so many of them that its original purpose, to get from A to B ... country, and it will get people from A to B in seconds, no matter ... âI'll call you tomorrow,â I said, looking out the window .... authors attend conferences, go on holiday, and may have ...
Views & reviews
Soundings The Devil’s bargain We all need a sense of the demonic, but it was still a shock when I heard that the Devil had made an appointment. This was shortly after I was made King of Ireland, on account of, firstly, being a doctor and, secondly, having a dome shaped head. Choosing me was not a snap decision; I had a six months’ trial as Prince of Rockall, where my subjects affectionately nicknamed me TPFKAD (The Prince Formerly Known As Doctor), but after all the dead solicitors had been swept up (my first edict) I was home and dry. The Devil proved to be a charming fellow, urbane, witty, and elegant, reminding me of Stephen Fry; a gentleman who doesn’t brag himself, as G K Chesterton observed. “I have a proposition, your Majesty,” he said, sipping his gin and tonic, which I noticed was steaming slightly, though served with plenty of ice.
“The motor car has had catastrophic effects on your environment,” he continued, “despoiling your countryside, polluting your air, devouring your resources; and you have so many of them that its original purpose, to get from A to B efficiently, has been lost, forgotten; its main function is as a status symbol, a toy.” I nodded, cautiously interested. “What I can offer,” he announced, “is an utterly new transport system, which my people have spent aeons developing, a form of solar powered train. As it can warp time and space there need be only two in the whole country, and it will get people from A to B in seconds, no matter how far the distance. Each train will carry 100 passengers. Speedy, efficient, and environmentally clean; could you ask for more?” I’d heard about Faust, I’d seen The Devil and Dan’l Webster. “But what will this miracle of rare device cost?” I asked circumspectly. “Ah, the price,” he mused, and there was the faintest whiff of sulphur in the air. “You humans are always so concerned with the consequences of your actions; carpe diem, as we say down below. The price is but a trivial
thing; all we ask is that once each year, and at a random time and place, the two trains will crash.” “Crash?” I said in shock, “and what about the passengers?” “Why, they will die, of course,” he shrugged, “these trains travel at great speed.” “So 200 innocent people will die every year?” His tone became earnest. “I appreciate your difficulties,” he said, “it would take a very brave man to defy such powerful vested interests; change will prove most unpopular with the oil and motor industries, in which I have many clients. So—an answer, your Majesty, if you please; will you dance with the Devil in the pale moonlight?” He smiled as if he spoke in jest, but his eyes glinted red with madness. “The Devil hates a coward,” my Uncle Paid used to say, but my initial outrage was waning. Only 200 killed, I thought; but who will ride the hell bound train? “I’ll call you tomorrow,” I said, looking out the window at my Merc.
Dewey (BMJ 1993;306:318-20) has discussed several problems in the editorial process. Drawing on and adding to his work I should like to propose a set of guidelines for editors that may improve communication and relationships between authors and editors and enhance the integrity of the editorial process. Editors, as responsible social agents and therefore accountable to society for their actions, should view authors both as their clients and as agents of society in pursuit of knowledge through scholarly endeavours. As such, editors should respect and be seen to respect authors as well as expecting high standards from them. Information for aspiring authors should be as comprehensive as possible and should
include details of editorial policy on the review process—for example, whether this is blinded, the time given for reviewers to respond, how long it may take to receive a decision, and the approximate time to publication following acceptance. A brief annual report (as provided by Thorax) could provide authors with an updated review of these details as well as of acceptance rates, analyses of reviewers’ compliance with editorial requirements, and the institutional affiliations of the authors of published (and perhaps even rejected) articles. Given the high rejection rate by many journals, authors should not be required to meet highly individualistic journal styles for footnotes and references as a prerequisite for review. Clearly, for any manuscript that is
Liam Farrell, general practitioner, Crossmaglen, County Armagh
Personal views Editorial ethics Since the 1970s an ethic of scholarly work and its publication has evolved to guide the conduct of research and the dissemination of scientific and scholarly information. Journal editors and many others have contributed to setting the ethical standards and editorial policies on which the prestige and standing of journal publications now depend. Yet as Horton and Smith have recently stated “there is a huge gap between the strict, some might say astonishingly out of touch, criteria for authorship set out by the International Committee of Medical Journal Editors and what happens in the real world of research ... It is time for editors to listen to researchers, not simply to impose their arbitrary and anachronistic rules” (Lancet 1996;347:780). BMJ VOLUME 316
10 JANUARY 1998
155
Views & reviews accepted such specific requirements would subsequently have to be met. Insisting on specific requirements when rejection rates are high is burdensome and irritating for authors, who may have to wait many months for replies and then have to reformat the manuscript for submission elsewhere. All manuscripts received should be promptly acknowledged and a brief communication sent out at three monthly intervals to inform authors of progress. Reviewers should be asked to be collegial and constructive in their criticisms (Chronicle of Higher Education, 25 October 1996). All reviewers’ reports should be made available to authors, whether or not the article is accepted. Both supportive and critical comments can be helpful to authors. Even inaccurate comments, perhaps based on misunderstanding by the reviewer, may help to identify sections which could be clarified through revision of language. The review process is an arduous and responsible one for reviewers, and authors should have the opportunity to benefit maximally from such peer review. An editorial comment on reviewers’ reports should be added whenever feasible. Keeping appropriate records would help editors to track unreliable or obnoxious reviewers. Listing the proportion who act in this way in the annual report, would let authors and reviewers know of the journal’s internal audit process and provide a perspective on attempts to effect constructive change. Inadequate reviews should be contestable by authors and the editor’s weighting of reviewers’ recommendations should be commensurate with the scholarly standard of the review.
Reviewers should sign personal responsibility for their reviews. Where the help of research fellows or others has been enlisted this should be declared. Reviewers and their assistants should also sign a commitment not to use material or ideas from manuscripts without permission. While clearly the editorial process must involve considerable trust, intermittent spot checks on reviewers’ publications should be undertaken to deter and monitor plagiarism.
“Editors should set ethical standards at least as high as they expect from authors” Any major changes to manuscripts by the editor should be accompanied by justifying reasons. It is unacceptable for editors to use the transparent excuse of space limitation to censor authors, especially at the galley proof stage. Editors who face the problem of insufficient space in their journal must at least use reference and footnote systems that do not waste space—for example, the Vancouver style. Requirements to meet space limitations should be uniform and authors should not be subjected to arbitrary editorial deletions, especially nonnegotiated changes. Authors should have the opportunity to review galley proofs to ensure their approval of the final publication. Reasonable deadlines should be given to review galley proofs as authors attend conferences, go on holiday, and may have other pressing commitments. When editors receive several papers on a similar topic and decide to publish only one
on the basis of merit the other authors should be told so that when the chosen article is published the rejected authors have no reason to believe that their work has been used. Editors should also be required to indicate that they have no conflicts of interest. All copies of rejected manuscripts should either be returned to authors or destroyed and the authors informed. There should be a mechanism for reviewing questionable editorial practices and for holding editors publicly accountable for their actions, without opening the flood gates for frivolous complaints. Editors should set ethical standards at least as high as they expect from authors. An authors’ ombudsman (as recently appointed by the Lancet) could facilitate the evaluation of charges against editors and allow editorial discretion to be balanced by accountability. These views are offered to encourage open debate on a contentious issue that has received insufficient public attention in an era when all professionals are being held to high standards of public accountability. The anticipated reply from editors that the amount of work involved would be great and costly can be pre-empted by pointing out this also applies to the procedures required of researchers in obtaining ethical approval of studies and to authors from editorial delays. As with all rules and guidelines the requirement for these is not directed at the many editors who do their job well but at those who do not. Solomon R Benatar, professor of medicine, University of Cape Town Medical School
Kenya eye safari Time might not exactly stand still in Mudogashe but neither does it move apace. The river has dried up but will flow again with the advent of the seasonal rains. And the rains will bring the return of the cattle, which have been sent far away in search of grazing. This is Kenya’s north eastern province, a huge expanse of scrub and semidesert populated by pastoralists. We have flown to this desolate place with a medical team from Kenya’s oldest hospital, the Presbyterian Church of East Africa Hospital, established in 1908 at Kikuyu near the capital, Nairobi. On board are two British eye specialists: Dr Mark Wood, director of the hospital’s eye unit, and Dr Roger Gray, a consultant retinal ophthalmologist from Somerset who regularly visits Kenya to help train eye surgeons. They are accompanied by an ophthalmic assistant and a nurse. The trip to Mudogashe is part of a programme of bimonthly flying safaris which brings the eye unit all over Kenya, as well as to Somalia and Sudan. The unit uses the word safari in its true Swahili meaning of journey. Like much of the unit’s work, this mission has 156
been funded by a German aid agency, the Christian Blind Mission, which has a fundraising and information office in Cambridge. The patients wait quietly. There are many more people than expected but this is perhaps not surprising—locals say that it was eight years ago when the last doctor visited Mudogashe. There is no public transport. The blind are led by a younger family member, the two connected by a long stick. Many of them have walked for days, carrying cooking utensils and food for the journey. When the eye unit agreed to include the district in its busy schedule the various health officials were informed of the impending visit. Outlying dispensaries and health centres were requested to refer their ophthalmic patients to Mudogashe on the agreed date. Word of the visit was also spread on the bush telegraph by the district officer, the local chiefs, and village elders, letting people know that even if they had not been referred they could still turn up at Mudogashe. The inhabitants of this region, a mixture of ethnic Somalis and Boranas, were until recently locked in a vicious conflict over
cattle. Over the generations many Somalis have left their homeland, migrating to Kenya in search of more security and better economic prospects. By the time of our visit, the Boranas (an indigenous Kenyan tribe) and the Somali settlers had overcome their differences and were facing together their common enemy: drought. In remote areas which are seldom visited by doctors, an affliction such as cataract can go untreated for years, reducing its victim to blindness. In Britain there is one ophthalmologist for every 30 000 people. In Kenya there is not even one eye specialist per million people. More than 80 000 Kenyans are blind from cataract. Yet a simple intracapsular cataract extraction lasts only 20 minutes. Great strides have been made in ophthalmic treatment in recent years. On some of these remote safaris the unit is now implanting intraocular lenses. But this type of surgery can be done only where there is an ophthalmic nurse who can deal with postoperative problems. BMJ VOLUME 316
10 JANUARY 1998
Views & reviews Having set up a consulting room, the doctors start their examinations. The majority of those seen have cataracts. Distributed among them are people with other conditions: pterygium, a malignant growth on the conjunctive associated with AIDS; glaucoma; and trachoma. In the cases of a couple of people complaining of great pain, eviscerations are required. The lack of equipment and medicines attest to the neglect experienced by health centres in this country. Even the calendar on the wall is six years out of date. At the time of independence from Britain in 1963, Kenya inherited one of the best healthcare systems in Africa. But bad management, inadequate funding, and overcentralisation have reduced many public health institutions to near collapse. There are some hospital wards where patients lie two or three to a bed because of overcrowding. The main public hospital in Nairobi is so run down that seriously ill people often prefer to stay at home rather than risk treatment there. As for health centres like the one in Mudogashe, the Ministry of Health says that funds are simply not available to upgrade them. Kenya’s president, Daniel arap Moi, says that non-governmental development organisations should be encouraged to improve the health infrastructure in Kenya. Without their involvement the future for
health care could be bleak. So many newly qualified doctors are leaving that there are now more young Kenyan doctors working in southern Africa than in Kenya’s own district hospitals.
“More than 80 000 Kenyans are blind from cataract” Mudogashe’s police post is a decrepit couple of shacks, the school a sad collection of low huts without glass in the windows. Ironically, there is a lesson on the benefits of tourism scribbled on the blackboard of one of the classrooms. The schoolteacher says that he cannot remember ever seeing a tourist. One good reason for avoiding the region is its insecurity. This is the land of “shifta,” bandits who roam the border area between Kenya and Somalia with virtual impunity. When a four wheel drive vehicle passes through town in the evening I notice its uniformed occupants are bristling with automatic weapons. The visiting doctors and their assistants work late into the night in their makeshift operating theatre, the electricity generator thrumming outside the open window to provide light. Prior to surgery, the theatre has been prepared by the unit’s nurse to ensure as
much sterility as is possible. With flies buzzing around and people wandering in and out, the conditions are far from ideal but the team has brought along an impressive array of equipment, and everything is done to ensure maximum hygiene. By midnight, 35 operations have been performed. A check up is done the following day to make sure no complications have arisen. The unit prides itself on the low postoperative infection rate. In order to maintain this standard, the patients for surgery are given intensive topical antibiotics for two hours beforehand. The patients receive a free pair of glasses and medication, which have been prepared at the hospital before the safari. Funding for the raw materials and lenses is provided by the Christian Blind Mission. Mohammed, a nurse in Mudogashe who was trained in ophthalmology at the eye unit, is essential to the success of the venture. If there are any postoperative complications he has the knowledge to deal with them. As the aircraft banks over the town we wonder what stories will be told of the day the eye doctors came from out of the sky. Fortunately, the unit plans to make further trips to Mudogashe this year. From the evidence of our short visit the team is bound to be welcomed back.
David Orr, Africa correspondent, Ingrid Cox, nurse in charge, Kikuyu eye unit
The poster session: is the writing on the wall? Despite the global improvement in telecommunications, the size and number of international medical conferences continue to grow. Demand for such meetings is fuelled by the often exotic locations, which have been made more accessible by the increasing ease of intercontinental travel. As conferences grow, delegates’ fees and subsidies from the pharmaceutical industry ensure that they are now rather profitable and more about business than about education or research. Large medical meetings traditionally allow “experts” to lecture large audiences from high podiums. For some reason, probably a hangover from the over-reaching 1980s, it is rather unfashionable to attend a conference merely to learn something. So in an attempt to involve as many people as possible—that is, increase revenue— organising committees have come to rely increasingly on the poster presentation, where new research work (and new researchers) can be presented to smaller groups of interested delegates. There are positive aspects of poster sessions. They allow research to be presented at an earlier stage, and provide a source of feedback which can shape the final work. For non-English speaking or inexperienced researchers, posters will always be less threatening, allowing any grammatical or BMJ VOLUME 316
10 JANUARY 1998
scientific difficulties to be ironed out in advance. Some people would argue that the threshold for accepting poster abstracts should be low, on the grounds that it encourages talent from underdeveloped medical cultures. It is a rather cynical encouragement, however, which necessitates the handover of substantial amounts of money in conference registration fees. The main incentive for many people— despite the attractions of travel—in presenting a poster is that the abstracts for any self respecting congress will be published, usually in one of the relevant specialty’s more highly regarded journals. My recent conference experience would suggest, though, that this trend is having less than beneficial effects on research and researchers. At one session at the recent World Congress of Neurology, 24 out of 78 poster sites remained vacant, the remaining sites being occupied by small audit projects, or poorly constructed, ill conceived and (by implication) unethical trials, or even (despite the conditions stated in the original call for abstracts) single case studies. Anyone looking for respite from the demands of randomisation or control groups would have been delighted. You might wonder why you should pay any attention to this, my own small
uncontrolled study? Admittedly, if the only negative aspect of poster sessions is that delegates have to bear the sight of some rather poor science, while avoiding eye contact with the nervous authors, then I would accept that abolishing the sessions would be unnecessarily harsh. The matter, however, is somewhat more sinister. Automatic acceptance of abstracts for poster presentations means that unscrupulous doctors can gain citable publication (and therefore academic credence) with work that might never have been seen in public, never mind subject to adequate peer review. The potential for such abuse is realised when abstracts appear with eponymous titles, reading more like advertisements than considered science. In four years’ time the next World Congress of Neurology will be held in London. I hope that there will be some vigorous vetting of the submitted abstracts, imitating those meetings where acceptance of an abstract is an honour, not a basic right. Ideally, the need for income will come second to the desire to see good clinical science rewarded before bad. Evidence from other conferences, though, would suggest that the profit motive will win once again. John Paul Leach, specialist registrar in neurology and neurophysiology, Liverpool
157
