Writing a global health case report
The editor in chief of BMJ Case Reports guides you through the writing process
What makes our patients ill? Writing a global health case report gives you the opportunity to take a step back and consider the wider determinants of health that affect populations, not just individual patients. The study of global health recognises taking an individual approach to treating patients does not always deal with the underlying problems that caused them to present in the first place. Michael Marmot, director at the Institute of Health Equality at University College London, says, “What good does it do to treat people’s illnesses and send them back to the conditions that made them sick?” For example, you could prescribe antibiotics for a patient with pneumonia, but what good is it if you send them back to the same cold and damp housing where they acquired the pneumonia in the first place?
To make a difference in the lives of patients we must look at the causes of disease, which are often intrinsically related to the environment individual patients and the wider community live in. The field of global health considers the social, cultural, economic, and political determinants of health of patients with the aim of raising awareness of these causes to achieve equity in health for all people worldwide.
Writing a global health case report is something you could consider exploring as part of your medical training, either abroad or in the UK, or as part of a special study module (student selected component). The type of patient you choose for a global health case report is not restricted to faraway or exotic locations; cases in your home country are equally valid. For example, a case report abroad might look at “Why are women in the world still dying during child birth?” whereas a UK focused case report might look at questions such as access to healthcare for migrants or health needs of individuals or groups caught up in people trafficking.
By viewing how patients live, we can understand the choices they make, the circumstances in which they make decisions that affect their health, and what we have to do for them to experience improved health and an improved quality of life.
What is a global health case report?
Global health can cover anything from expedition medicine, humanitarian work, refugee health, conflict, violence, sexual violence, human trafficking, humanitarian aid, telemedicine and e-health, and health innovations. Read the global health case reports on the BMJ Case Reports website to help familiarise yourself with the language used to present a case and the variety of patients that are featured.
Currently there are no other publications that extensively discuss global health issues at an individual level, but Case Studies for Global Health (casestudiesforglobalhealth.org), the Center for Global Development (cgdev.org/page/case-studies), and the International Federation of the Red Cross (ifrc.org/en/what-we-do/humanitarian-diplomacy) publish projects that aim to improve health outcomes for communities around the world.
The Lancet (thelancet.com) and BMJ Global Health (promotions.bmj.com/globalhealth/) are two other important global health resources, and you may find clinical cases discussed with perspectives from experts in global health. JAMA publishes clinical cases for learning which often have a strong global health component, and the JAMA Forum is a useful global health resource (newsatjama.jama.com/2015/09/16/jama-forum-3-critical-challenges-for-global-health-security).
If you are interested in writing a global health case report, BMJ Case Reports has a template for authors to follow:
- Case presentation—an explanation of the relevant features of the case, looking at the history of the problem and forward to the outcomes that have resulted
- Global health problem list—a bullet point list of the problems raised in the case, which are discussed more precisely in the section below
- Global health problem analysis—a deeper review of the literature around each problem raised. Appraisal of all the relevant medical, epidemiological, and socio-political literature
- Learning points
- Patient perspective—written by the patient or next of kin.
Box 1 provides links to published global health case reports and questions to consider from a global health perspective.
Box 1: Examples of published global health case reports
A woman bleeds to death post-partum.
- Mahadik KV, Swami MB, Pandey N, Pathak A. Exsanguinated uterus after massive atonic postpartum haemorrhage. BMJ Case Rep 2013; doi:10.1136/bcr-2013-009371
- Questions to consider How did this happen? Why did she bleed? Did she have any antenatal or obstetric care?
A child is badly burned in Turkey. Now he is blind.
- Istek Ş. The devastating effects a fire burn in a child. BMJ Case Rep 2015; doi:10.1136/bcr-2014-206663
- Questions to consider How did the fire start? What specialist burns care was immediately available to him? How will he manage now?
A young man is paralysed after cervical spine injury
- Litwak B, Dobie A, Safadi W. Lifestyle changes of a family caring for a 25-year-old quadriplegic man after delayed spinal cord infarction. BMJ Case Rep 2015; doi:10.1136/bcr-2015-211100
- Questions to consider What services are available for him to be cared for at home? How can his family afford home care? What adjustments have they had to make to care for him at home? How do they recognise when he is becoming ill? How do they access care when emergencies arise?
Identifying a suitable patient
Once you have identified a suitable patient ensure that you have asked for their consent to write about the case. Explain the purpose of the case report and that the patient’s details can be kept anonymous. You must ask the patient to sign a consent form (http://journals.bmj.com/site/authors/editorial-policies.xhtml#patientconsent) before you submit your article.
Before you start writing, brainstorm the situation of the patient. How did they present? How is their life affected by the symptoms? What are their health beliefs? How will illness affect life at home and at work? When did the patient decide to go to a doctor? Was it easy to get an appointment? Did they feel comfortable talking to the doctor? What treatment will they need? Are all the health services they require readily available?
List all the global health problems you think your patient faces. As you think about the case history, the social determinants resulting in your patient’s ill health may become obvious, including housing, employment, education, access to water and electricity, poverty, conflict, political stability, migration, and asylum status.
Consider your patient’s access to health services—the proximity of the local clinic, opening hours, health insurance cover, eligibility for treatment, and the cost of medication. Explore your patient’s experience of treatment at health centres and how, at home, they live with disease and disability.
Some of the problems you identify might be new and unique to a particular region or community, whereas other problems could be major global health challenges such as poverty, lack of access to healthcare, bad housing, poor sanitation. Don’t worry if you have identified a well known global health problem, as your case report is valuable in terms of adding to the literature of what is known and provides a basis for how to improve the situation. Box 2 offers useful links to global health websites to help you in your background reading.
Box 2: Global health resources to help you write your case report
- World Health Organization. Global health atlas. apps.who.int/globalatlas
- Department of Health and Human Services. The global health strategy of the U.S. Department of Health and Human Services. globalhealth.gov/pdfs/Global%20Health%20Strategy.pdf
- World Bank. Health. worldbank.org/en/topic/health
- World Health Organization. Social determinants of health: the solid facts. 2nd ed. euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf
- CancerIndex. www.cancerindex.org
- INTERPOL. Trafficking in human beings. www.interpol.int/Crime-areas/Trafficking-in-human-beings/Trafficking-in-human-beings
- UK Home Office. Immigration rules. www.gov.uk/guidance/immigration-rules
- UNHCR: the UN refugee agency. Refugees. http://unhcr.org/pages/49c3646c125.html
- BMJ Case Reports. Searching journal content for GLOBAL HEALTH in full text. http://casereports.bmj.com/search?fulltext=GLOBAL+HEALTH+&submit=yes&x=0&y=0
Structure of the case report
Begin by writing the story of your patient (see box 3). Describe how and when they reached the hospital or the clinic and discuss how they were affected by their disease. Questions to consider: How did the patient get there? How long did it take? What services were available? How did they pay for treatment? How is the patient now? Were they able to afford treatment? Were they able to return for follow-up?
Now look at the root causes of the illness. Questions to consider are: How does the patient live? Where do they work? Do they have regular health screening? How did they become ill? What determined their perception of their symptoms? What were their notions of illness and seeking help? How did they access healthcare? Did they encounter any barriers? Were they able to overcome these and how? What type of treatment did they have? What were their views on this? How does this treatment compare with globally accepted standards? How has illness affected their financial income and working life? What about their family?
Box 3: Case presentation from a published case report
- Jackson CR, Fernelius C, Arora N. Ramifications of poor medical education and screening in minority populations: an extensive acral melanoma. BMJ Case Rep 2015; doi:10.1136/bcr-2014-207139
An 82 year old Samoan man, skin phototype V, presented with left heel pain due to a large, exophytic, hyperpigmented, polypoid mass. He had initially presented to the dermatology clinic two years previously with a small, dark macule but had decided to self medicate holistically on his home island until his heel pain prompted his return. Physical examination revealed a lesion consisting of black, necrotic nodules and friable granulation tissue along with ulcerations and purulent and serosanguinous discharge. At the base of the lesion was a hyperpigmented, asymmetrical macule with nodularity. The patient had no other associated symptoms and no lymphadenopathy.
Analysis and discussion
On the basis of the global health problem list, you should start to explore these issues in more depth by reviewing the relevant published literature. Find out what has already been done to tackle the health problems that affect your patient. Begin by looking for examples of community interventions, and then explore the work of local and national government and international organisations.
Refer to the references cited in your initial search of the literature. In addition to standard medical databases, search socio-political databases such as Social Science Research Network (http://ssrn.com/en/) and health statistic resources such as those of the United Nations (http://research.un.org/en/un-resources/statistics) or the World Bank (http://data.worldbank.org/).
In this section, rather than ending with a summary of the relevant literature, try to focus on the issues specific to your patient. Discuss competing priorities, health policy, and initiatives that seek to deal with these problems. These might include policies that may have failed in their implementation, potentially as a result of competing priorities in public services or sustainability.
Finally, offer the patient the opportunity to give their point of view. Not all patients will want to give an account in their own words, but you should ask them if they would like to contribute. Even if the patient does not want to be involved, they should read, or have read to them, the submitted version so they are aware of how the published report will appear.
A discussion of global health issues can leave patients feeling exposed and vulnerable. We encourage you to anonymise patient details as much as possible and check that your patient is satisfied and feels secure before you submit. Their stories are important, however, and unless we tell their story we cannot show that their circumstances need to change.
BMJ Case Reports medical student elective competition—win £500 (deadline 30 April 2016)
Are you travelling somewhere exotic on elective? Write up your adventures and experiences in a global health case report for BMJ Case Reports and you could have the chance of winning a £500 travel bursary.* The winning entry and two runners-up will be published on the journal’s website and be included in a special edition of the print journal.
Read more about the competition and how to submit your cases here: http://bit.ly/ghcasereport. The deadline is 30 April 2016.
Check out our global health case report template (bmj.co/casereporttemplate) and consent procedure (bmj.co/casereportconsent) before you go ahead and write.
*Travel bursary will go towards the cost of attendance at a related medical conference or event.
Correspondence to: firstname.lastname@example.org
Competing interests: SB is editor of BMJ Case Reports.
Provenance and peer review: Commissioned; not externally peer reviewed.
- Commission on Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health. WHO, 2008. www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf.
- Beaglehole R, Bonita R. What is global health? Global Health Action 2010;3:5142.
- Istek Ş. The devastating effects a fire burn in a child. BMJ Case Rep 2015; doi:10.1136/bcr-2014-206663.
- Horton R, Berman P. Case reports in The Lancet: a new narrative. Lancet 2015;385:1277.
- BMJ Case Reports: Instructions for authors. http://casereports.bmj.com/site/about/guidelines.xhtml.
Cite this as: Student BMJ 2015;23:h6108