New Delhi: India has the most centres of medical instruction and care for any country, with 579 registered, and on the back of which it expects to host a 54,000-crore rupee medical tourism industry by 2020. However, this expectation stands in stark contrast to the number of institutions that are actually capable of supporting an industry of such scale: fewer than 50% of them published any peer-reviewed research in the last decade. This result, among others, was obtained by a group of doctors from the Sir Ganga Ram Hospital in the city, and published on April 19 in the journal Current Medicine Research and Practice (CMRP).
Peer-review is a definitive part of conventional scientific publishing. It involves a group of experts on a topic reviewing a scientific paper submitted for publication, and checking for pertinence and rigour, among other things. For all the flaws it has accrued, completing peer-review accords the paper’s authors some credibility and authority. On the other hand, not publishing peer-reviewed material is a strong indication that no original research was produced.
The contention in this case isn’t if there was any non-peer-reviewed material – on the contrary, in a country where educational degrees can be manufactured for a few thousand rupees (or with a few lakh rupees paid as donations to learning institutions) and whose school-level standards have been widely decried, claims that there is a lack of research aren’t misplaced. However, it is quite worrisome what the conclusions bode for a country with one of the world’s highest burdens of disease. To be sure, publishing original research doesn’t correlate perfectly with being able to provide a good education. At the same time, as Samiran Nundy, the study’s lead author as well CMRP’s editor, told The Telegraph, “These findings support long-standing suspicions that for many private colleges in the country, medical education is just a business.”
Nundy & co. had combed through the giant Scopus database, which contains information about papers’ abstracts and their citations, and found that some 4% of institutions – 25 out of 579 – were able to account for over 40% of all the research produced in the decade. Moreover, they also found that the largest institutions, led by the All India Institute of Medical Sciences, in terms of intake also produced original research more prolifically.
The question of peer-review becomes relevant in the context of the fact that all postgraduate students of medicine are required to produce an original thesis, which upon completion becomes eligible for publication in a journal or at a conference. Does this mean graduates of over 330 medical institutions (57.3% of the 579 institutes) didn’t produce original theses? It’s not implausible for at least two reasons.
In December 2013, a student from Pune submitted two ‘fake’ papers, containing nothing of meaning or value, to the International Conference on Recent Innovations in Engineering, Science and Technology (ICRIEST). That student, Navin Kabra, had then told this correspondent that the conference had accepted his papers with review scores of 60, 70, 80 and 90.75, and that he could present them himself during the proceedings if he could pay an entry fee of Rs.5,000. So, the first reason is that there exist many entities such as ICRIEST to facilitate the publication of non-peer-reviewed research.
And conferences like ICRIEST are abundant at all because they are able to subsist on the second reason: that many universities in India often require graduating students to publish research of the first class, to which their teachers can tag their names onto, while not aspiring to provide a commensurately first-class education at the same time. As Pushpa M. Bhargava, an senior scientist and founder of the Centre for Cellular and Molecular Biology, Hyderabad, had told The Wire in the context of an incident of plagiarism at the University of Hyderabad, “Because of the low standard of our scientists, they are unable to produce research output of any originality.”
Such papers, of substandard quality and/or which have been published in predatory journals and conferences, won’t find mention in Scopus while graduates of 290 medical institutions in the country will technically have had their theses published. At the same time, the incentives for publishing a legitimate paper also suffer when leadership positions are filled on the basis of bureaucratic and political considerations instead of quality of work. One solution to eliminate this problem is to decouple the grades students receive from whether or not their projects or theses have been accepted for publication. A second-degree option is even more difficult to execute, not just in India but around the world: to decouple the quality of research published from the journal it is published in. A recent case in point was the New England Journal of Medicine‘s misguided editorial on the falsifiability of research published in its pages.
All these considerations in turn feed into policy questions seeking resolutions for India’s notorious lack of qualified doctors as well as healthcare regulators. Recently, toward addressing the former, a West Bengal-based NGO named the Liver Foundation even announced a programme in which it would teach untrained medical practitioners (or quacks, of whom there are 2.5 million) “to treat the simplest of medical illnesses”. India has one doctor for every 1,700 people – the WHO has prescribed a ratio of one-to-1,000. Moreover, over 81% of specialist positions in community health centres were vacant (2015). And the principal effect of there being fewer healthcare regulators than required is that drug-manufacturers like Ranbaxy have been able to get away with egregious practices for much longer periods than they should have.
So, the CMRP data is just one link in an interconnected chain of problems faced by India bereft of any clear beginnings or endings. Nonetheless, stakeholders in the healthcare sector have recognised that both quantitative and qualitative problems are always only worsened when they don’t have enough resources to work with. Two recent instances when this has come to be with startling suddenness: when the Ministry of Finance shortchanged over 15 schemes of the Ministry of Health and Family Welfare in 2015, asking them to rely instead on funding from state governments, and when the budget of the National AIDS Control Organisation was cut by 22% the same year.