Three weeks after the surgery that shot her into national -- even international - fame, two-year-old Lakshmi Tatma continues to make news even when there is really no news. Sporadic updates on her recovery process - which, happily, seems uneventful -- still appear every now and then in the Bangalore press.
The little girl, born into a poor rural family in Bihar, went through a complicated and apparently risky 27-hour surgery, performed by a 36-member team of medical specialists, at a multi-speciality hospital on the outskirts of the city on 6-7 November. According to the doctors treating the child, hers was a rare case of 'ischiopagus conjoined parasitic twin' and the operation to separate her from the half-formed sibling was the first of its kind in India.
Exactly a week later, on the day she was shifted from the Intensive Care Unit to the ward, Lakshmi was presented to the media at a press conference on the premises of the hospital. Carried without any apparent support in her father's arms and exposed to lights, cameras and crowds just a week after undergoing a major, marathon surgery, the normally vivacious kid did not seem very comfortable. Some papers reported that she started crying and appeared tired, scared and somewhat dizzy. Bangalore Mirror even questioned the premature exposure, pointing out in a small side report that, since the doctors themselves had admitted that her wounds were still raw, she was probably susceptible to infection.
Fortunately the little girl is not being paraded any more and she will presumably recuperate all the better in relative peace and privacy. However, media coverage of the case raises a number of questions about whose "best interests" were served by the hype and hoopla.
The surgery was supposed to enable little Lakshmi to lead a more normal life. Did all the publicity help or hinder that desirable end? Was it in any way necessary for her sake? What and whose purpose did it serve? Did the fact that she was from a poor family and that her parents would never have been able to afford the treatment without the free medical care offered by the hospital play any role in making her something of a pawn, if not quite public property?
It is entirely possible that the publicity blitz that accompanied and followed the surgery had the approval of Lakshmi's parents, Shambhu and Poonam Tatma. But "informed consent" is a tricky issue in India, especially vis a vis the healthcare system and medical research, since even educated and affluent citizens here are not always fully aware of their rights as patients or as participants in research studies. Even in other parts of the world, where consumers are more conscious and assertive about their right to privacy, patient confidentiality remains a contentious issue. However, many medical associations and hospitals have taken the time and trouble to formulate detailed guidelines about if and when it is permissible to make confidential medical information public, not only through the mainstream media but also in journals and books.
Can the undue publicity that attended this case be justified in the name of public information? Considering that the doctors themselves described Lakshmi's condition as rare, it is not clear that such a lot of media coverage was required for the purpose of informing other possible sufferers about the surgical option. Reporting of the successful procedure in a reputed medical journal would probably have served the purpose. In any case, as some doctors have pointed out, publication in a professional journal is the correct first step towards disseminating information about a landmark case and/or medical breakthrough.
Was this surgery particularly newsworthy because its success demonstrated extraordinary qualities in both the doctors and the hospital involved? This is certainly a possibility, although other doctors have raised doubts about the claim that the procedure was unprecedented. Moreover, the Indian media's track record in independently verifying such assertions before rushing to report them does not inspire much confidence.
Section 6.1 of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, which relates to "Advertising," is quite clear on what is not allowed. According to the very first clause, "Soliciting of patients directly or indirectly, by a physician, by a group of physicians or by institutions or organisations is unethical. A physician shall not make use of him/her (or his/her name) as subject of any form or manner of advertising or publicity through any mode either alone or in conjunction with others which is of such a character as to invite attention to him or to his professional position, skill, qualification, achievements, attainments, specialities, appointments, associations, affiliations or honours and/or of such character as would ordinarily result in his self aggrandisement." The clause also stipulates that a doctor should not "boast of cases, operations, cures or remedies or permit the publication of report thereof through any mode."
Traditional restrictions on advertising by doctors at one time more or less universal - were based on perceived differences between a trade and a profession, and the assumption that medical practice belongs to the latter category, with its emphasis on an ethic of service in addition to technical expertise. Accordingly, most organisations of medical professionals across the world formulated strict rules defining what doctors could and could not do in terms of self-promotion. Interestingly, the American Medical Association's ban on physician advertising was lifted in 1982 after it lost a court battle with the Federal Trade Commission, which had filed an anti-trust suit on the issue. Although medical associations in some countries have relaxed their rules against advertising in recent times, most still have detailed guidelines on ethical advertising by physicians, focusing particularly on ensuring that it is not false or fraudulent and that it serves the interests of patients.
Of course, hype generated through the news media amounts to (presumably) free publicity or, at most, surrogate advertising rather than advertising per se, which must be paid for according to established rates. But the growing trend is obviously causing concern within the profession across the country. For example, in 2004 the West Bengal Medical Council responded to the increasing tendency of doctors to publicise their work through the media by adopting a new Code of Ethics clearly directing doctors in the state to refrain from soliciting patients, directly or indirectly.
In any case, Lakshmi's is not the first instance of a medical case being subjected to a media blitzkrieg. For example, the 2003 case of Noor Fatima, the two-year-old heart patient from Pakistan, was an even bigger story emerging from Bangalore. Questions of privacy, confidentiality and the public interest also surfaced more recently in the case of Gitanjali Nagpal, the Delhi-based former model fallen on bad times, whose medical records were made public through the media.
In fact, the day before the recent follow-up report on little Lakshmi's health status appeared in a newspaper, the Sunday supplement of The Times of India (25 November) featured a long interview with Gitanjali, complete with a quote from her psychiatrist confirming that she has "encapsulated delusion about people and events in the past." It was not clear whether the interview was conducted in a hospital or a home, and with whose permission (although unidentified "well-wishers" were mentioned as being present). And it was certainly unclear what public purpose was served by interviewing a mentally disturbed patient who still has a long way to go on the road to recovery (as the writer herself admitted).
Not so benign neglect
The inordinate amount of media attention attracted to a few select medical cases contrasts sharply with the media's relative neglect of other health-related events and issues within the country. For example, in a typical week (20-26 November, inclusive), the largest number of items in the Bangalore-based press were either articles sourced from international media and/or reports on the findings of sundry international research studies.
The selection appeared rather arbitrary and whimsical: a Washington-datelined Agence France Presse story on Alzheimer's patients and social relationships, an Associated Press story from New York on a breakthrough in cell research, a Press Trust of India story from London on how sleeping can help new mothers lose weight, an Indo-Asian News Service story about the links between handwriting and heart condition, a Daily Mirror piece on the connection between obesity and cancer, and so on. Most such pieces were just reproduced, with no reference to local information or work, if any, on the topics.
Another category of health-related material in the media that week comprised bizarre factoids - e.g., "The strange case of the giant hairball," informing us that doctors in Chicago had removed "a mass of black, curly hair, weighing 10 pounds, from a woman's abdomen." Then there were the usual "lifestyle" features on diet and exercise. Yoga is, of course, particularly popular these days and several papers regularly carry instructions on asanas for various ailments.
"Pop health" articles offering banal advice are also fairly common (e.g., in a column on 'women and wellness' that dealt with sleep problems: "Make sure your bedroom is dark, quiet and that your pillows, sleep surface and coverings are comfortable ;" in a report on winter healthcare: "Combat dryness and itching of skin by using emollient creams and lotions as they moisturise the skin "). Some of these pieces occasionally included questionable information: according to the one on winter blues, "Asthma is caused because of the severe temperature difference between the outside air and the airways " It is difficult for even a relatively alert reader to determine whether the interviewer or the interviewee is at fault in such cases.
Some news reports on health and medicine raise questions about what makes news and what serves whose interest. For example, during the survey week, one highlighted new private medical facilities in the city ("Spine centre inaugurated"), another marked 'National Newborn Week' with a report headlined "Neonatal care gets fillip" - mentioning new equipment and facilities and quoting doctors in two private hospitals, one in Bangalore and the other in Hyderabad, and a third piece reported a supposed surgical breakthrough ("Team of doctors saves woman with 'ovarian pregnancy' in Madikere"). The only public health issue covered in a local news report that week was the reappearance of dengue in the city.
A report headlined "A doc who knew not his pulse," discussed the sudden, apparently mysterious death of a former minister's doctor son-in-law, but had contradictory information about possible causes. A business story forecast healthy growth for "our" corporate health care giants.
News items based on official statements constitute another category of health-related coverage in the media. Apart from the apparently unending spat between the Union Minister for Health and Family Welfare and doctors at the All India Institute of Medical Sciences, Delhi, reports during the week featured a number of announcements and exhortations by the former inside and outside Parliament.
Among other health-related reports was an all-too-brief one based on an international study reported in the science journal, Nature (with one Indian on the research team), which highlighted the likely national economic losses due to India's burden of chronic non-communicable diseases (CNCDs) -- to the tune of US$ 237 billion! Another item reported that the Medical Council of India (MCI) would now make it mandatory for doctors with foreign degrees to clear a screening test before being allowed to practice in the country.
Through the week under review the press also featured two health-related editorials (both on HIV/AIDS) and two major health-related interviews (both with foreign doctors - one on the fight against tuberculosis and the other on the introduction in India of a different surgical treatment for corneal blindness). However, through the entire week only one story represented original investigative work on health: a pair of Bangalore Mirror reporters surveyed city pharmacies operating without a trained pharmacist and displaying rented pharmacy certificates.
Health is clearly a matter of great public interest as well as considerable, legitimate individual self-interest. Under the circumstances it is surprising that media coverage of health-related events and issues is as ad hoc, haphazard and superficial as it is. It is also a matter of concern that health coverage is all too often susceptible to manipulation that makes a mockery of the ethics and standards of both the media and the medical profession.