World Medical Association demonstrates complete lack of judgment

The World Medical Association (WMA), the international organisation representing the world's doctors, has a long-standing tradition of issuing guidelines on everything from conflict of interest, to dual loyalties, standards of care in clinical research and other such issues. Many of these documents are quite sensible actually, and by virtue of the WMA's claim to represent the world's doctors, carry some moral weight.

Recently though the organization completely shot itself in the foot. It elected Ketan Desai, the
president of the Medical Council of India as its President elect. Well, here's bits and piece from the British Medical Journal about this lovely medical professional that makes you wonder whether he's such a good choice... - you might want to keep in mind that the current allegation are just that, allegations. However, the incoming President of the WMA was found guilty by the High Court in Delhi of corruption charges and abuse of power in 2001. Obviously the good doc is a wily operator, how else would he have managed to sneak back into positions of power in the medical profession in India. You might want to check his CV that's kindly on display at the WMA website (note the breaks in appointments to regulatory medical bodies in India that he held in 2001, when he was found guilty of corruption and abuse of power by the Delhi High Court, only picking up a few years later and straight going back for power). Anyhow, that's for India to resolve.

Published 29 April 2010, doi:10.1136/bmj.c2355

Cite this as: BMJ 2010;340:c2355

Top education regulator in India is arrested on bribery allegations

Ganapati Mudur

India’s Central Bureau of Investigation has arrested Ketan Desai, the president of the Medical Council of India, on allegations of bribery in a fresh case that threatens to sully the image of the country’s top agency involved in regulating medical education. Dr Desai is also president elect of the World Medical Association. (Emphasis as in BMJ)

Investigators said last week that Dr Desai had sought 20 million rupees (£296 000; €350 000; $450 000) as a bribe from a private medical college in the northern Indian town of Patiala for approving admissions of students in the college for the academic year 2010-11. The council has the responsibility of inspecting and approving colleges.

See also:
prior BMJ reporting:

BMJ VOLUME 323 15 DECEMBER 2001

Head of the Medical Council of India removed for corruption

Rohit Sharma Mumbai

The High Court in Delhi has ordered that Dr Ketan Desai, the president of the Medical Council of India, be removed from his post after it found him guilty of corrupt practices and abuse of power.

Besides heading the council, which regulates the medical profession in India, Dr Desai also heads the Indian Medical Association, which represents India’s doctors.

Minutes of the council meetings showed that all critical decisions were concentrated in Dr Desai’s hands. Dr Bhalla presented details from an income tax raid at Dr Desai’s house last year, which showed unexplained receipt of 6.5 million rupees (£95 000; $136 000) via bank drafts in the names of his wife, daughters, and himself from several people in Delhi.

AMA investigates JAMA Editors' actions

The Wall Street Journal reports today that the American Medical Association, the owner of the Journal of the American Medical Association (JAMA), has ordered its oversight committee to investigate claims that the journal's editors effectively bullied a scientist critical of a study it published. Read more about the background of the matter here and here.

Medical journal primadonnas - the end (not)

I have reported a short while ago (you might want to re-read this before continuing this blog posting) how editorial staff at the Journal of the American Medical Association (JAMA) seemingly bullied Dr Leo after he disclosed in the British Medical Journal (BMJ) an undisclosed conflict of interest of authors of a study JAMA published.

Here now, without further ado, the end of the saga. It's been reported on the websites of the WSJ, JAMAs as well as Dr Leo's. My analysis will make use of content (analysis) provided by subscribers to a bioethics discussion list hosted by the Medical College of Wisconsin.

JAMA's editors have not exactly helped their case. They effectively admit contacting Leo's Dean to complain about his conduct (ie publishing his conflict of interest allegations - 5 months after bringing them to the attention of JAMA's editorial staff) on the BMJ website. They deny having bullied the Dean as well as Leo. However, the Dean confirmed that the gist of the JAMA editors' complaint about Leo contained a threat to the school. Here's an excerpt from said bioethics discussion list: '"In an interview Friday, Dean Ray Stowers said Dr. DeAngelis “flat out” threatened him and attempted to bully him during the conversation. The telephone call was followed by an email exchange. In a March 11 email, Dr. DeAngelis wrote to Dr. Stowers: “As I’ve already expressed to you, I don’t want to make trouble for your school, but I cannot allow Jonathan Leo to continue to seek media coverage without my responding. I trust you have already or soon will speak with him and alert me to what I should expect.” Dr. Stowers responded the next day by saying he couldn’t find any fault in Dr. Leo’s actions and pressed JAMA editors for more specifics on what they believed was wrong with Dr. Leo’s writing or actions. “I think this can be worked out without your continued threats to our institution which are not appreciated and I believe to be below the dignity of both you and JAMA,” he wrote. Dr. Stowers says he has not heard from JAMA since sending that email.'

The JAMA editorial suggests, mistakenly, that Leo was under confidentiality related obligations not to publish his letter to the BMJ until after JAMA had completed its investigation. It's entirely unclear why this should be the case. Leo is perfectly entitled to publish anywhere (as he did) allegations of conflict of interest. After all, everything he reported is a matter of public record (accordingly there were plenty of others who would have been witness to the conflict of interest). What is particularly amusing, perhaps, is that the journal objecting to Leo blowing the whistle on the conflict of interest it omitted to report, had not hesitation to blow the whistle on him (by calling his superior, the Dean of the school). Obviously, one standard for authors, another for editors...

JAMA claims in its editorial that Leo's disclosure of his allegations would hamper its ability to undertake its own investigation. As it happens, however, according to JAMA's own reported timeline, it actually completed its investigation some time before Leo's letter in the BMJ was published. The journal claims, however, that it was unable to publish the subsequent 6 line conflict of interest declaration (even on-line) that it received some time in January until some time in March due to space considerations. Of course, there are no on-line space considerations, as everyone knows. In addition to this, the editors were capable of rushing their above mentioned editorial on-line within about a week. Not overly credible the editorial explanation of space constraints here...

JAMA's new policy on this issue is truly pointless. It aims to enforce censorship on people reporting potential omissions of conflicts of interest declarations to the journal and expects them to keep quiet until it has investigated the matter. Anyone who goes instead directly to the news media would accordingly be in the clear as far as the new JAMA policy is concerned. The solution then would be, instead of waiting for JAMA's breathtakingly long 'investigation' of a simple matter (did you omit to declare a potential conflict of interest?), to issue a press release straightaway, or to write a letter to a different medical journal (as Leo did).

Significantly, the BMJ that published Leo's complaint has refused to withdraw his letter, because, according to the BMJ editor, the complaint was factually accurate.

It is deeply disconcerting that a leading biomedical journal such as JAMA tried to bully an academic as well as a medical school dean for doing nothing other than report the omission of a conflict of interest declaration. A clear abuse of the powers that journal editors are invested with by virtue of the job they hold. This is what really is at issue here!

Medical journal primadonnas

Interesting story on conflict-of-interest reporting in biomedical journals. As you may or may not know, most leading biomedical journals require their authors (as well as peer reviewers and editors) to declare any kind of conflict of interest that they might have with regard to the manuscript/content under consideration by the journal. JAMA, the high-impact journal of the American Medical Association published a piece on the use of a particular anti-depressant in stroke patients. The study duly underwent anonymous peer review, passed peer review and so it went into print. Standard operating procedure as far as as biomedical peer reviewed content publishing is concerned.

The Wall Street Journal health blog reports an interesting fall-out between a neuro-anatomy professor in the USA and some of JAMA's editors. What happened, according to the WSJ blog is this: Jonathan Leo, the neuro-anatomy professor in question, published a letter on the website of the British Medical Journal's website alleging that the authors of the study in question failed to disclose a financial conflict of interest. Turns out that the allegations were correct. JAMA published in its March 11, 2009 issue an erratum including the omitted conflict of interest declaration as well as an apology from the study's lead authors.

What's interesting, however, is what happened in-between. Jonathan Leo, a professor at a small college in Tennessee received shortly after publication of his letter on the BMJ website a call from one of the editors of JAMA. He claims that that bloke threatened him this way: 'He said, ‘Who do you think you are,’ ” says Leo. “He then said, ‘You are banned from JAMA for life. You will be sorry. Your school will be sorry. Your students will be sorry." That's the story according to Leo. JAMA claims, not unexpectedly perhaps seeing the inappropriateness of this, that Leo's recollection of the conversation was incorrect.

Leo gets a second call from another editor at JAMA, someone even higher up than the first caller. Things didn't exactly improve... - Here's what the WSJ reports: 'The call from Fontanarosa was followed up by one from JAMA editor-in-chief Catherine DeAngelis to Leo’s superiors, Leo says. He said she asked his superiors to get him to retract his article in the BMJ. Leo says he decided to call DeAngelis directly to find out what, in particular, she might be objecting to. He said she was “very upset” but didn’t make specific complaints about the article. In a conversation with us, DeAngelis was none too happy to be questioned about the dust-up with Leo. “This guy is a nobody and a nothing” she said of Leo. “He is trying to make a name for himself. Please call me about something important.” She added that Leo “should be spending time with his students instead of doing this.”When asked if she called his superiors and what she said to them, DeAngelis said “it is none of your business.” She added that she did not threaten Leo or anyone at the school.'

So, clearly it's a he says - she says story but it's not insignificant that Leo seems to have received two critical calls from JAMA editors. As it turns out, however, his claims in his letter on the BMJ website were actually substantively correct.

Makes you wonder about JAMA's ethics standards. It is quite remarkable - in a bad way - to call a biomedical scientist who correctly flags the omission of an important conflict of interest disclosure with regard to a paper your journal published 'a nobody and a nothing'. Seriously, JAMA, you'd reconsider how you deal with such matters!

From Biko to Guantanamo - Doctors' involvement in torture

This Letter to the Editor was published in THE LANCET in September 2007. It was also reported on the Canadian Medicine Editors' blog. They note that only one Canadian signature was amongst the signatories of the Letter. The Letter draws parallels between the conduct of doctors in the case of the torture and eventual murder of South African anti- apartheid activist Steve Biko and the treatment of prisoners on Guantanamo.

The irony of the letter, of which I am a signatory, is that its instigators (David Nicholl, Trefor Jenkins and Steve Miles) chose THE LANCET as the outlet for the Letter. THE LANCET, of course, is at the receiving end of an international boycott aiming at its owner, Elsevier. Elsevier is heavily involved in facilitating international arms trade, a profit driven mission that doesn't gel too well with its academic publishing activities.

From Steve Biko to Guantanamo - 30 years of medical involvement in torture


This week marks the 30th anniversary of the death of anti-apartheid activist Steve Biko while being detained by security police. Initially, the South African Minister of Justice suggested Biko had died of a hunger strike. The inquest revealed that he had died of the consequences of head injuries sustained during police interrogation, and identified gross inadequacies in the medical treatment from the two doctors responsible for his care including the falsification of records. The regulatory authorities failed to take firm action, and it was only grass-roots action by doctors that led, almost 8 years later to Dr Benjamin Tucker being found guilty of improper and disgraceful conduct and being struck off, whilst Dr Ivor Lang was found guilty of improper conduct and was given a caution and a reprimand1.

There are strong parallels with the Biko case and the ongoing role of US military doctors in Guantanamo and the War on Terror. Last year, we suggested that the physicians in Guantanamo force-feeding hunger strikers should be referred to their professional bodies for breaching internationally accepted ethical guidelines2. One of us (DJN) lodged formal complaints with the Medical Boards for Georgia and California as well as pointing out to the American Medical Association (AMA) that the former hospital commander at Guantanamo, Dr John Edmondson, was a member3. After eighteen months, there has still been no reply from the AMA, the Californian authorities have stated that “they do not have the jurisdiction to investigate incidents that occurred on a federal facility/military base”, the Georgian authorities stated that the “complaint was thoroughly investigated” but “the Board concluded that there was not sufficient evidence to support prosecution”, yet an analysis of the same affidavit by the Royal College of Physicians concluded that “in England, this would be a criminal act” (Personal communications to DJN).

The UK government has refused a request from the British Medical Association for a group of independent doctors to assess the detainees4 and, to date, there has been no formal report on the 3 alleged suicides in Guantanamo that took place in June 2006.

The resolution of the Biko case was instrumental in the rehabilitation of the South African Medical and Dental Council and the Medical Association of South Africa which had been subject to boycotts during the apartheid years. The failure of the US regulatory authorities to act is quite simply damaging the reputation of US military medicine. No healthcare worker in the War on Terror has been charged or convicted of any significant offence despite numerous instances documented including fraudulent record keeping in detainees who have died as result of failed interrogations5. We suspect that the doctors in Guantanamo and elsewhere have made the same mistake as Dr Tucker who in 1991, in expressing remorse and seeking re-instatement said “I had gradually lost the fearless independence …and become too closely identified with the organs of the State, especially the Police force…I have come to realise that a medical practitioner’s first responsibility is the well-being of his patient, and that a medical practitioner cannot subordinate his patient’s interest to extraneous considerations.” (cited in1)
The attitude of the US medical establishment appears to be one of ‘See no evil, hear no evil, speak no evil’.



References

1. Jenkins T McLean GR. The Steve Biko affair: a case study in Medical Ethics. Developing World Bioethics 2003; 3(1): 77-102.
2. Nicholl DJ and 262 other doctors. Forcefeeding and restraint of Guantanamo Bay hunger strikers. Lancet 2006; 367:811.
3. Nicholl DJ. Guantanamo- a call for action. Good men need to do something. BMJ 2006; 332:854-855.
4. Nicholl DJ and 119 other doctors. Doctors at Guantanamo. The Times 18th September, 2006.http://www.timesonline.co.uk/tol/comment/debate/letters/article642161.ece
5. Miles, SH (2006) Oath Betrayed: Torture, Medical Complicity and the War on Terror. Random House, New York

Some good news from South Africa - at long last

Here's good news from today's BRITISH MEDICAL JOURNAL. It's a copy-paste job really. I am tempted to go on raving again about human lives lost due to the unimaginable incompetence of the current South African minister for health prevention, Dr (Beetroot) Manto Tshabalala-Msimang, and, of course, the country's slightly paranoid President Thabo Mbeki, but what's the point... readers of this blog will know. So, here's the BMJ item:

South Africans to get AIDS plan

Pat Sidley

Johannesburg

The South African government has finally introduced a full and far reaching plan to deal with its HIV/AIDS epidemic. But it will cost the country some 14bn rand (£970m; 1.4bn; $1.9bn) over the next five years. This amount was not planned for in the present budget for the year ahead.

The plan aims to give antiretroviral treatment to up to 80% of people with AIDS who need the treatment; to halve the new infection rate by 2011; and to ensure that all pregnant women who are HIV positive have access to treatment to prevent transmission to their babies. The plan envisages better spending of the large donations that pour into the country, with the intention of strengthening the health system and using health staff more efficiently. The whole process will be properly evaluated and monitored.

Less than a year ago, Mr Mbeki's government followed the president's view that AIDS was a syndrome and that "a virus could not cause a syndrome." Mr Mbeki thought that the extent of disease in the country could be attributed to poverty. He voiced misgivings about white Western experts who claimed that AIDS originated in Africa as though Africans were dirty and immoral. And he presided over a cabinet which approved a product as a cure for AIDS that was later found to contain an industrial solvent (BMJ 1997; 314:450).

The health minister Manto Tshabalala-Msimang, who had a liver transplant earlier this month (15 March), has previously advocated the virtues of beetroot and garlic over antiretrovirals and appealed against court decisions fought for and won by the Treatment Action Campaign to compel the government to provide treatment (BMJ 2006,333:167)