DOI: https://doi.org/10.20529/IJME.2015.029
The Fifth National Bioethics Conference (NBC) was co-hosted by St John’s National Academy of Health Sciences (SJNAHS), Bangalore; Society for Community Health Research Awareness and Action (SOCHARA), Bangalore; and Forum for Medical Ethics Society (FMES), Mumbai, which publishes the Indian Journal of Medical Ethics (IJME). The conference was held at the St John’s campus, Bangalore from December 11 to 13, 2014. The theme of the Fifth NBC was “Integrity in medical care, public health, and health research”.
The focus and theme of this conference arose from a recognition of the widespread public perception of corruption in the health sector. Prevailing malpractices have led to a loss of trust and confidence in the health system. This conference aimed to encourage discussion on the role of bioethics as a value base influencing concepts and practice in medical care, public health, and health research. Bioethics must evolve not just as a discipline, but also as a widespread movement that effects change.
The conference was attended by 695 registered participants (including at least 250 students) and more than 50 others who came for specific sessions, including pre-conference events. They included medical professionals, social scientists, academics, bioethicists, counsellors, economists, lawyers, journalists, theologians, community workers, researchers, advocacy organisations, and administrators. Participants came from 14 states in India and 10 countries. The conference was covered in the Indian and the German press as well as through the social media.
Two major pre-conference events were organised on December 10, 2014.
The workshop, which was jointly organised by the departments of Medical Ethics and Medical Education from St John’s and from Christian Medical College (CMC), Vellore, aimed to develop a draft curriculum for learning and teaching ethics in medical colleges; discuss the challenges faced in teaching ethics; network for continued support to facilitate learning and teaching ethics in medical colleges; and develop a resource database to support this process. Participants were from the medical faculty of teaching institutions and included bioethicists and theologians.
This colloquium was organised to evolve action points for health education and research with a gender perspective. The axes of ethics in gender that were discussed included: sex selection and gender ratio; gender issues among adolescents; maternal and reproductive health; domestic violence; and gender issues among women in the health workforce. Participants stressed that women’s empowerment is currently not on the political agenda of the country. Another point of discussion was the lack of sex education, leading the young to imbibe the prevalent social values of commodification of and violence against women. A speaker used the term “obstetric violence” in the context of maternal mortality, deploring the fact that medical students are not taught about gender issues in healthcare, leading to a lack of respect and privacy during childbirth. A participant pointed out that the Bilaspur tragedy, in which 16 women died during sterilisation, was a violation of reproductive health rights resulting from the continued “targeted” approach to family planning. The plight of women subjected to domestic violence and burns, and the need for a comprehensive approach to the issue, was discussed.
The Fifth NBC was inaugurated by the Director of St John’s, Rev Dr Paul Parathazham, renowned sociologist and researcher. In his address he quoted Karl Marx’s – “Ruling ideas of the time are necessarily the ideas of the ruling class,” modifying it to: “Ruling morality of the time is necessarily the morality of the ruling class.” He called for this perspective to be challenged and changed.
In his inaugural address, Dr Amar Jesani traced the origins of the FMES, which co-hosts the NBC and publishes the peer-reviewed and indexed journal IJME. He said the existence of FMES and IJME has shown that “a counter-current can become a reality,” and “integrity becomes visible when it is challenged and tested.”
The inaugural plenary set the tone for the conference through vibrant keynote addresses by Professor Shiv Vishwanathan, Professor, School of Government and Public Policy, OP Jindal Global University and Senior Fellow, Centre for the Study of Developing Societies, Delhi; and Dr Farhat Moazam, Professor and Founding Chairperson, Centre of Biomedical Ethics and Culture of the Sindh Institute of Urology and Transplantation in Karachi, Pakistan.
Professor Vishwanathan, speaking on “Ethics: between event and philosophy,” asserted the need for medical ethics to be rooted within a framework of deeper philosophical, sociological, and cultural understanding; medical ethics journals can be criticised as lacking a philosophy. He proposed that the history of the body be seen as a relation between the body and body politic. The “anatomised, medicalised, and forensic body” as seen during the forced sterilisations of the Emergency, foetal destruction, and in some aspects of medical practice, are linked. Yet they appear distant from violence and suffering. He urged the audience to look deeper into the idea of sickness and the definition of disease, and to understand the language of suffering. There is a need for the patient to be seen as a person of knowledge with a medical imagination and cultural ideas; and for providers to see themselves as tacit constitutionalists listening to the unstated, and to have insights into suffering and healing. He urged the medical and medical ethics community to challenge the corrupt practices of the present leadership of the Medical Council of India (MCI) and the World Medical Council and to expose the current doctor–politician nexus.
In her keynote address on “The dualism of biomedicine: a Cartesian heritage,” Professor Farhat Moazam took the audience through the history of the evolution of modern medicine, the birth of the “scientific gaze” and of how the Cartesian philosophy brought about a mind–body dualism leading to medicalisation of the human body and the understanding of disease. She asked whether it is possible to humanise medicine that is dehumanised. She brought out the differences between the physician’s world as one working with “objective reality” and the patient’s world of “subjective reality”. She questioned the myth of an “autonomous”, “self-governing” individual and the concept of “informed consent” as an answer for everything in bioethics. She underlined the fact that bioethics is becoming a specialisation rather than a way of doing things, and developing and understanding relationships between those who suffer and healers. In her concluding remarks, she said: “We fix organs and parts, but the human body and human person are lost.”
At the conclusion of the first plenary, the NBC felicitated Professor Farhat Moazam and Professor MV Sankaran Valiathan for their lifetime contribution to the field of medical ethics and bioethics.
Second plenary. The speakers at the second plenary were Dr Anura Kurpad, Professor of Physiology, SJNAMS and Dr Sanjay Nagral, department of Surgical Gastroenterology, Jaslok Hospital and Research Centre, Mumbai.
Speaking on “Ethics as an essential element in evidence and health policy,” Dr Kurpadquestioned the current cereal-centric food subsidies, and spoke of the difficulty in putting nutrition on the agenda of an agriculture that is oriented to commercial crops. He also pointed out that unrealistic targets were being set in public policies, calling for concrete practical ethical frameworks to guide public health programmes. He ended his speech with the declaration: “Hunger is the most political disease.”
Speaking on the “Role of professional councils and healthcare regulators in upholding integrity of medical practice,” Dr Nagral differentiated between internal regulations through instruments such as the MCI, the Indian Medical Association, and institutional review boards (IRBs), and external regulation through mechanisms set up by the state. Citing recent high-profile cases, he said that while recent trends have been encouraging, some honest medical practitioners have ceded space to the corrupt. He stressed the importance of role models for practice of ethics in medical colleges. Regulation can act as reference points for the honest; generate a fear of punitive action and be a rallying point for civil society advocacy.
Third plenary. The third plenary featured addresses by Dr Ravi Narayan, Senior Community Health Consultant, SOCHARA; Ms NB Sarojini, Founder, SAMA Resource Group for Women and Health, Delhi; and Dr Anand Zachariah, Professor of Medicine, CMC, Vellore.
Dr Narayan, speaking on “Integrity in public health: systemic challenges and policy paradigms,” pointed to the ethical issues forewarned in reports such as the Indian Council of Medical Research (ICMR)/Indian Council of Social Science Research (ICSSR) report, and the Karnataka Task Force Report on Health in 2002. He quoted Atul Gawande’s book Better to highlight actions that could be taken at the individual level, and drew the audience’s attention to the People’s Health Charter of the People’s Health Movement and its expression of collective action. He pointed to positive developments such as the Masters of Public Health (MPH) curriculum developed for the Rajiv Gandhi University of Health Sciences, which he described as “mainstreaming the alternative”.He distinguished between the “activist professional” and the “professional activist” and urged the medical fraternity to choose the former.
Ms Sarojini, speaking on “Integrity in access to public health services with a specific focus on gender and reproductive health,” posed fundamental questions such as: Are women aware of the various programmes available to them? Are programme benefits reaching them? Which social groups have or lack access? What of quality and privacy? She pointed out that only the public health system can provide equity in healthcare, and it must be strengthened; but it has been neglected, pushing women towards private services. The Bilaspur tragedy was part of population control fundamentalism. Right wing politics and economics have come together at the Union level in the country, and we risk losing ground that has been won with much struggle. She referred to emerging positive trends, such as the Supreme Court’s recognition of the third gender, and the setting up of the National Legal Services Authority.
Dr Zachariah, speaking on “Crisis in education of health: ethical challenges in upholding scientific and moral integrity,” took up the case of type 2 diabetes. He started with the changed representation of diabetes. Earlier it was diagnosed by the Oslerian symptom base of polyuria, polydipsia, and polyphagia. Today it is done through epidemiological and statistical values with the adoption of new threshold criteria which over-medicalise pre-diabetes. According to the new criteria, 50% of adults are pre-diabetic.
Dr Zachariah flagged the structural problems affecting the food habits of the urban poor that have resulted in an epidemic of chronic conditions such as diabetes. There is a need to map development vectors against the epidemiological risk factors for diabetes. He concluded with the comment that computer-based learning and diagnostics have replaced the old method of clinical teaching between a mentor and mentee, leading to a decline in integrity in practice.
The fourth plenary had three speakers: Dr Peush Sahni, Professor, department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences (AIIMS) and Editor, The National Medical Journal of India; Dr Roli Mathur, Scientist D, ICMR; and Dr Nandini Kumar, former Deputy Director General Sr Grade (ICMR); Dr TMA Pai Endowment Chair, Manipal University and Adjunct Professor, Kasturba Medical College, Manipal.
Dr Sahni, speaking on “Scientific misconduct,” said that ethics in science has become a major concern with increased instances of scientific misconduct. He discussed the requirements of research ethics that need to be considered, such as: privacy and confidentiality of patients and their informed consent; ethics approval; design of and justification for studies; and control of data for sponsored studies, and registering clinical trials. He also spoke on issues in publication ethics such as redundant publication, the need for peer review, and criteria for authorship.
Dr Mathur, speaking on “Conflicts of interest,” discussed various types of conflicts of interest: financial and non-financial; institutional and individual; perceived and real. When publishing research studies, disclosure of the sources of funding, sponsorships, and possible conflicts of interest is required as is an explanation of the methodology and how the ethical guidelines were followed. She drew the attention of the audience to the Vancouver guidelines for authorship as well the need to acknowledge the contribution of people who would not satisfy the criteria for authorship. She enumerated other types of misconduct such as recklessness and negligence; malicious accusations; violations of due process; reprisals against whistleblowers; and cover-up of misconduct.
Dr Kumar, speaking on “Research ethics guidelines and regulations for upholding the integrity of research,” highlighted the need for the scientific community in India to take the issue of misconduct seriously. She pointed out that cases of serious misconduct by prominent scientists in India had been treated lightly.
The fifth plenary was an “International symposium on corruption in healthcare and medicine.” The speakers were Dr Sujatha Rao, former Union Principal Secretary, Health, India, IAS (retd); and Dr Peter Mansfield, General Practitioner, Australia and Founder of Healthyscepticism.org. The session started with the launch of the fourth Global Health Watch report, produced by the People’s Health Movement, which provides critical analyses of health-related issues and policies (available on www.phmovement.org).
Dr Rao, speaking on “Corruption in healthcare,” said that after the revenue and police departments, the health department is seen as the most corrupt. She referred to the siphoning off of the funds of the National Rural Health Mission in Uttar Pradesh for which the State Health Secretary was sent to jail and the Health Minister obliged to resign. She criticised the regulators’ abdication of their responsibility to regulate the health system and lamented the politicisation of a professional body, the MCI. She advocated for a strong public health law that governs both the public and private sectors in medical care.
Dr Mansfield, talking about “Temptation and biases in the context of the pharmaceutical industry and the links with the medical profession and ethical medical practice,”, distinguished between intended errors or temptations and unintended errors or unintended biases. He said systems are to be blamed rather than individuals for the malaise afflicting healthcare.
The final plenary titled “Just a gift?” highlighted the influence of pharmaceutical marketing activities on prescription behaviour. DrChristiane Fischer of MEZIS (“No free lunch”), Germany reported that there were 50,000 doctors and 15 million pharmaceutical company representatives in Germany. However, she also argued that one must go beyond demonising the pharmaceutical industry and start engaging with members from the industry – getting them to the table, and holding them accountable to a code of conduct.
These were organised under four broad themes: research ethics; clinical ethics; public health ethics; and cross-cutting themes. An outline of these discussions, according to the theme, is given below:
I RESEARCH ETHICS
Informed consent: A session on integrity of informed consent looked at the ability of women seeking maternal or child health services in public hospitals in India to make decisions about research participation, and found them vulnerable to coercion.
Authorship: The issues of plagiarism, conflict of interest, publication bias and authorship were discussed. The category of authorship was found to be frequently abused among Indians. “Honorary authors” were the heads of departments and seniors. The most common form of contribution cited was proof reading and statistical analysis. Good authorship practices were highlighted through discussion of two case studies of unethical authorship.
Conflict of interest: A session discussed what constitutes conflicts of interest and analysed the four A’s of managing these conflicts, namely, awareness, assessment, acknowledgement, and action. Speakers and participants discussed how the physician–pharmaceutical industry nexus influences prescribing practices; the dialectical relationship between governmental and self-regulation; the efficacy of self-regulation and governmental control; and intellectual property rights and their impact on access to medicines. The suggestions that emerged from this session included bringing these issues before college students; the need for neutral institutions which undertake research; contributions by pharmaceutical companies to set up a fund that helps finance such bodies; and the ethical challenges that could arise.
Institutional ethics committees (IECs): A study of 22 IECs in Mangalore revealed that only 26% were registered and they did not have representation from the various categories required. It was felt that IEC members needed more training and IECs should meet the criteria set by the Forum for Ethical Review Committees in the Asian and Western Pacific Region-Association for Healthcare Accreditation Professionals (FERCAP/AHAP) for accreditation.
Knowledge, attitudes, and practice in research: A study on knowledge, attitudes, and practice of research ethics and clinical trials revealed that all those interviewed could report at least one instance of unethical research practice, such as inadequately explained consent documents; forged study samples; adjusted data, and offers of guest authorship. Suggestions that emerged from the session included organising classes for research methodology in postgraduate teaching programmes; arranging refresher courses; and orienting and sensitising researchers about patients’ concerns.
Human embryonic stem cell research: The ethical dilemmas that human embryonic stem cell research presents were debated. These included scientists’ preference for embryonic to adult stem cells; destruction of extra embryos that are produced during in-vitro fertilisation (IVF); and the resulting dilemma on when life begins. The argument that IVF embryos which are orphaned would die and hence could be used for research was contested by some.
Audio-visual (AV) recordings of informed consent: The merits of AV recordings of the informed consent process were debated in a preliminary study of researchers’ experiences with AV recordings. The study found that, overall, both researchers and patients responded positively to this recent requirement.
II CLINICAL ETHICS
Ethics of care: The dilemmas of confidentiality, boundaries, competence, and emotional experiences for health professionals were brought out. There was a consensus that professionalism should not override humanitarian concerns. The dilemma was raised in the case of nurses in palliative care: patients may prefer to be cared for at home or in the hospice, and sometimes refuse treatment, but their families may be unwilling to accept the financial or care-giving burden. More effective communication with family members was the solution offered. Another question raised was: what does death mean to health professionals? The need for a holistic support system was highlighted. There was also an urgent need for a fundamental shift from the industrialisation and the principle of “return on investment” driving healthcare. There is a need to impart values among medical graduates as change cannot come overnight.
Ethics of disclosure: The ethical dilemmas arising while educating family members of a patient with mental illness were discussed. There have been cases where the mental illness of the bride is hidden before marriage, for fear of stigma. Some barriers identified were limited precedence, confidentiality, and trust. The dilemma of who benefits, science or the patient, was discussed; if the patient does not benefit should this be disclosed? In a workshop on stored samples of stem cells it was noted that ethical aspects on this subject are still poorly defined. The UNESCO declaration that the “owner should share the benefit” was mentioned. Ethical issues of ownership of body tissue; custodianship; transfer; commercialisation were discussed.
Over-diagnosis: The harms of unnecessary treatment, needless suffering and high costs resulting from over-diagnosis were highlighted. Various groups are responsible for the widespread practice of over-diagnosis, including doctors, patients, the healthcare industry, and the media; so the problem requires a response at multiple levels. Possible actions discussed included evolving monitoring mechanisms; and looking at recent experiments such as the AIIMS’ crackdown on over-diagnosis and unnecessary tests through the Society for Less Investigative Medicine (SLIM) initiative.
Clinical ethics committees (CECs): The different roles of IRB and CEC were discussed; the former are responsible for review of research proposals and the latter for clinical ethics. It was noted that doctors also find it burdensome to make personal decisions for patients. CECs can help them make difficult decisions.
The need for boundaries: The workshop explored the meaning and need for boundaries in the professional–patient relationship through discussions and use of film clips. The role of context in differentiating an acceptable “boundary crossing” from an exploitative “boundary violation” was discussed. The harm that occurs due to both non-sexual and sexual boundary violations was emphasised. Various scenarios were discussed to enable health professionals to prevent or deal with boundary issues in clinical practice. It was pointed out that boundaries in clinical care ensure a safe framework for a warm and empathic health professional–patient relationship.
III PUBLIC HEALTH ETHICS
One question is: how does public health ethics inform the health crisis perpetrated by certain industries such as mining and the allied forms of development? It is useful to refer to the values underpinning public health ethics such as equity, solidarity, and social justice. This is illustrated in the discussions on direct transfers, screening, polio eradication, and occupational health (OH).
Financial inclusion: Financial inclusion is an ethical imperative for various benefits to reach the marginalised. However, most women who qualify for benefits through various social programmes do not have a bank account in their names, and are deprived of these benefits.
Screening: There is often no value in dental screening, as patients generally already know their dental condition. Private medical colleges often use screenings to look for cases, leaving patients with large bills. Further, dental camps do not conduct proper follow-up. There are ethical implications in screening technologies, such as ultrasonography in pregnancy and breast cancer screening. There is also concern that the cost burden of screening should not fall on patients.
Immunisation campaigns: The ethics of the polio eradication campaign was explored through data from newspapers, archives, and interviews. The technical and anthropological dimensions of the programme were presented. The challenges of implementing the programme were discussed: many people perceive the drops as being harmful; other public health interventions are neglected, and the campaign ignores the other determinants of health.
Occupational health (OH): The dual loyalties of OH physicians were presented: their obligation is to protect workers’ health but they are paid by the management. It was highlighted that the Code of OH Ethics has expanded the definition of OH to include health conditions of communities surrounding the industry. Some issues discussed pertaining to OH were:
IV CROSS-CUTTING THEMES
WHO session on integrity and corruption in healthcare: Transparency and integrity in the provision of healthcare and in the pharmaceutical sector are the key concepts in public health ethics. Corruption decreases the funds available for public health programmes and medicines, and unethical practices have a direct impact on health outcomes. Thus, tackling these practices is of crucial importance.
This session explored the concepts and modalities of transparency and integrity, and how they can lead to improved efficiency in healthcare. It provided an overview of WHO’s activities, as well as perspectives from Singapore, India, and Thailand illustrating the relevance of the issues at the country level, and recommended best practices on how to address corruption in the health sector. The experience of Thailand and Singapore in promoting good governance for medicine (GGM) at a national level was shared with outcomes and impacts after introduction of the WHO GGM and its operating framework. In Thailand this included the development of policy guidelines; national networking; an information database; and dissemination of ethical practice information and assessment. These steps resulted in a better drug procurement and management system; mechanisms for transparency; and participatory and consultative processes. The case of Singapore where physicians both prescribe and dispense drugs was highlighted. The laws place the onus on physicians to follow ethical practices. The fact that Singapore uses a multi-pronged approach to drug regulation was also highlighted. It was hoped that India could move from micro- and state-level initiatives to a larger national-level approach in this regard.
Corruption in healthcare research: The discussion covered the practice of payments for drug approval, and the existence of a plethora of regulations and cumbersome procedures, both conducive to corruption. One point of discussion was whether corruption was more widely practised in the AYUSH or allopathic streams; and in the private or public sectors. The need for students to have role models of ethical practice was highlighted. Corrupt practices will not vanish through individual change alone; there must be wider policy and systemic changes. It was argued that globalisation is resulting in an accentuation of the profit motive, leading to human rights violations and unethical practices. The ethics of the revolving door of regulation was discussed. Finally, while corruption in the public health system gets highlighted more frequently, there are more corrupt practices in the private sector.
One suggestion that emerged from a workshop on how to prevent corruption in healthcare was to start teaching ethics to young doctors. Other suggestions were to pursue legal activism, implement monitoring systems, encourage publicity on the subject, and set up a people’s forum for tackling issues in healthcare.
Ethics and gender: A presentation on surrogacy and assisted reproductive technologiesnoted thatsurrogates were vulnerable at many levels: gender, class, and caste. Another presentation on sexual violence looked at issues of confidentiality and autonomy of the survivor; the dilemma of the counsellor who is required to report violence to the authorities; and the physical and mental health implications of sexual violence. Such issues must be addressed in the Protection of Women against Domestic Violence Act. Also expressed was the need for addressing the multiple pathways of perpetration of domestic violence; and for strengthening the healthcare system’s responses to it.
Ethics of digital media: In a workshop on the ethics of digital media, various scenarios were put before the participants in order to identify several grey areas and propose steps for ethical decision-making here. Another workshop dealt with how the medium of film can be a powerful teaching tool for bioethics even in resource-poor settings. The workshop facilitators’ experiences highlighted the array of bioethical themes which can be addressed through this medium.
This session saw several posters being displayed to an active and appreciative audience. A wide range of themes were covered; these included:
A unique feature of the conference was the parallel arts festival organised by the Division of Health and Humanities, St John’s Research Institute, together with “Empathize now!” a not-for-profitorganisation that aims to enhance empathy in all walks of life. In addition to the films screened during the conference, there were plays specially developed for the NBC enacted around the theme of empathy. Two medical students curated an exhibition of newspaper cuttings around the theme of integrity in the health profession, aptly named “Heal thyself”. An exhibition by Francoise Bosteels of more than 100 hand-made dolls depicted the life of the common person, particularly with respect to healthcare.
In the concluding session, Dr Sunita Simon Kurpad from SJNAHS; Dr Anant Bhan from FMES; and Mr Prasanna Saligram from SOCHARA presented a summary based on the rapporteurs’ notes. They highlighted the key issues, messages, and action points that emerged during the plenary sessions, paper presentations, and workshops. Dr Thelma Narayan from SOCHARA and Dr GD Ravindran from SJNAHS reflected on future action. Dr Amar Jesani noted that this was the biggest bioethics conference held in India, and was proof of the interest in and commitment to bioethics. Dr Thelma Narayan mentioned the need for further work around social science and public health ethics and hoped that a Bangalore Bioethics Forum would emerge from this NBC. Based on the workshop organised by WHO, she saw the possibility of setting up of a high-level National Bioethics Commission as has been done in other countries, similar to the National Human Rights Commission and the National Commission for Women. Dr Christiane Fischer observed that corruption was a global problem and called for the creation of “ethical medicine” as a counter to “unjust medicine”. Dr GD Ravindran acknowledged the efforts of the many organisations which made the conference a success. A lot of voluntary work had gone into both the preparation and the conduct of the Fifth NBC and the effort of every volunteer and participant was appreciated.
Donor partners who provided solidarity and support for the Fifth NBC were thanked. These include:ICMR, Delhi; MCI, Delhi; Sir Ratan Tata Trust (for participation of alumni and fellows of the SOCHARA CHLP); Sudha Memorial Trust, Bengaluru, India; Bread for the World, Germany; Misereor, Germany; David and Lucille Packard Foundation, USA; Open Society Foundation, USA; and Wellcome Trust, UK.
We gratefully acknowledge the painstaking efforts of the rapporteurs who sat through the sessions, took notes and sent in their observations in a timely manner without which it would not have been possible to capture the essence of the vibrant conference that unfolded over four days. The rapporteurs were mainly drawn from among the students of the Masters in Health Administration of St John’s Medical College and from the fellows, interns and staff of SOCHARA. The student rapporteurs from the Health Administration Department of St John’s Medical College were: Sr Shobhashini, Sr Tessme, Sr Alphonsa, Sr Archana, Fr Biju, Fr Arul, Fr Shijo, Fr Anthony, Ms Ayeesha, Ms Chaithra, and Ms Sandra Travasso.
The rapporteurs from SOCHARA were: Ms Sharanya Thanapathy, Ms Anusha Purushottam, Dr Deepak Kumaraswamy, Ms Jyothilakshmi, Ms Sudha Nagavarapu, Mr Sabu George, Dr Adithya Pradyumna, Ms Janelle De Sa Fernandes, Ms Bharti Sahu, Ms Akanksha Reddy, Ms Samantha Lobo, and Dr Rahul ASGR.
Note: The full Conference Report is available at: www.ijme.in