CORRESPONDENCE

analysis. The introduction states that this is an edited versionof the training modules that have been used for a number ofshort courses on this topic sponsored by the World HealthOrganization's Regional Office for the Western Pacific andthat the manual might be useful to students who are writingtheses to meet academic requirements in health-relatedsubjects.

The topics in the book have been covered under 11chapters.After an introduction to research planning in the first five,the manual discusses 'bias, confounding and basic riskmeasurements' in Chapters 6 and 7. Chapters 8 and 9 dealwith actual data analysis covering tests of significance andassociation as well as causation. The ethical aspects ofhealth research have been covered in Chapter 10. The detailsof preparing a typical research proposal have been lucidlydealt with in Chapter 11.

At the end of the book three annexures are given, the firsttwo explain the design of a health research questionnaire andconstruction of statistical tables and graphs. In Annexure 3,details of a workshop on 'Health Research Methodology'have been explained with the help of flow charts.

This practical training manual covers, with the help ofseveral examples, the basic concepts and principles ofscientific research, from the selection of the area of researchto the analysis of data and interpretation of results.

The topics have been covered systematically, explainingvarious essentials of conducting a health research study and

Correspondence

193

. the methods of analysis of data. The best parts of the bookare the two chapters on bias and confounding and basic riskmeasurements. These topics have been covered in simplelanguage with clear examples. Extensive empirical data havebeen presented in the chapter on the tests of significance.Similarly ••the chapter on association and causation will alsobe very useful to readers. However, the chapter on samplesize determination and sampling methods should have beenillustrated with more examples. Though different samplingmethods have been explained in this chapter the reader mayhave to supple merit his knowledge by reading other books aswell.

The ethical aspects of health research (covered in only fourpages) provide useful information but the researcher mayhave to refer to a book dealing more specifically with thistopic if he or she needs help on this important problem. Thethree references given at the end of this chapter suggestwhere this help might be found.

Though several books are available on health researchmethodology, I feel that this book is among the best and willbe very useful to both statisticians and health care personnelengaged in research.

K. R. SUNDARAMDepartment of Biostatistics

All India Institute of Medical SciencesNew Delhi

The Consumer Protection Act and I

Sir-I have recently had an unfortunate experi-ence as a result of the Consumer ProtectionAct. A 37-year-old lady was admitted to anursing home in Delhi on 6 May 1991 wantingher fallopian tubes to be reopened so that shecould conceive again. Both her sons had died,she had only one living daughter and hadundergone a tubectomy during a Caesareansection 12years previously.

A hysterosalpingogram (HSG) showed thatthe uterine cavity was well seen but no tube wasvisible on the right side and a small part of thetube was seen on the left. We explained to thepatient that a tuboplasty could be done but ather age the chances of conception were small.

. We also said that since we used microsurgicaltechniques the results of the reversal oftubectomy were generally better in our handsthan in others and cited examples of childrenhaving been born to other patients who hadundergone a similar procedure.

Our patient underwent a tuboplasty on 8 May1991 and immediately after the operation injec-tion of methylene blue into the uterus showed agood flow of the dye through both tubes. Theovarian capsules appeared thickened, so we

performed a wedge resection of the ovaries tohelp ovulation.

She was discharged well on 15 May 1991.Three months after the operation another HSGshowed that the anastomotic site allowed a freeflow of contrast up to the fimbriae but notbeyond. We explained to the patient that thismay be because of fimbrial adhesions as well assome tubal spasm because the examination hadbeen done only three months after surgery. Wedid not see the patient afterwards but were toldthat she had undergone two more HSGs else-where both of which had showed that the rightfallopian tube was open while the left showedscanty spillage of contrast into the peritoneum.

However, eight months later, to our surprise,we heard that this same patient had filed a suitagainst us under the Consumer Protection Actstating that she had undergone this operationbecause she wanted a son and she had been tonursing homes where the sums demandedranged from Rs 5000 to Rs 8()()(). However, theywere prepared to give only a 25% to 50%guarantee of success but our nursing home, shealleged, had given a 100% guarantee andalthough we had asked for Rs 12 ()()()she hadopted to have the procedure done by us. Thiswas completely untrue.

After hearing about this charge, we sent oneof our doctors to the patient's house and toldher that the operation had indeed achieved itsimmediate aim but it was too early to expectpregnancy. We also told her that she shouldhave come back to us instead of going to courtif she felt that she had been wronged.

She refused to acceptour explanation. So wedecided to contest the case because we weresure we could vindicate ourselves against thetwo main charges: (i) that we gave a 100%guarantee and (ii) that the operation had beenunsuccessful.

At the first hearing, we provided a writtenstatement denying all the allegations. Our con-tention was that even if one tube was found tobe open in one of three consecutive X-raystudies, it meant that the operation had beensuccessful. We quoted extensively from TeLinde's operative gynaecologyt to supportour claim.

We were told by the court to submit this inthe form of an affidavit which we did at the nexthearing.

The patient then filed a counter-affidavitrepeating all she had said and insisting, withoutany proof whatsoever, that a 100% guaranteehad been given.

194

An oral hearing took place on 9 December1992. There the patient's lawyer repeated thecharges and we showed the court the X-rayreports which indicated that the operation hadbeen successful. At no time did the court statethat it did not understand what we were sayingor what we had done had been wrong. The datefor the award was fixed for 23 February 1993and later postponed to 9 March 1993. Beforewe got a copy of the award, the NavbharatTimes of 16 March 1993 announced that wewould have to pay Rs 25 000 to the claimant.

We eventually received a copy of the judg-ment on 20 March 1993 dated 16 March 1993,i.e. the day it was announced in the newspaper.This report said that the court had agreed withthe claimant as it felt that a 100% guarantee hadbeen given for conception. It asked us to payRs 25 000 in damages, Rs 1000 in lawyers' fees,as well as Rs 18 813 as the cost of the operation,medicines and X-rays as well as travellingexpenses incurred by the patient.

I cannot yet understand how this team ofhonourable judges made this decision, especiallyas they have no experience in the medical field.

20 June 1993 S. B. GogiaNew Delhi

REFERENCEMattinglyRP,ThompsonJD. Te Linde's operativegynaecology. NewDelhi:JaypeeBrothers, 1989.

Prejudice against reservation

Sir-Drs Murmu, Kant and Ranga Rao- haveread far more into my 'Letter from Madras?than what I intended. They state, 'Dr Manisuggests that reservation creates unemploy-ment, and hence if this is abolished all bright,"open" category youths will be admitted tomedical courses and become employed later.' rwent back to the letter as it was published andread it again and again, but I am afraid I couldnot find the passage they allude to, or anythingremotely like it. What I implied was that selec-tion to any college course should be based onmerit and merit alone. It is impossible for all the15204 applicants to squeeze themselves intothe 957 medical seats available. However, ifselection were on merit and merit alone, I sub-mit that the 958th candidate, while he or shewould obviously have regrets, would have nogrouse against the system. He might be morereconciled to the fact that his performance onthe day was not good enough.

Dr Murmu and friends accuse me of'perpetuating caste prejudice'. On thecontrary, when I look for a doctor to treat afriend or a relative who falls ill, I never for amoment think of his caste, his religion or thelanguage he speaks. I look for the one who ismost likely to cure my patient. This is the criter-ion for just about everyone who falls ill, includ-ing the politicians and the doctors I see whoadvocate reservations ..

I do not deny that for centuries grossinjustice has been done to a large section of ourpopulation and we should correct this. But isthis the proper solution? Should one choose a

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 6, NO.4, 1993

candidate who is clearly unfit to undertake therigorous training a career in medicine involves?He or she will only get through examinations ifthey are made easier. Should we, therefore,deliberately undermine our educational stan-dards? In fact Drs Murmu, Kant and Rao, bearout the bankruptcy of this policy by their ownstatement, 'Scheduled Castes and Tribes stu-dents have been trained at the All India Insti-tute of Medical Sciences since 1956 but did notobtain a single faculty appointment for the next28 years.'

If one body of students isunable to compete onequal terms with another, the need is for reme-dial education at an early stage. Teachingmethods should be improved in primaryschools and thereafter, the students whosuffer because they do not have a tradition ofscholarship in their families should be drilled tocatch up with the brightest, so that they can winentry to colleges on their own merit.

15 July 1993 M. K.ManiDepartment of Nephrology

Apollo HospitalsMadras

REFERENCES

Murmu LR, Kant S, Ranga Rao KRP. Prejudiceagainstreservation.NaIL Med J India 1993;6:97-8.

2 ManiMK. Letter from Madras. NaIL Med J India1992;S:29~.

Attitudes to liver transplantation in India

Sir-There has been a considerable debateover whether liver transplantation is appro-priate for a poor country like India. Manyhealth planners feel that our efforts should bedirected towards primary health care and ourscarce resources should not be squandered onhigh cost medicine which is likely to benefitonly a few. The situation has been compared tohaving 'CT scanners on malarious swamps'.Others argue that unless we apply newertechnologies we will forever remain 'under-developed' and as long as we remain democraticwe will not be able to prevent our citizens fromseeking the best treatment abroad. We will con-sequently rely on the developed world for thetreatment of complicated illnesses even morethan we do now. Liver transplantation is aneffective yet expensive form of treatment forend stage liver disease-the cause of death of200 000 Indians every year. Should it be donein India?

To assess the opinion of a cross-section ofIndian doctors on this subject, I carried out apostal survey in October 1992.

A questionnaire was sent to 451 individualsincluding all the deans of medical colleges,heads of departments of surgery, medicine andgastroenterology as well as some well knownphysicians and surgeons in private practice.

In the first set of questions, I asked whetherbrainstem death should be recognized andwhether liver transplantation should be startedin India. The next set of questions soughtopinions on who should fund Iiver transplanta-tion, whether the procedure should be done

widely or restricted to a few hospitals, whatmight be the advantages and disadvantages ofsuch a programme, the number of patients whowould be likely candidates and whether anysteps had already been taken by them to startsuch a programme.

Of the 451 individuals to whom question-naires were sent, 102 (23%) replied. Over halfthe responses were from hospitals and medicalcolleges not located in the major cities. Thenumbers of positive and negative replies tocertain key questions are listed in Table I.

TABLEI. Responses to the various questions

Questions Yes No Noopinion

Shouldbrainstemdeathbe 89 2 11recognizedin India?

Shouldlivertransplantation 88 4 10beperformedinIndia?

Are financesavailable? 26 66 10Are trainedpersonnel 37 58 7

available?Is the necessaryinfra- 37 56 9

structureavailable?Willit resultinthe improve- 56 12 34

mentofexistingmedicalcare?

Haveyou taken anystepstowards1. trainingpersonnel? 28 42 322.' improvingfacilities? 23 42 37

Shouldpublicfundsbe used? 46 34 22Shouldtheprocedurebe 22 64 16

restrictedtopublichospitals?

The respondents felt that it would take about 4years to start a liver transplant programme. Inresponse to which hospitals should be allowedto start such a programme the replies were:All India Institute of Medical Sciences, NewDelhi (45); Postgraduate Institute of MedicalEducation and Research, Chandigarh (36);Sanjay Gandhi Postgraduate Institute of MedicalSciences, Lucknow (35); King Edward MemorialHospital, Bombay (31); Apollo Hospital,Madras (22); Christian Medical College,Vellore (18); and Madras Medical College,Madras (13).

There seems to be general agreement thatbrainstem death should be recognized in Indiaand that liver transplantation should be carriedout. However, only a quarter of .the respon-dents felt that they had either the money or thepersonnel to start the programme. More thanhalf felt that with the start of such a programmethe existing medical facilities would improve. Itwas interesting to find that at least 20 centreswere preparing to start the programme. Therespondents also felt that it should be done inboth private and public hospitals.

My survey suggests that the majority ofdoctors are in favour of liver transplantationbeing started and many centres in this countryare actually moving towards it.

1 July 1993 Subhash GuptaDepartment of Gastrointestinal Surgery

and Liver TransplantationAll India Institute of Medical Sciences

New Delhi 110029

OBITUARY

Another viewpoint

Sir-I read with interest Dr N. H. Antia's letter'Another viewpoint" on doctors returning toIndia after a spell abroad. However, I wouldlike to remind him that experience makes a manwiser. He himself, when young, might not haveaccepted the same advice he offers today. Iknow some foreigners who greatly improvedtheir surgical skills through the volume andvariety of clinical material available in ourcountry. They stayed in India, overcame thedifficulties, and provided effective medicalcare to our people. Some names like Ross,McCarrison, Somervell and Eggleston come tomind.

The desire to specialize is natural for youngdoctors today and training abroad is of a qualityoften not available in this country. The frustra-tion of not being able to put into practice whatthey have learnt can be expected. Nevertheless,those who have modified their experience wiselyto suit our situation have often provided animproved quality of care to their patients.

I believe that our doctors are second to none.It has surprised many visitors that we have been

Obituary

able to maintain high standards in medical caredespite limitations, and have kept pace withmedical advances. However, our training systemwith its emphasis on high technology medicineand western models prompts many of ourbrightest and best to go abroad.

There is an urgent need, therefore, to providesuitable conditions, to harness and use ourindigenous talent. There should be much greateremphasis during training on clinical methods.and laboratory techniques. Regular audit on allaspects of medical care and the reorientation ofresearch towards improving the managementof diseases prevalent in our part of the world,within our resources, will not only help us butmay show the way to developed countries manyof whom are now unable to afford the everincreasing costs of health care.

5 July 1993 S. K. SrivastavaC-39, Sarita Vihar

New Delhi

REFERENCE

1 Antia NH. Another viewpoint. Natl Med JIndia 1993;6:49.

195

Free drug samples and gifts

Sir-Representatives from the pharmaceuticalindustry provide free drug samples and gifts todoctors to increase their sales and are notinterested in the needs of patients. A fewdoctors give these samples away to the poor,but the bulk of these drug samples lie uselesslyin locked cupboards till their expiry dates areover when they are thrown into dust bins anddestroyed. Some doctors sell these samples topatients and chemists. These marketing tacticsraise the prices of the drugs putting adequatehealth care beyond the reach of most of ourcountrymen.

I think, we as doctors must decide whetherwe should allow this high pressure salesman-ship to continue.

25 June 1993 o. Joychandra SinghDeputy Drug Controller

LamphelpatManipur

Dr Sudhir Chandra Pal (MB,BS, Dip Bact, MD)(1 May 1931-16 December 1992)

Sudhir Chandra Pal was bornon 1 May 1931 in Pukhuria. Heattended the Bankura ZillaSchool, West Bengal andreceived his medical educationat the National Medical College,Calcutta (MB,BS, 1956). Heobtained the Diploma in Bac-teriology (Manchester) in 1962and MD in Microbiology (AllIndia Institute of MedicalSciences) in 1964. He worked atthe National Institute of Com-municable Diseases (1965-73),the Cholera Research Centreand served as Director of theNational Institute of Choleraand Enteric Diseases, Calcutta(1973-92).

Dr Sudhir Chandra Pal, former Director of the NationalInstitute of Cholera and Enteric Diseases, Calcutta, passedaway on 16December 1992 at the age of 61. Dr Pal started hisresearch career at the National Institute of CommunicableDiseases (NICD) and was instrumental in developing itsmicrobiology laboratory:

He subsequently moved to the Cholera Research Centre

of the Indian Council of Medical Research (ICMR) in Calcuttaas its Director. His foresight on issues such as the extent ofthe problem of diarrhoeal diseases in a developing countrylike India was valuable in shifting the focus of the centre frombeing oriented towards a single disease to a multi-facetedinstitute which could tackle the problem of all enteric diseases.Under his supervision, research on diarrhoea was initiated atthe basic as well as the applied levels with a greater emphasison the latter. This led to the National Institute of Cholera andEnteric Diseases (NICED) becoming not only the first of itskind in India, but also a referral centre for the SoutheastAsia Region and a World Health Organization (WHO)Collaborating Centre for Research and Training in DiarrhoealDiseases.

Among the pioneering research programmes carried outby Dr Pal and his team at the NICED, the most importanthas been the promotion and implementation of the oralrehydration solution (ORS) and of oral rehydration therapy(ORT) for reducing diarrhoea-related deaths in children andinfants. The magnitude of this achievement can only beassessed in terms of the number of lives ORS saves annuallyin India and in several other developing countries. This studywas followed by the introduction of a 3-tier strategy forimplementation of ORT which led to the formulation of aplanned scheme to tackle the problem of diarrhoeal diseasesat the national level. The only known field trial for anindigenously prepared cholera vaccine, the existence ofcholera carriers, and the concept of cholera chemoprophylaxisin an endemic area were also contributions by Dr Pal and his