Laws on occupational health

Occupational health and safety in the informal work sector has always been a low priority for policy makers and industrialists alike in India. Not too long ago, in Mayapuri near Delhi, radiation exposure at a scrap dealer’s shop led to the death of one worker, and serious injury to others. This incident happened to catch the attention of the media and became widely publicised. However, in such cases, very often, the focus is on monitoring mechanisms and regulations; little is done to protect workers working in polluted conditions. This commentary expresses concern over the proposed revision of the Civil Nuclear Liberty Bill without having protective legislation and social security measures for workers in place. The writers note that existing laws are ineffective in providing protection and implementing welfare measures for informal sector workers in this case. The health workforce is also not trained to deal with cases of radiation exposure; it is also often ill equipped to deal with industrial and natural disasters.

What has to be kept in mind while formulating policies is that informal sector workers are the poorest, most vulnerable and at the lowest rung in an industrial setting. Ensuring proper healthcare to survivors of such accidents, and providing reliable social security measures as a right, and not as charity, is the least that should be done in case of a mishap which should have never been allowed to happen.

Remesh B P, Vinod P C. Radiation incident in Mayapuri: disquieting signals to labour. Econ Polit Wkly. 2010 Jul 24; 45 (30):16-8.

Reviving biomedical journals in India

Indian doctors, researchers and scientists are known for their excellence, in India as well as abroad. Yet, it is an established fact that many of the biomedical journals published in India fail to reach international standards. India has around 600 biomedical/life science journals, of which only 39 are indexed in the database PubMed. A majority of Indian journals are not available to a global audience and do not have any impact factor. As these journals are not represented in global databases, the results and findings of good research published in these journals fail to reach a wider audience, defeating the main purpose of publication of research. Even after the introduction of the internet and web-based manuscript management systems, editors of Indian journals still have to grapple with a number of issues. Getting their journal indexed, getting authors to write, and then retaining those authors amidst tough competition, are major hurdles for editors; so too the efforts that have to be put in to tackle plagiarism and the abuse of authorship.

The second National Assembly of Medical Editors has identified the key issues that need to be resolved to improve the standards of Indian medical journals. The primary issue is the choice of the editor for the journal. The authors of this commentary stress the importance of proper training of editors of medical journals. The Indian Council of Medical Research has set up two databases to improve the visibility of those Indian journals not covered in international databases. An organised and sustained effort is needed to revive Indian biomedical journals while increasing the scientific rigour of research conducted by Indian researchers.

Satyanarayana K, Sharma A. Biomedical journals in India- some critical concerns. Indian J Med Res. 2010 Aug;132:119-22.

Public health research funding: whose interest is paramount?

A consortium of five leading companies producing dietary goods has entered into a partnership with the Biotechnology and Biological Sciences Research Council in the United Kingdom to form the Diet and Health Research Industry Club (DRINC). One stated goal of DRINC, whose research scope is set by a steering group dominated by industrialists, is “to develop products that deliver enhanced health benefits for consumers”. However, this organisation’s research has drawn criticism since it is associated with the very companies producing nutritional food products. The organisation’s research helps these companies to come up with “profitable products” which are lent credibility by their association with scientific councils. Even if such products are nutritionally enhanced, these niche “functional foods” are hardly affordable for low income groups most affected by nutritional deficiencies. This kind of research backed by commercial funding may also bias research findings in favour of the funders. The commentators also argue that such research will enable food companies whose products are “calorie-rich and nutrient poor” to be viewed as a part of the solution rather than being considered as the problem itself. They also point out that despite making a relatively small contribution to the research fund, these companies get a say in the research. This casts a shadow over the relative benefits to the scientific council from the alliance. On the other hand, the limited funding could also restrict the influence of such companies on the decisions taken, and their participation in such research might encourage these companies to give more importance to population health. However, it is important to remember and recognise that public money should be used for the kind of research which will directly benefit a wider population, to ensure it is not influenced by any vested interests.

Knai C, Gilmore A, Lock K, McKee M. Public health research funding – independence is important. Lancet. 2010 Jul 10;376;75-7.

Time to resuscitate medical education in India

The writer of this commentary has exposed the gloomy reality of the medical education sector in India. In the name of correcting the imbalanced doctor-patient ratio in the country, more medical colleges are being opened. But 70% of these colleges have been sanctioned in the private sector, and with a skewed geographical distribution. The author points out that Puduchery with a population of 9,00,000 has seven private medical colleges; clearly, sanctions are given without appraising the needs of the population. High capitation fees charged by these colleges put the financial capabilities of the prospective student in the driving seat, whereas those with talent may opt out of such a costly educational experience. The author also expresses his concern about the lack of research in Indian medical colleges and about the acute shortage of teaching staff in medical colleges. He holds the Medical Council of India (MCI) largely responsible for the fact that few doctors are interested in pursuing research: it does not to give any weight to the research experience of doctors during recruitment or promotion. The government policy aiming to reduce the requirement of teaching staff, rather than to increase their availability, is also criticised. The author laments the declining quality of education; students get inadequate clinical experience, with bed occupancy rates of less than 50% in many private institutions. The staff in various medical colleges are also not trained well in modern methods of teaching and little effort is put in to the capacity building process. He also questions the role of the government and courts in permitting new medical colleges to be set up. The MCI’s inability to ensure availability of teaching staff and of clinical and other logistical requirements is identified as its major failure. The author suggests that the MCI’s role should be transformed from that of being merely a “head counting organization” to an organisation with a clear vision for improvement of the quality of medical education and greater involvement in policy making to revamp the sector.

Ananthakrishnan N. Medical education in India- is it still possible to reverse the downhill trend? Natl Med J India. 2010;23(3)156-60.

Ghost writing: the new plagiarism?

This article looks at the case of medical ghost writing and states that it is to be likened to plagiarism. “Medical ghost writing” is the process by which pharmaceutical companies get reputed academic physicians and researchers to sign on as authors for medical articles which are subsequently published in medical journals. “Honorary” authors are paid for taking authorship of these articles and scientific credibility is imparted to these articles which are often drafted in favour of the pharmaceutical product of the company. The writer argues that this ghost writing amounts to plagiarism, and that up to 40% of articles on a drug during the marketing phase are written by a medical education or communications company, and later endorsed by paid academics or researchers. In this process, the reporting of serious adverse reactions, side effects and other flaws of the drug are either underplayed or left out.

The writer argues that ghost writing violates the rules of authorship and is equivalent to plagiarism, as the credit for authorship is dishonestly attributed to people who are not actually involved in the drafting of the article. These honorary authors do not have access to raw data and are not even completely aware of the drug or product that they are endorsing through an article carrying their name. The writer suggests many steps to tackle medical ghost writing: implementation of guarantor policies by journals, sanctions against companies indulging in ghost writing, and regulation of biomedical companies, and of researchers who write for the pharmaceutical industry in return for monetary benefits. It is pointed out that declaring conflicts of interest, and the process of peer review, may not be sufficient to bring out the biases in the document. The writer refutes the argument that scientists will endorse an article only if it is found to be scientifically credible; many scientists have been associated with seriously flawed articles that were ghost written for them by the pharmaceutical industry. The writer concludes: “the best way to avoid bias from ghostwriting is to fight ghost writing directly.”

Anekwe TD. Profits and plagiarism- the case of medical ghost writing. Bioethics. 2010;24(6):267-72.

Euthanasia in the context of suicide attempts

The writer of this article looks at suicide attempts and subsequent treatment refusals. Refusal of life-sustaining treatment by competent patients, and through advance directives in the case of patients unable to comprehend and make informed medical choices, are both considered legal in the UK. But there is confusion regarding the correct steps to be taken in case of refusal of treatment after a suicide attempt, either direct refusal or refusal through an advance directive. The author presents the case of a patient who had attempted suicide a number of times and was saved by the timely intervention of doctors. However, after the final suicide attempt she produced a document refusing treatment on admission to the hospital which was honoured by the hospital staff, subsequent to which the patient died. The authorities after conducting an enquiry decided that the hospital acted lawfully by abiding by the patient’s wishes.

The author quotes a United States Supreme Court judgment in which the court ruling clearly states that patients have a constitutional right to refuse life-sustaining treatment, but not a right to physician-assisted suicide. Even though the doctors in this case had acted respecting the wishes of the patient, in the US, the court would have taken a different stand, permitting life-saving treatment against the patient’s wishes. The author explains why suicide attempts by physically ill people and their subsequent refusals of treatment are treated differently from those of a physically strong person. Intervention in such cases may also result in a sustained need for life saving interventions. The author reminds us of the difficult choice with which healthcare professionals and authorities are often confronted. “At what point would imposed treatment begin to violate the patient’s right to refuse?”

Dresser R. Suicide attempts and treatment refusals. Hastings Cent Rep. 2010 May- Jun:10-11.

Research on stored biological samples

In their perspective in the New England Journal of Medicine, the authors analyse the use of stored biological samples for research. The Arizona State University in the United States conducted a study among the Havasupai Indian tribe in 1990. While the informed consent form vaguely stated that the study dealt with behavioural/ medical disorders, the study was projected to the community leaders as a diabetes study. The tissue samples that were collected were shared with other researchers and used in unrelated studies, some of which had effects that could lead to stigmatisation of the tribe or that could undermine the beliefs of the tribal people about their origins. The university finally settled the issue by offering monetary compensation and by formally apologising to the tribe.

Further research can be conducted on biologic samples after obtaining new informed consent only when the samples cannot be traced back to the original participants; when there is minimal risk involved, when seeking new informed consent will be impractical and if pertinent information can be given to the participant if required. Blanket consent is contested with the argument that consent given without fully knowing the nature and risk of future studies is not informed consent. It has been argued that samples can be coded and data anonymised, minimising the risk for the original participants. This argument however reduces the concerns of study participants to one simply of risk. The authors argue that more than the question of risk, participants have the right to decide what the samples taken from their body will be used for. Studies show that even though the majority of participants are satisfied with generalised permission while participating in studies, a significant number of people feel that they should have control over specimens taken from them, and some role in choosing the studies with which they can be associated. The authors opine that tiered consent, in which participants are given the freedom to give blanket consent or consent only for specific uses, is the best way to address this issue. They feel that the Havasupai case, even if it does not have legal standing, will encourage researchers and institutions to approach the issue of using stored biologic samples for research with more respect and caution.

Mello M M, Wolf L E. The Havasupai Indian tribe case- lessons for research involving stored biologic samples. N Engl J Med. 2010 Jul 15;363(3):204-7.
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