  1. The importance of contraception and family planning in India
  2. Contraceptive options available for women

Family planning and population control

India has an interesting history of government level family planning options including a mass sterilisation campaign initiated in the 1960s and more recently, one that received much media attention due to 12 women who died at a government-run tubectomy camp. (1)  The Indian government has advertised vasectomy, tubal ligation and other reversible and temporary contraceptive methods for population control. In fact, there are government incentives for those who undertake sterilisation surgery, a tradition held on since the 1970s emergency and poverty-stricken period in India. (2) More than sixty years later, India continues to struggle with its population, and it appears that the mass sterilisation attempts have failed to adequately control the booming population.

Contraceptive options available

My experience of working in resource-poor settings in India has been that many women do not want to give birth immediately after marriage, or immediately after having given birth to a baby, but face enormous pressure from their husbands and families to give birth again. One big factor in India is that of a son preference, which results in families trying to conceive until they have a son or more. (3) As such, many women prefer concealed approaches to birth control that they do not have to justify to their families – such as the depot or the IUCD. A recent study investigated the influence mother-in-laws have on contraception and family planning decisions because they found that “in casual discussions during the intervention project, rural women often mentioned that mothers-in-law were opposed to young women’s desire to limit family size.”(4)

Some real solutions or alternatives to sterilisation and these reversible contraceptive methods are fundamental. Some include: (i) Spacing out children, (ii) Delaying first pregnancy, and (iii) Education of both men and women.

What do you think? Are there other alternatives and solutions?


  1. Burke J. India mass sterilisation: women were ‘forced’ into camps, say relatives. The Guardian. 2014.
  2. Matthews Z, Zoë M, Sabu SP, Inge H, Juliet M. Does early childbearing and a sterilization-focused family planning programme in India fuel population growth? Demographic research. 2009;20:28.
  3. Char A, Saavala M, Kulmala T. Influence of mothers-in-law on young couples’ family planning decisions in rural India. Reproductive health matters. 2010;18(35):154-62.
  4. Pachauri S. Priority strategies for India’s family planning programme. The Indian Journal of Medical Research. 2014;140(Suppl 1):S137-S46.

Case Report: An 11-year-old boy with silico-tuberculosis attributable to secondary exposure to sandstone mining in central India

28 Aug, 15 | by Jenny Thomas

By Midhun Mohan

This is a case about an 11-year old who developed silicosis after being exposed to sandstone mining. Stone-mining is a lucrative industry producing billions of dollars in export every year. Despite being highly profitable, the health impacts of the industry are severely under researched.

The authors state that:

“no preventive measures have been instituted in the stone-mining industry and children are exposed to respirable silica dust when their mothers take them to their work places”

Despite the fact that legislation exists to protect these workers, employers disregard the law and turn a blind eye. Extreme poverty means these workers are not able to quit thus enduring these conditions to earn a living.

Why is the state not penalising the mine owners?

Simple answer – Corruption.

Corruption aids and amplifies this situation. The state ignores the problem since the industry generates much foreign exchange.

How can these poor families be empowered to take a stance against the mine owners?

Can technology help reduce childhood blindness in developing countries?

22 Jul, 15 | by Kristy Ebanks

By Midhun Mohan

This case report outlines an extremely important treatable global health issue: childhood blindness.

Access to essential paediatric eye surgery in the developing world: a case of congenital cataracts left untreated
Untreated childhood cataracts remain prevalent especially in developing countries. They are a major health burden, not only affecting the individual’s quality of life but also predisposing the individual to becoming a financial burden for the country. This report is of a case of congenital cataracts in a young boy from the Philippines who was left blind since birth.
The mother observed the boy’s vision problems when she noted him bumping into things at the age of 1. When the boy was 2, the health care worker noted opacities on both lenses. The boy was seen at the rural health clinic at the age of 5 and diagnosed with bilateral congenital cataracts and referred to an opthamologist.
Note above the three year delay in getting the boy seen at the rural health clinic. This delay is likely due to:
The poor education of the parents affecting their health seeking behaviours and thus not fully appreciating the seriousness of their child’s condition
Inadequate competency levels of the health care workers. This is could be due to a lack of proper training, which is likely to stem from a lack of funding

Despite being diagnosed, the patient remained untreated for the next 7 years!
What was the reasoning behind such a long gap between diagnosis and treatment? There were two reasons:
The family were not able to afford the treatment
There was a lack of funding from the national health provider

The patient was not able to attend follow up, and three months after surgery, the patient’s visual acuity started to decrease.
There are 3 main factors that that can result in good visual outcomes after cataract surgery:

  • Early recognition
  • Surgical intervention
  • Good follow up after surgery

The report states that:
“Early diagnosis is essential for appropriate and timely intervention and good visual function. Visual outcome is largely dependent on the timing of surgery when dense cataracts are present. Good results have been reported in children undergoing surgery before 6 weeks of age for unilateral cataract and before 10 weeks of age in bilateral cases”

What are the ways in which early diagnosis and intervention can be increased?
It is important to note that any proposed method of increasing early diagnosis has to be economically viable for this developing country. A novel tool that has been recently introduced is the “Portable Eye Examination Kit (PEEK).”

Portable Eye Examination Kit (PEEK)
PEEK is a multifunctional, smartphone based tool which aims to empower eye health workers to diagnose eye diseases and provide a low-cost device for managing and monitoring the treatment of patients.
The modified smartphone contains a series of eye tests in the form of apps that can be used by individuals with little training. Furthermore, because the eyes tests are on a smartphone, it is extremely portable being able to reach the most remotest areas.
One of the app’s it contains is the “Acuity App” which uses a shrinking letter that appears on screen and is used as a basic vision test. It uses the camera’s flash to illuminate the back of the eye to check for disease.
The smartphone is relatively cheap, costing around £300 rather than using bulky eye examination equipment costing in excess of £100,000. The low cost of this device makes it very appealing for developing countries.

Below are useful links to learn more about the Portable Eye Examination Kit (PEEK)

Technology has the potential to greatly enhance patient care especially in developing countries. If PEEK was available in this boy’s village, could his blindness have been prevented?


The Devastating Effects of a Fire Burn in a Child

6 Jul, 15 | by Kristy Ebanks

By Manasi Jiwrajka 


I recently completed a surgical placement with a Burns Unit, and was drawn to a recent case report on Global Health describing the appalling effects of severe paediatric burns. The Devastating Effects of a Fire Burn in a Child (1) is about a 2-year old boy with 40% burns to his head and arms. He was not seen immediately after the burn, instead, he presented 1 month later to an eye clinic in Hakkari, Turkey. By then he was blind.

This case raises two main issues:

  1. “Accidental house fires cause nearly half (49%) of the injuries resulting in death” (1). How could these be prevented?
  2. Delayed presentation without adequate first aid led to a poor outcome for the child. Would the outcome have been different if the patient had better access to healthcare?


“Burn injuries represent a significant public health concern in both developing and developed countries” (1). Specifically, the WHO estimates that 265 000 deaths occur each year from fires alone, with more than 96% of deaths occurring in low and middle-income countries. Mortality due to burns is over 10 times higher in low and middle income than in high income countries (2). Many studies have found a correlation between socioeconomic deprivation and the incidence and severity of burn injury (3-5). The socioeconomic factors including crowding, poverty and poor maternal education pose as significant risk factors for paediatric burns (6).

Causes of burns

The relevance of this case in Hakkari, in Turkey is that “the incidence of childhood fire burns in Turkey is unknown because of inadequate records.” (1). “In Turkey, tea is made using two narrowly based containers that are stacked on top of each other”; these may easily topple (7). Globally, most burns occur at home, especially in the kitchen. Paediatric burns often occur when parents leave their children alone (even for a moment). His mother “left [her] baby at home sleeping near the electric heater” (1, 8, 9).

Worldwide, open flame burns are the most common, followed closely by scalds. Ignition of clothing is a common cause of burns in low and middle income countries including Ethiopia, India and Papua New Guinea. In Ethiopia, it was found that 93% of burn injuries in rural areas were due to open fires inside homes causing the ignition of clothing. In India, saris catching fire whilst cooking on kerosene stoves are a cause of deaths due to burns amongst adults. Similarly, 50% of hospitalizations due to burn injuries in Papua New Guinea are due to ignition of grass skirts (10-13). In Mexico, Ghana and Taiwan, boiling liquids and hot baths were found to cause scalds among children (2, 14-16).

Global Health Issues

There are several socio-economic factors that play a role. The authors write:

“Socio-demographic factors linked to an increase incidence of burns include low household income, living in a deprived are, living in rented accommodation, young mothers, single-parent families and children from ethnic minorities. The parental educational level, parent occupation and the type and size of accommodation are also important.”

The issue of access to healthcare is two-fold: (i) access to treatment and (ii) access to prevention. This patient’s mother quotes, “because we are poor and have no health insurance, I could not take the child to the hospital right away. It was only one month later that I was able to take the child to an ophthalmologist” (1). Access to a reliable electrical supply precludes the use of open fires.

Burn care costs comprise preventative measures, emergency response, and treatment and follow-up. In Turkey, Sahin et al. showed that the mean cost associated with per percent of burn area was $368 (compared to $927 per percent burn in New Zealand), and each percent burn corresponded to 2 days in the hospital. In the case of the 2 year old patient with 40% burns, the total cost would be about $15000 with 80 days in the hospital. This overall cost of burn management is higher than other medical problems such as stroke and HIV/AIDS (17, 18). In comparison, cost analysis of burns management in Australia showed that management of burns patient was not significantly higher than other patients in ICU receiving a similar level of care. The only difference, however, was in physiotherapy, dressing and medication costs (19). This lack of discrepancy in Australia could be attributed to overall increased healthcare costs rather than specifically for burns, similar to the high cost in New Zealand. In low and middle-income countries, including Turkey, the costs associated with HIV/AIDS and cardiovascular issues is lower than burns due to the availability of knowledge, resources and medical specialists compared to burns management that requires highly specialised care. A lack of specialist burn services is, therefore, an important factor not only in burn care, but also in healthcare funding.

Interventions to prevent burn injuries can be divided into education programs, engineering programs and enforcement, and include “improvement in socioeconomic status, improved housing, provision of basic amenities (eg, water), proper regulation and design of industrial products (eg, kerosene stove), proper storage of flammable substances, and supervision of children” (20).

Education is also fundamental to long-term awareness of burn injuries. The authors suggest “the establishment of a national programme would help ensure sufficient funds are available and allow coordination of the efforts of district, regional and tertiary care centres.” Others suggest the need for public education, broadcasting programmes, and the implementation of stringent government regulation (7).


  1. Istek Ş. The devastating effects a fire burn in a child. BMJ Case Reports. 2015;2015.
  2. Agbenorku P, Agbenorku M, Fiifi-Yankson PK. Pediatric burns mortality risk factors in a developing country’s tertiary burns intensive care unit. International Journal of Burns and Trauma. 2013;3(3):151-8.
  3. Edelman LS. Social and economic factors associated with the risk of burn injury. Burns : journal of the International Society for Burn Injuries.33(8):958-65.
  4. Cubbin C, Smith GS. Socioeconomic Inequalities in Injury: Critical Issues in Design and Analysis. Annual Review of Public Health. 2002;23(1):349-75.
  5. Park JO, Shin SD, Kim J, Song KJ, Peck MD. Association between socioeconomic status and burn injury severity. Burns : journal of the International Society for Burn Injuries. 2009;35(4):482-90.
  6. Delgado J, Ramírez-Cardich ME, Gilman RH, Lavarello R, Dahodwala N, Bazán A, et al. Risk factors for burns in children: crowding, poverty, and poor maternal education. Injury Prevention. 2002;8(1):38-41.
  7. Nursal TZ, Nursal TZ, Yildirim S, Tarim A, Caliskan K. Burns in Southern Turkey: Electrical Burns Remain a Major Problem. Journal of burn care & rehabilitation. 2003;24(5):309-14.
  8. Forjuoh SN. Burns in low- and middle-income countries: A review of available literature on descriptive epidemiology, risk factors, treatment, and prevention. Burns : journal of the International Society for Burn Injuries. 2006;32(5):529-37.
  9. Rossi LA, Braga ECF, Barruffini RdCdP, Carvalho EC. Childhood burn injuries: circumstances of occurrences and their prevention in Ribeirão Preto, Brazil. Burns : journal of the International Society for Burn Injuries. 1998;24(5):416-9.
  10. Sawhney CP. Flame burns involving kerosene pressure stoves in India. Burns : journal of the International Society for Burn Injuries. 1989;15(6):362-4.
  11. Kalayi GD. Burns in children under 3 years of age: the Zaria experience. Annals of tropical paediatrics. 1996;16(3):243-8.
  12. Barss P, Wallace K. Grass-skirt burns in Papua New Guinea. Lancet. 1983;1(8327):733-4.
  13. Peck MD. Epidemiology of burn injuries globally. 2015. In: UpToDate [Internet]. Waltham, MA: UpToDate.
  14. Hijar-Medina MC, Tapia-Yanez JR, Lozano-Ascencio R, Lopez-Lopez MV. [Home accidents in children less than 10 years of age: causes and consequences]. Salud publica de Mexico. 1992;34(6):615-25.
  15. Tung KY. A seven-year epidemiology study of 12,381 admitted burn patients in Taiwan–using the Internet registration system of the Childhood Burn Foundation. Burns : journal of the International Society for Burn Injuries. 2005;31 Suppl 1(1):S12-7.
  16. Forjuoh SN. Childhood burns in Ghana: epidemiological characteristics and home-based treatment. Burns : journal of the International Society for Burn Injuries. 1995;21(1):24-8.
  17. Sahin I, Ozturk S, Alhan D, Açikel C, Isik S. Cost analysis of acute burn patients treated in a burn centre: the Gulhane experience. Annals of Burns and Fire Disasters. 2011;24(1):9-13.
  18. Lofts JA. Cost analysis of a major burn. The New Zealand medical journal. 1991;104(924):488-90.
  19. Patil V, Dulhunty JM, Udy A, Thomas P, Kucharski G, Lipman J. Do burn patients cost more? The intensive care unit costs of burn patients compared with controls matched for length of stay and acuity. Journal of burn care & research : official publication of the American Burn Association. 2010;31(4):598-602.
  20. Peck MD. Prevention of fire and burn injuries. 2015. In: UpToDate [Internet]. Waltham, MA: UpToDate.


Safer prescribing by empowering patients?

1 Jul, 15 | by Kristy Ebanks

By Kristian Dye

For this post, I have chosen to write about a Case Report that comes from the United Kingdom. It’s about a patient with a complex set of management challenges, however none of them are rare – and the United Kingdom is almost certainly one of the best places in the world to be with such a complex constellation of conditions.

So far, this does not sound like compelling global health territory, however it addresses a problem that is universal within health care systems globally – polypharmacy. This is an issue which affects certain populations more than others (for example, in elderly populations (1), an average of 2-9 medications are taken daily, with one in six (2) over 65s taking 10 or more daily).

The issue, in this case, is further complicated by the prescriptions not all originating from a single physician. In an older person, they maybe taking antihypertensives, a statin and drugs to reduce cardiovascular risk – however, they will likely all originate with the primary care physician.

The patient… is supported regularly by general practice, the school nurse, ear nose and throat specialists, general and community paediatrics, dietetics, specialist dentistry and ophthalmology’

From this list of involved specialties, the potential formulary that prescriptions will come from is probably as wide as in any case imaginable. This opens up an enormous range of potential drug interactions.

This is a real day-to-day patient safety issue faced in all healthcare settings, whether the system is well integrated or highly fragmented.

‘An example where the lack of an up-to-date medication list led to a potential medication-related problem was the prescription of azithromycin for an ear infection by an ENT surgeon. There is a documented drug interaction between azithromycin and domperidone, a medicine used regularly to treat the patient’s gasto-oesophageal reflux’

The solution suggested in the case is to centralise the patient’s records, but not in the way we usually imagine.

Integrated health care records are usually conceived of as a centralised database that healthcare workers are able to tap into and pull down records for their patient. These systems are highly resource intensive and logistically difficult to deliver over large geographical areas. The alternative is wonderfully elegant.

We trust our patients. If we ensure that when we prescribe something, we add it to a patient-held record, then we know that our colleagues will know what we have done, and are able to factor this in to their own treatment decisions. The solution in the case is a smartphone app (3), which is highly convenient for the more than 1.75 billion smartphone users (4) worldwide – however there’s no reason why a similar approach couldn’t be undertaken on old-fashioned paper for those who don’t have access to the technology – in the UK we’ve been doing this for child health (5) for years.

Surely, then, this seems like an easy decision. We can improve the safety of our patients, by trusting our patients. If we can trust patients with the risk of possessing the medicines, why not trust them with the records too?


Jogini Culture and HIV

5 Jun, 15 | by Kristy Ebanks

By Manasi Jiwrajka

The case report HIV in India: the Jogini Culture presents a case of a 32 year old Jogini from rural Andhra Pradesh who is HIV positive.

‘Jogini’, ‘Devadasi’ or ‘Mathamma’ are terms used to describe a girl committed to theogamy, or in other words, who is ‘married’ to a deity when she reaches puberty, and spends her entire life being sexually exploited by the deity’s priests or devotees. (1-3). Although similar practices have existed in many ancient European and Middle Eastern cultures, this practice is currently prevalent in Andhra Pradesh, a state in southern India. It is estimated that there are 16,799 documented Joginis in Andhra Pradesh and 22,943 Devadasis in Karnataka. (1)

Historically, the practice originated in medieval India when a woman “would become a Jogini in order to upkeep the services of the temple…sweeping the temples, and carrying the utensils for workship.” (1) However, the current practice involving sexual exploitation has emerged as a result of the caste system in India, and specifically due to “a schism [that] appeared between the ‘clean’ and the ‘unclean’ castes,” whereby the “Jogini from the ‘unclean’ castes were often pushed into the sexual exploitation,” and women from the ‘clean’ castes were somewhat protected by The Madras Act V of 1929 or the 1934 Bombay Devadasi Protection Act that “tried to emancipate the Jogini from their servitude.”(1) Whilst technically the practice is prohibited in India since Indian Independence, clandestine practices still exist, and in fact, some argue that the “efforts to abolish these practices since the days of British rule has increased the stigma attached to its victims and reinforced their risk of entry into commercial sex work.”  Today, all Jogini or Devadasis are Dalit, or “untouchables” from the lowest caste. (4)

Inherently, the Jogini culture is religious in nature but other cultural beliefs also play a role in the continuation of these practices. For example, Borick mentions that the patient’s father was worried about who would cremate him after his death, and his cultural beliefs dictated that “only a son could light his funeral pyre.” However, “since he did not have a son, he was in danger of becoming a ghost,” and as such he decided that if his daughter were a Jogini, “because of her special relationship to Goddess Yellamma, she would be able to light his funeral pyre when he died.”

Some of the Global Health issues that arise in this case are as follows:

1.       Poverty

2.       Lack of education

3.       Gender Equality and Women Empowerment

4.       Child Mortality

5.       Maternal Health

6.       HIV/AIDS

It is important to note that this one case of the Jogini raises 6 out of the 8 issues that are addressed by the Millenium Development Goals.

The patient’s father, as previously mentioned, decided that his daughter should be a Jogini compelled by his poverty and lower socioeconomic status as a Dalit (or untouchable). In his case, poverty prevented him from paying a dowry, a cultural practice that still exists in India, and as such, “the options for his daughter were limited.”

Due to this poverty, or perhaps as a result of a lack of education and literacy among Dalits in general (5), “the patient never attended school.” Dalit women “suffer from 17% more illiteracy” compared to women from other castes and “92.8% of Jogini” are illiterate. (1)

Education is intrinsically linked to women’s empowerment, child mortality, maternal health and HIV/AIDS. “Education is one of the most important means of empowering women with the knowledge, skills and self-confidence necessary to participate fully in the development process.” (5) Borick speculates that “perhaps even a few years of primary school would have provided [the patient] with literacy skills and the confidence necessary to seek an alternative way to earn a living,”(1) and had the patient been given educational opportunities, she would have had a different source of income.

Additionally, literacy and child mortality are linked as well: “in India, literate mothers have lower rates of severely stunted (40% compared with 44%) and severely underweight (7% compared with 9%) children when compared with illiterate mothers. For every 10% increase in female literacy in India, there is a 9/1000 decrease in the child mortality rate.” (1)

Similarly, there is evidence to suggest that educated mothers have better maternal health compared to those who are not educated, as they have “a greater spacing between pregnancies [and] the more education that woman has, the more likely she is to understand contraceptive methods taught by health workers including condom usage.” (1)

Safe contraceptive methods can prevent sexually transmitted diseases including HIV, which is “five times as high” (2.6%) in Devadasi districts compared to the state average (0.52%). Joginis and Devadasis, are at a higher risk of HIV and other sexually transmitted infections “due to high risk sexual activity.” Additionally, Jogini have a ten times higher mortality rate due to AIDS compared to the national average of women in India. (1)

Whilst the Jogini culture is known only in India, similar ‘ritual servitude’ practices exist in other countries; the practice is known as ‘deuki’ in Nepal or ‘trokosi’ or ‘vudusi’ in Ghana, Togo and Benin wherein “a female child, usually a virgin, is selected by her family to serve in a shrine in reparation for crimes committed by other members of the family.” (6, 7) Therefore, similar global health issues exist around the world where just like the 32 year old patient, women are sexually exploited, come from rural areas, with a lack of educational opportunities and suffer severe discrimination.

1. Borick J. HIV in India: the Jogini culture. BMJ Case Reports. 2014;2014.

2. Black M. Women in Ritual Slavery: Devadasi, Jogini and Mathamma in Karnataka and Andhra Pradesh, Southern India*. Pakistan Journal of Women’s Studies = Alam-e-Niswan = Alam-i Nisvan. 2009;16(1/2):179-205.

3.Misra KK, Rao KK. Theogamy in Rural India: Socio-Cultural Dimensions of the “Jogini” System in Andhra Pradesh. Indian Anthropologist. 2002;32(1/2):1-24.

4.Torri M-C. Abuse of Lower Castes in South India: The Institution of Devadasi. Journal of International Women’s Studies. 2009;11(2):31-48.

5. UNFPA. Report Of The International Conference On Population And Development. Cairo: UNFPA, 1994 1994. Report No.: (94/10/18).

6. Ameh RK. Child bondage in Ghana: A contextual policy analysis of trokosi [Ph.D.]. Ann Arbor: Simon Fraser University (Canada); 2002.

7.  CEDAW. Shadow Report on the 4th & 5th Periodic Report by The Government of Nepal on CEDAW. 2011

This article is published under a CC-BY-NC licence for permissions email

Socioeconomic Privation & Congenital Birth Defects – Cause or Coincidence?

1 Jun, 15 | by Kristy Ebanks

By Kristian Dye

This week I’m looking at two very sad cases of stillbirth in Cali, Colombia.

When we think of disease caused by social circumstance we often imagine non-communicable diseases or infectious diseases, usually where poor living conditions loom large in the aetiology.

When we consider the higher rates of genetic birth defects in socially disadvantaged populations we often express our dismay at what rotten luck it is that this happens to people who are also poor. Here, we miss a key to understanding these diseases. The circumstance of being socioeconomically deprived can provide the conditions necessary for defects of the type in these cases to occur.

Sirenomelia is a rare congenital defect with a prevalence rate of around 1 in every 100,000 birth, and 300 cases have been reported in the literature. The aetiology and pathophysiology of the defect is not well understood, but is thought to be related to vascular abnormality.

‘The vascular steal hypothesis suggests the existence of an anomalous vessel impeding proper blood flow to the caudal end of the embryo. One of the most important early findings in prenatal imaging is a SUA [single uterine artery] of abnormal origin, with SUA of vitelline origin being considered characteristic of sirenomelia.’

There are a number of known risk factors associated with sirenomelia, including maternal diabetes and exposure to teratogenic drugs (such as anti-convulsants or retinoids). Neither mother had abnormal glycaemic control, and neither had been exposed knowingly to teratogens. Incidence of sirenomelia appears to decrease with advancing maternal age – and both women were in the non-increased prevalence group. The only common risk factor between the women was their access to water. Both women relied upon a nearby river for their water – a river which is known to be contaminated with leachate from landfill.

‘During their normal daily activities they were exposed to the river that flows near their homes, where they would wash their clothes and perform personal hygiene activities.’

The contaminated water is known to affect changes in the fish population. The women lived less than 2km from one another. There is a large amount of literature which has observed a correlation between socio-economic status and increased incidence of congenital abnormality – and in particular between proximity to landfill and deformity. One study, of centers in the UK, found that the relative risk of non-chromosomal abnormalities increased by 40% between the most affluent quintile and the most deprived. Where the literature perhaps underestimates the effect at the level of the global population is that the majority of studies are based in the North America or Europe, where socioeconomic deprivation is less relative to the global standard, and where there is a great deal more environmental regulation than elsewhere in many other parts of the world.What is clear, however, is that we can’t think of socially determined health in simple terms of diseases that are transmitted within poor conditions, or are developed as a result of poor nutrition, education or living conditions. Children can be born with disability and disease as a result of the conditions their mothers live in.

5. Page 23

Ramifications of poor medical education and screening in minority populations: an extensive acral melanoma

26 May, 15 | by Kristy Ebanks

By Manasi Jiwrajka

Ramifications of poor medical education and screening in minority populations: an extensive acral melanoma reports a case of a Samoan man with acral melanoma and explores the precipitating factors leading to the progression of a condition that may otherwise have been screened for and treated at a much earlier stage.

This case is from the Naval Health Clinic in Honolulu, Hawaii. The authors report the case of an 82 year old Samoan man who presents with pain in his left heel “due to a large [9x7cm], exophytic, hyperpigmented, polypoid mass.” No lymphadenopathy or symptoms were reported. A diagnosis of acral lentiginous malignant melanoma was made after an MRI and a biopsy of the fungating mass. The case reports that “Native Hawaiians and Pacific Islanders were one of the only two racial groups where the leading cause of death was cancer, with rates above the national average.”

The Pacific Islands including Fiji, Tonga and Samoa have a rich cultural history dating back to about 1000BCE, followed by German, American, New Zealand and British colonial rule until the 1900s (2).Samoa is made up of nine volcanic islands, located in the Pacific Ocean. The islands are divided into two territories: the American territory and the Independent State of Samoa. Of cultural and political relevance is the social structure of families and groups, whereby although nuclear families exist, traditionally, each family is part of an ‘aiga’ or an extended family headed by a mataai (leader) who has a voice in the village.

Whilst the American part of Samoa is developed due to the resources available from the United States, the Independent Samoa lags behind economically as well as in terms of healthcare. In the 1940s, many primary healthcare institutions were set in place as an after-effect of the historical colonial rule, and medical practitioners now exist in Samoa. “In 2005, Samoa had 0.27 physicians per 1,000 population, 0.02 pharmaceutical personnel per 1,000, 0.03 dentistry personnel per 1,000, and 0.94 nurses and midwives per 1,000 [compared to Australia that had] 2.99 physicians per 1,000 population, 1.04 pharmaceutical personnel per 1,000, 0.69 dentistry personnel per 1,000, and 9.59 nurses and midwives per 1,000.” (3) In many Samoan villages the traditional healers or fofo (most recent estimate is 900 traditional healers in Samoa) still continue to provide traditional care (3). In more recent times, these fofos have received public health training, which has given rise to a combination of both biomedical and traditional theories of illness, while at the same time creating a conflict between the two paradigms (2). For many Samoans overseas in Australia, New Zealand or the United States, there is a belief that illness occurs either through spirits or because they have not helped their family back in Samoa (4). Perhaps as a consequence of previous colonial rule, there is a lack of trust towards Western medical practices, and if medicine does not work, Samoans refer to the fofo (4).

Melanoma as a Global Health Issue

Melanoma is a Global Health issue; globally, it is the 19th most common cancer and 232,000 new cases were diagnosed in 2012, which constitutes 2% of all cancers (5). The WHO estimates that one in three diagnoses of cancer is in fact skin cancer. In countries such as Australia, melanoma is the fourth most common cancer diagnosed (6) and as such national preventative strategies have been implemented, and screening processes have been employed by healthcare services for early identification and excision of melanomas. These preventative strategies include reducing sun exposure, sun protection and a complete skin examination by the primary care doctor (7). In the case, the Samoan patient there was a two-fold delay: first, in the delay of diagnosis, which is common in people of colour because of the common misconception that melanoma does not affect dark-skinned people (8); and second, a delay in seeking care at an earlier stage of his condition “due to lack of understanding of knowledge to disease and the long distances that must be traveled to obtain proper, specialty care.” (1)

Accessing Healthcare – Equity and Barriers

There are biological and social determinants of health. In the above mentioned case, a biological determinant of the Samoan patient would be his dark skin tone, and as such his increased predisposition to acral melanomas. Some of the social determinants include socioeconomic status, education, cultural beliefs and health insurance. Specifically, the case report mentions that “low socioeconomic status patients generally know little about their own medical condition, tend to have a high school education or less, and have difficulties arranging transport, all factors contributing to care barriers.”(1) These factors have a follow-on effect that influences access and compliance of care. Problems with access or proper compliance invariably results in patients presenting with advanced disease, which is a burden both for the patient as well as the health system.

The three-delay model (9) used in maternal health is a useful tool to conceptualize the barriers experienced by minority groups: (i) a delay or barrier in making a decision to seek care (ii) barrier to reaching care, as well as (iii) barriers to receiving adequate health care.

(i) Delay in seeking care

Lack of knowledge

In the case report, the authors write about the relevance of education: “low socioeconomic patients generally know little about their own medical condition, tend to have a high school education or less”. As a result, they present to the doctor much later in the progression of their disease compared to patients of a higher socioeconomic status who “tend to recognise skin changes when they self-screen and obtain medical treatment earlier”(1).

Some Samoans believe in the role of traditional healers or fofo, creating a conflict between Western medicine and traditional beliefs. “Healthcare practices often clash with societal beliefs, and so patient education regarding their disease and its possible progression is important.” (1)

Cost – benefit

Similarly, other factors causing delay in seeking care are economic in nature. There is an opportunity cost associated with seeking care — leaving work to go to a healthcare practice implies that the patient (and maybe another relative) will need leave from work and lose income.  In the case of acral melanoma, where early identification of the melanocytic lesion is hugely influential on prognosis, a delay in seeking care due to a lack of knowledge or due to the cost of seeking care can have significant implications on the progression of the condition.

(ii) Barriers to reaching care

These barriers are often physical or geographical. Remoteness and a lack of transportation networks for access to even basic services is prohibitive of Global Health. “Poor access to care for [rural and isolated] populations is mainly due to remoteness, travel time, lack of speciality care, and the cost of obtaining healthcare services, with longer distances correlating with infrequent doctor visits, decreased use of preventive services and fewer routine follow-up visits” (1). There is good evidence that rural populations have poor access to healthcare services and consequently poorer health outcomes (10-12). “Having a usual source of care improves access to medical screening services and decreases health disparities; however, this is often not available to minorities.” (1)

(iii) Barriers to receiving adequate care

These barriers are crucial to identify and address as they are a pervasive barrier to Global Health. In Samoa, there is no universal medical benefit system; however some government healthcare agencies provide some free healthcare (3). American Samoans and other “uninsured minorities are eligible for insurance [but] they often do not sign up for it due to lack of awareness or limited proficiency in English” (1). Language barriers can cause poor communication and decreased trust between the doctor and the patient. Another barrier to receiving good care is the cultural competency of the physician. “Typically, the ethnicity of physicians does not reflect that of their patients, who consequently believe that their physician is unaware of popular culture alternative/holistic medicine. Perhaps a Samoan provider would have related better to our patient…and would have educated him about his advanced disease and need for modern medical treatment, thus leading to a better outcome (1).”

We as health professionals can play a crucial role in addressing some of these barriers to adequate healthcare, and subsequently reducing the burden on health systems globally.

1. Jackson CR, Fernelius C, Arora N. Ramifications of poor medical education and screening in minority populations: an extensive acral melanoma. BMJ Case Reports. 2015;2015.

2. Ember Ea. Encyclopedia of Medical Anthropology: Health and Illness in the World’s Cultures. New York: Kluwer Academic Publishers; 2004 2004.

3. Boslaugh SE. Health Care Systems Around the World: A Comparative Guide. Health Care Systems Around the World: A Comparative Guide. SAGE Publications, Inc. Thousand Oaks, CA: SAGE Publications, Inc.; 2013.

4. Queensland Health SoQ. Samoan Ethnicity and Background [Web]. 2014 [updated 12 June 2014]. Available from:

5. Holmes D. The cancer that rises with the Sun. Nature. 2014;515(7527):S110-S1.

6. Waterford K. Melanoma: from little things, deadly things can grow: Australian Medical Association; 2014. Available from:

7. Markovic S, Svetomir NM, Lori AE, Ravi DR, Roger HW. Malignant Melanoma in the 21st Century, Part 1: Epidemiology, Risk Factors, Screening, Prevention, and Diagnosis. Mayo Clinic proceedings. 2007;82(3):364.

8. Gupta S. Skin colour: No hiding in the dark. Nature. 2014;515(7527):S121-S3.

9. Thaddeus S, Maine D. Too far to walk: Maternal mortality in context. Social Science & Medicine. 1994;38(8):1091-110.

10. Armstrong KEJPJV, B K, K. E. Jong PJV, Armstrong BK. Rural inequalities in cancer care and outcome. Medical journal of Australia. 2005;182(1):13-4.

11. Casey MM, Thiede Call K, Klingner JM. Are rural residents less likely to obtain recommended preventive healthcare services? American Journal of Preventive Medicine. 2001;21(3):182-8.

12. Nemet GF, Bailey AJ. Distance and health care utilization among the rural elderly. Social Science & Medicine. 2000;50(9):1197-208.

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