Clinical evidence from humanitarian settings: the case report and its importance
Authors: Dr Marta Aleksandra Balinska and Joanna Ventikos
Clinical case reports – or descriptions of an individual’s illness and treatment – are probably the oldest form of medical investigation. Before epidemiology emerged as a major health science in the 20th century, case reports (including notes from examinations of patients after their death) were the most common “evidence” on which physicians could draw, beyond their own experience. Today, we are more familiar with medical studies looking at multiple individuals in specific population groups and using statistical analysis to describe what happened to them and to predict what might happen in the future. However, the case report remains a corner stone of medical research and medical education, as a unique tool to identify new or under-reported diseases, record rare events, explore differential diagnosis, and describe hands-on experience in the management of patients. It can also draw attention to an unrecognized public health need or illustrate an ethical dilemma.
Since a case report can be written by individual clinicians and – importantly – does not require a large (if any) research budget, one would think that they would be used extensively in resource-limited settings. Right? Wrong! A review of the literature reveals quickly that there are surprisingly few case reports from developing countries in scientific journals. There are many reasons for this, including: insufficient training in medical writing for clinicians working in humanitarian and resource-limited settings, language issues, loss of patients to follow-up, missing informed consent, or lack of awareness that the case report is a form of medical evidence. Nor should one forget that case reports from low-resource settings can appear irrelevant to journals publishing reports from high-resource settings. Why? Perhaps because journal editors believe that healthcare providers in affluent settings will not be interested in how their peers manage cases in very different circumstances and with very different means.
So what benefits are we missing by not publishing case reports? Well, let’s say an MSF clinician is treating a refugee with a severe and rare dermatological condition. The medical literature tells her she needs to put him on expensive drugs, which are unavailable in the country where she was working. Instead, with very modest means, she develops her own treatment protocol and significantly improves this patient’s symptoms and quality of life. A case report about this patient could be used by other clinicians in low-resource settings to help patients with the same disease, who might otherwise go untreated (or mistreated).
With the aim of helping communities of practice across the world share such examples of clinical innovation and learning, Médecins Sans Frontières (MSF) has initiated the Clinical Case Reporting Project (CCRP). It is based on two pillars: 1) providing MSF clinical staff with the training and tools needed to write rigorous case reports; and 2) a partnership with Oxford University Press to publish peer-reviewed case reports from humanitarian and resource-limited settings in their open access journal, Oxford Medical Case Reports. This new project is not just for medical doctors. It also encourages nurses, midwives, and psychologists to prepare case reports, and to include systematically the patient’s perspective.
We know that the project will take time to gain visibility (especially beyond MSF), but believe it can become self-sustaining and multidimensional, as clinicians working in low-resource settings become aware of this forum and as we begin to partner with other actors in global health. . Our aim is to start filling this important gap in the clinical literature and contribute to building up evidence that can improve quality of care and reduce mortality in low-resource settings.
We’d welcome your help for us to advance with this project. One way you can do so is by participating in our online survey on the value of case reports from humanitarian and low-resource settings:
http://limesurvey.malbela.net/index.php/583483?lang=en
… and please don’t hesitate to contact Marta Balinska, the project coordinator, if you are interested in getting involved in any way: marta.balinska@geneva.msf.org
About the authors:
Marta Balinska has a background in public health and has worked in a variety of settings including academia, national health agencies, the pharmaceutical industry, and humanitarian NGOs. She joined MSF Switzerland in 2015 as an advisor within the Medical Departmentthe The idea for the Clinical Case Reporting Project arose from her investigation into how MSF manages, processes, and optimizes its medical knowledge. It is her conviction that as an important actor in global health, MSF can contribute much precious experience to the clinical evidence base for resource-limited settings.
Joanna Ventikos is a publisher at Oxford University Press (Academic Division), specialising in open access journals and working across all subject areas. She has acquired substantial experience in major aspects of publishing, having held editorial positions at Wiley-Blackwell and Taylor & Francis. She has extensive international experience in project management and publishing and is responsible for the Press’ Oxford Medical Case Reports journal, for which she contributed in establishing a close partnership with MSF, aiming at the publication and dissemination of case reports relevant to low-resource settings.