FROM OTHER JOURNALS
Medical tourism in India
Medical tourism is one sector which has gained tremendous momentum in recent years in India. The author of this commentary looks at the potential impact of medical tourism on the health workforce and health system in India. Besides the definite cost advantage, the presence of a well trained and English speaking work force, a mix of modern and indigenous systems of medicine, and super specialty centres which boast of the best technologies available in the world are some of the factors in favour of India. Along with the corporate sector, the government of India has also responded to the growing sector of medical tourism in India, through the National Health Policy, 2002, and by issuing medical visas for tourists seeking treatment in India.
The author comments on the increasing inequities in the health system with government resources being diverted to the private sector in the form of subsidies to set up expensive technologies which will be used by very few; this is one potential harm that medical tourism can have. The migration of skilled health professionals from the public to the private sector, concerns about the quality of medical care and accreditation of the centres, and the spiralling costs of treatment in private hospitals are some other pitfalls associated with the unregulated growth of the medical tourism sector.
To counter these negatives, the author points out, steps should be taken to regulate the private sector. In addition, investment should be increased in the public health sector by diverting a part of the revenue generated from the trade in private health services to public hospitals. Capacity building of staff in the public sector, ensuring good working conditions to retain them in the public health sector, improving the quality of care delivered in government hospitals and sharing of resources, in the form of money, manpower, infrastructure or technology, are some other steps suggested by the author to improve the public health infrastructure while promoting India as a "global health destination".
Hazarika I. Medical tourism: its potential impact on the health workforce and health systems in India. Health Policy Plan. 2010 Apr;25:248-51.
The state’s role in health in developing countries
International funding agencies, foreign governments and international health agencies contribute significantly to maintain the health services of developing countries. But there is a significant role and responsibility that the state and officials in developing and middle income countries owe towards the healthcare needs of the public in such countries.
The author identifies three crucial responsibilities that countries have towards their people and their health needs. First, there is a need to spend adequate resources so that at least the basic needs of the people are met. The author describes the "substitution effect" in which developing countries cut down their budgetary allocations for health in response to the foreign aid that they are receiving. He cites the examples of countries where foreign aid accounts for more than two thirds of the total expenditure on health. Governance of healthcare is another issue: it must be transparent, true, dedicated, accountable and inclusive of the opinions of all the stakeholders involved. Healthy policies, efficient services and productive use of available resources will result from a good governance system, whereas an inefficient governance system will eventually erode the trust of the public in the system. The author quotes Transparency International which states that health systems in developing and middle income countries are among the most corrupt of government mechanisms. Finally, the author identifies the ethically challenging task of prioritising between competing needs as the third responsibility of the developing state. This task, which may be biased depending on the priorities set by international funding agencies, and skewed by "complex tradeoffs" between competing health needs, is not an easy one. And it may not provide any ethically right answers. But the best chance of arriving at the right decision for developing countries is through an honest and open deliberation which ensures community participation as well.
Gostin LO. What duties do the poor countries have for the health of their own people? Hasting Cent Rep. 2010 Mar-Apr;40(2):9-10.
Sex verification in international sports
Sports gender divisions have always been plagued by controversies. The author cites the example of a South African runner whose sex was called into question after winning an international athletic medal. The author points out that a "clear policy with definitive, consistent, private and precompetititve rulings" is the need of the hour to ensure fairness in gender divided sports and also to protect individual athletes from the danger of their sex being discussed in the open and made into a media circus.
The task before the International Olympics Committee (IOC) and the International Associations of Athletics Federations (IAAF) is not a simple one. While sex refers to the physiological and anatomical features distinguishing males and females, gender refers to the self and social identity of an individual. The issue of sex becomes problematic when an athlete has a disorder of sex development or when that person is a transgender. Male bodies with more androgens have an advantage when it comes to sports that require strength and speed. The author cites several medical conditions which can put an individual at a more advantageous or disadvantageous position, and it becomes tough to decide what the "acceptable" natural advantage is. It is difficult to settle the sex division issue by drawing a line on the functional testosterone level; concerns are raised about the permissible level of error, daily and life time variation and whether or not to allow participants to artificially raise or lower their androgen levels if they happen to have a recognised medical condition.
The author suggests that one possible solution would be to just look at the sportsperson’s gender identity and accept physiological variations among women. However, this suggestion goes against the IOC and IAAF stand that transsexual athletes may play in their post transition gender. The author urges the authorities to come up with a sound policy which will take the science of sex into account but which "isn’t so beholden to that science as to treat athletes as blobs of molecules whose lives and needs end at the finish line".
Dreger A. Sex typing for sport. Hasting Cent Rep. 2010 Mar- Apr;40(2):22-4.
Bioethics, professionalism and TV medical dramas
The visual mass media is a powerful double-edged word in formulating public opinions and beliefs. Erroneous and illusory depictions of medical ethics and professionalism adversely affect public perceptions. At the same time these television dramas and films can be used as an effective tool for educating students on various issues pertaining to bioethics and professionalism. The authors of this article analysed the content of two popular TV shows, Grey’s Anatomy and House MD, covering a total of 50 episodes. They focused on episodes on ethical issues which were classified as "bioethical issues" and those on interpersonal relations which were classified as "professionalism".
The authors came across depictions of many ethical issues. Consent was the most frequently depicted ethical concept. The patient’s refusal of treatment, ethically questionable deviations from standard practices, issues related to access to and availability of healthcare, organ transplantation and human experimentation, were some other ethical issues that came up in the episodes. There was only one episode touching on ethical concerns related to conventional clinical research. Respect amongst physicians and towards patients, sexual misconduct, care and compassion towards patients, integrity and responsibility towards colleagues were some professional issues discussed in the two dramas. The authors point out that these incidents can be used in a teaching setting where students can comment on and discuss the various ethical issues that they might come across in future during their clinical practice.
Czarny M, Faden RR, Sugarman J. Bioethics and professionalism in popular television medical dramas. J Med Ethics. 2010;36:203-6.
Homoeopathic medicine and funding of unscientific remedies
There is increasing uncertainty about the effectiveness of the homoeopathic medicine. In November 2009, the UK Parliament’s Science and Technology Committee heard evidence on homoeopathy. The Medicines and Healthcare Products Regulatory Agency (MHRA) in the UK has licensed homoeopathic treatment. This system of medicine is also promoted by the British Homoeopathic Association and funded by the UK National Health Service (NHS).
The writer of this editorial points out that the basic argument of homoeopaths is that their treatment is as good as placebo. This is a notch below the practice of evidence based medicine. However, homoepathy diverts people from seeking treatment from the traditional allopathic system of medicine, and this could prove costly to patients with serious ailments. Reference is made to the WHO directive which banned homoeopathic treatment for ailments like malaria, TB and HIV. He points out that instead of revealing the placebo nature of the treatment (which would render it totally ineffective), homoeopaths try to gain the patient’s trust by describing whaty they say is the treatment’s scientific basis. This violates the principles of informed consent and autonomy of patients. The author argues that though homoeopathic treatment is cheap,spending NHS money on a treatment system which lacks an evidence base is unethical and inefficient spending of public funds. The author also argues that by sponsoring homoeopathic treatment, the NHS will weaken its own system and the credibility of science and medicine before the public. Supporting a system of medicine which is not evidence based will also erode the credibility of the MHRA as a system that claims to support only evidence-based practices and products. There are also ethical issues in not supporting other complementary therapies which might be more efficient than homoeopathy. The editorial asks the NHS to withdraw funding to homoeopathic medicine and to use the funds for evidence-based medicine. The editor also urges the NHS to increase awareness among the general public about the drawbacks of homoeopathy.
Shaw DM. Homeopathy is where the harm is: five unethical effects of funding unscientific ‘remedies’. J Med Ethics. 2010 Mar;36(3):130-31.
Revamping medical education in India
The recent arrest of the president of the Medical Council of India for bribery is an indication of the level of corruption that has seeped into all levels of medical education in India. Private colleges are willing to pay huge sums as bribes as they stand to gain immensely from the business of medical education. The author explains that though this corruption is an open secret, few steps are taken against the culprits as the regulatory mechanism itself has been compromised. The MCI comprises members nominated by central and state governments as well as members elected by doctors of different states. "Medical politicians" abuse their power and position to make personal profits. The shortage of teaching staff especially in the departments of anatomy, forensic medicine and radiology is exploited by the MCI which then extorts money from private medical colleges for overlooking the deficiency of staff.
The author concludes with some practical suggestions for improving the functioning of colleges as well the MCI. Medical colleges should be allowed to utilise the services of a general surgeon, or an individual qualified in MSc anatomy, in the anatomy department. The shortage of forensic pathologists can be overcome by modifying the pathology postgraduate curriculum. The present government-nominated council which has come to power after the dissolution of the MCI is not the long term answer. To ensure autonomy as well as accountability to the government, the medical fraternity and the public at large, there should be representation from nonmedical groups including lawyers and the general public, which will increase transparency in the functioning of the council.
Thomas G. Regulation of medical education- time for radical change. Econ Polit Wkly. 2010 May 29;XLV(22):13-4.
Conflict of interest in medical journals
Conflict of interest can bias the researcher and can undermine the credibility of the research and the medical journal. The World Association of Medical Editors (WAME) is an organisation with 1,595 members representing 965 journals across 92 countries that looks into matters concerning publication ethics in the field of medical journalism. In 2009 WAME issued an updated policy document, "Conflict of interest in peer reviewed medical journals", which will aid journals in establishing their policies regarding conflict of interest. The WAME statement extends beyond financial conflicts of interest and includes academic interests, personal relationships, institutional beliefs as well as political and religious beliefs as potential reasons for conflicts of interest. WAME does not set a universal standard but encourages journals to make their own policies based on their definitions and recommendations. WAME also urges journals to investigate and take proper action if a conflict of interest surfaces after acceptance or publication of a manuscript. Though it may be impossible to eliminate conflicts of interest, they can be minimised to limit damage to the credibility of the journal and its content. The problem of conflict of interest in journals can be solved to some extent by requiring a full written disclosure statement from the author. Editors may use their discretion once they have this information. The editorial also notes the significance of detecting conflicts of interest of editors and reviewers who are the "gatekeepers of medical journalism and literature". WAME advocates that individual journals develop their own policies and make them accessible to other journals as well.
Conflict of interest in peer reviewed medical journals: the World Association of Medical Editors (WAME) position on a challenging problem. Natl Med J India. 2010;23(2): 65-8.
Breast cancer screening: role of evidence
In November 2009, the US Preventive Services Task Force (USPSTF) published its updated recommendations on breast cancer screening. The new guidelines recommend against routine mammography in women of age 40 to 49 years. After the age of 50, screening should be done routinely for breast cancer.
The 2009 taskforce based its recommendations on a judgement that breast cancer screening was of ""minimal net benefit" compared to the earlier judgement of "moderate to substantial net benefit".
This editorial refers to the journal’s website based survey to assess readers’ response to the recommendation. The respondents included physicians, other healthcare providers and the general public. More than half the healthcare providers who responded stated that their advice to patients regarding breast cancer screening would change based on the new recommendations. However, women from the general public who participated in the survey believed otherwise; more than 70% of the women who responded stated that they were highly unlikely to refrain from doing routine mammograms even when the physician recommended against it.
The editorial states that women should be given correct information about the effectiveness of current breast cancer screening methods. It also explains that the new recommendations are supportive of patients from a medicolegal perspective. They encourage a rational discussion between doctor and patient and provide evidence-based, population-level guidance instead of imposing a universal recommendation on all sections of the population.
In response to the upheaval following the recommendations, the taskforce reexamined its processes and messages and has acknowledged that the new recommendation was communicated poorly to the public and healthcare community. The editorial fears that the taskforce will be sabotaged as its recommendations are unpopular among some constituents. "If the USPSTF sinks in turbulent waters whipped up by emotion, anecdotes, and politics, Americans should mourn its loss."
