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I feel there are some important lessons to be learned fromthis episode:

1. When an honest officer points a finger at powerfulindividuals and groups in politics or in industry, it is theundeclared policy of the central and state governments torender that officer powerless by transferring him or herfar away from the scene.

2. Should this not be possible, the report produced ispromptly consigned to the archives.

3. Should this too prove impossible (as in the case of JusticeLentin's report), it is ensured that those proven guilty areeither let off scot-free or, at worst, subjected to a gentletap on the knuckles.

4. Companies with a surfeit of funds, good political contactsand inside information on the working of the governmentneed not pay any attention to such 'technicalities' asethics, laws and the principles that govern the commongood. They also need never fear punitive action from theauthorities. Should a 'maverick' official attempt suchaction, he will be suitably dealt with by the powers-that-be.

Those who should be concerned with the health of thepublic-doctors and their associates-have their headsburied deep into the sand. This also happened with theglycerol tragedy in Bombay.

The only group that openly cautioned against the transferof Mr Bhatia, when the case against Glaxo (India) became

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public, was ACASH and it remains the only body fighting histransfer in the courts.

As I write this, Justice A. P. Shah of the High Court inBombay has upheld the FDA's order forcing Glaxo (India)to close down for ten days. Whilst the counsel for Glaxo(India) requested permission to appeal (which was grantedby the judge), the Consumer Guidance Society of India andseveral similar groups have urged Glaxo (India) todemonstrate that its oft-proclaimed ethical principles are stillin place by setting its house in order.

In contrast to Glaxo (India), German Remedies hasretired a key factory manager and reprimanded several otherstaff members.

It is unlikely that the situation in India will ever improve ifsuch events are left to be dealt with by either those in poweror the medical profession.

We must, therefore, applaud the consumer groups who areactively taking up such causes.

REFERENCESI Pandya SK. A review of the Lentin Commission Report on the glycerol tragedy

at the J. J. Hospital. Bombay. Natl MedJ India 1988;1:144-8.2 Bal A. Affidavit filed in the High Court of Judicature at Bombay. Ordinary

Original Civil Jurisdiction in writ petition no. 2719 of 1993. 9 December 1993.3 Anonymous. High Court upholds FDA order on Glaxo. The Times of India

(Bombay}. 1994 Jan 15.4 Fernandes A. Glaxo's defence exposes drug authorities' working. The Times of

India (Bombay). 1994Jan 15.

S. K. PANDYA

Association of Surgeons ofIndia, Madras, Tamil Nadu, India,27-30 December 1993

The four-day annual conference of the Association ofSurgeons of India (ASI) was held in Madras, the home of itsfounder, Colonel Pandalai, who with 22 of his colleaguesstarted the association in 1938. This city, in which theASI headquarter is situated, has produced many distin-guished surgeons such as A. Lakshmanaswami Mudaliar ,S. Rangachari, Guruswami Mudaliar and U. Mohan Raoamong others. The association has 8500 members and 15different chapters, and 9 sections relating to various surgicalspecialties.

About 1500 delegates attended the Madras conferencereflecting the interest of the members in its annual meetings.There was a comprehensive booklet for the social prog-ramme and scientific sessions but no abstract book, of thepapers presented, was published. A number of stalwarts,including those who had held high office, were conspicuousby their absence.

The continuing medical education programme was held aday before the actual conference in the newly constructedAnna Auditorium at the ASI headquarters. Parasiticdiseases, tuberculosis and leprosy, mycetoma, enteric fever

and tropical pancreatitis were discussed. This programmewas useful to general surgeons as well as postgraduates andprovided them a useful opportunity to interact with theteaching faculty. In the afternoon, Fellowships of the Associ-ation of Indian Surgeons (F AIS) were awarded during aconvocation. This fellowship is awarded to Indian surgeonswho have practised surgery for 5 years after postgraduation,and who pay a fee of Rs 5000. These surgeons can add FAISto their names. During the first day of the conference therewere 3 orations, 2 symposia and one guest lecture. The Co!.Pandalai Oration was delivered by Dr A. P. Pandey from theChristian Medical College, Vellore. The subject was renaltransplantation and Dr Pandey presented the work done byhim over the years and discussed what had been accomplishedand what could yet be done. The Kini and P. K. SenMemorial Orations were delivered by Drs K. V. Chaubal andA. P. Chaukar, both from Bombay. These orations, usuallygiven by persons with experience, carry great prestige andare usually well attended.

The guest lecture on 'The metabolic care of critically illpatients' was delivered by Professor T. Tashiro from Japan.Though an important subject, language difficulties interferedwith the discussion after the lecture.

A symposium on 'oral cancer' was conducted which

CONFERENCES

emphasized the practical as well as the practicable aspectsof management. Slides of oral cancer at different stagesand in different situations were shown and the convenors,Dr R. S. Rao from Bombay and Dr N. C. Misra fromLucknow, posed questions to a panel of specialists aboutwhat treatment they followed especially regarding neck nodedissection and radiotherapy or chemotherapy. It was wellattended and the discussion was good. The symposium on'Recent advances in the management of burns' highlightedthe role of honey and biomembranes besides primarysurgical excision.

The conference was inaugurated in the evening by theChief Minister of Tamil Nadu , Dr J. Jayalalitha, with thestage dominated by a large painting of her. Curiously,the balcony of the large centenary auditorium of MadrasUniversity, where the event was held, was full of non-medicalpeople shouting slogans in Tamil extolling their leader.

The ASI President, Dr S. S. Narasanagi, in his addressstressed that medical education should be based on need,with strict academic control, and clinically oriented training.In her keynote address, Dr Jayalalitha said that she hadobserved that the erstwhile brain drain was being reversedand doctors trained in the West were returning to India to usetheir skills for the benefit of their own people. Althoughshe favoured privatization of medical facilities, she wasconcerned that private hospitals concentrated and prolifer-ated only in the metropolitan cities. She was also worriedabout the rising cost of medicare, the commercial attitudesof doctors, the declining standards of the medical professionand the deterioration in the quality of patient care. Thereseemed to have been a lowering of professional ethics and astrained relationship between health providers and patients.She suggested that the ASI should strive to maintain uniformstandards to improve care. There was a distinction betweenhealth care as an industry and health care as a social service-a commitment to human life. She also said that indigenousmedical disciplines such as the Ayurveda, Siddha and Unanisystems should be encouraged as alternatives to westernmedicine.

Dr Jayalalitha was awarded an honorary membership ofthe ASI together with Mr P. S. Boulter, the President of theRoyal College of Surgeons of Edinburgh. She enhanced thelease period of the ASI land by another 30 years and fixedthe payment at a reasonable level. She also gave the ASIRs 5 lakhs to tide over its financial difficulties. The scientificsessions which followed were held in the Connemara Hotel,situated in the heart of the city. Its ballroom, however, albeitthe largest available, was inadequate for the large gathering.The other rooms were even smaller and some accommodatedonly 30 to 40 seats. Many in the audience had to stand in theaisles or outside the suites. The lectures by well knownspeakers and, papers on general surgery and surgical gastro-enterology, which attracted large audiences, were particularlyaffected. The concurrent sessions on general surgery,colorectal surgery, surgical gastroenterology, cardiothoracicsurgery, trauma and orthopaedics, oncology, paediatricsurgery, urology and plastic surgery in the different halls andsuites often led to an overlapping of papers which mighthave been of interest to any given individual. This was under-standable because a large number had to be accommodated,but the problem of attendance was made even more difficultby the speakers running over time, talking about matters

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beyond the scope of their papers and leaving little timefor discussion. This made it impossible to know what wasgoing on in another hall. A large number of the slides wereincomprehensible. There were too many and the material onthem was crowded. I felt that oral presentations need to begiven a much greater emphasis in our training programmesand this should include improving the quality of the slides.Furthermore, the audience, in sessions just before lunch,tended to move towards the dining halls, not because ofhunger but to avoid the long queues, soiled tables and usedplates strewn all over the place later.

On 28 December there were two guest lectures and twosymposia besides other sessions. Mr Boulter spoke on'minimal breast cancer' and emphasized, in a simple way,with the aid of beautiful slides, that through public educa-tion, self-examination and screening, early detection andminimal treatment is possible at very little risk. The mortalityrate can be reduced by 28% in a screened population. In situcancer is the tip of the iceberg of invasive cancer and re-currence occurs in edge-positive cases due to inadequatesurgery, the multifocal origin of tumours or biological factorssuch as oestrogen receptor negativity.

The other guest lecture by Mr R. M. Kirk on 'Teaching andassessment of surgical skills' was full of humorous anecdotes.The main message was that besides improving the art of yoursurgery 'do only as much as you can get away with'.

A panel of speakers in a symposium on 'peripheral vasculardisease' discussed its various aspects and Dr V. K. Agrawalpresented the results of using omental grafts in the manage-ment of these patients.

The symposium on 'surgical audit' moderated by Dr B. M.L. Kapur tried to highlight its various advantages. Audit andresearch. although two separate entities, are complementaryto each other. Research serves to enlarge scientific know-ledge from observations to hypotheses. which are accepted ordisregarded by a process of continuous testing, establishingvalid facts and then applying them to patients. Auditprovides a measure of that knowledge. If we want to improveand modify our surgical management, the importance ofaudit needs to be recognized. However, the speakers did notstimulate interest in the subject and this was reflected in thesparse audience and the lack of discussion afterwards.

In the colorectal section, there were talks on 'How I treatrectal prolapse', the Harry Bacon Oration on 'Colorectalcancer' by Dr P. B. Desai and a panel discussion on'Challenging problems in colon and rectal surgery'moderated by Dr I. Khubchandani from the USA. Thesewere well attended despite the constraint of space and werefollowed by stimulating discussions. However, another guestlecture by Mr Malcolm Puntis from Cardiff, in the oncologysection on 'cholangiocarcinoma' did not provide newinformation.

In the surgical gastroenterology section there was asymposium on 'endoscopic and surgical management ofbenign strictures of the oesophagus' and lectures on 'theuse of laser in open and endoscopic surgery' and 'portalhypertension'. Dr S. P. Kaushik of Lucknow provided anIndian overview of 'liver transplantation'.

There has been concern recently about the quality ofarticles published in the Indian Journal of Surgery, which isnot included in the Index Medicus. Therefore, there was agreat need for a discussion on 'how to improve the quality of

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articles published in the Indian Journal of Surgery?'However, the main speaker was absent, so a panel compris-ing of Drs N. Ananthakrishnan, Roshan Lal Gupta andS. P. Kaushik was arranged. Dr Ananthakrishnan gavereasons why he thought the quality of the journal was poorand suggested ways by which it might be improved. Whereasnearly everyone including the panelists and the audienceagreed with his assessment, Dr Roshan Lal Gupta tried todefend the Journal. Dr Patnaik from Pune commented thatcommitment is necessary to achieve excellence and cited theexample of The National Medical Journal of India publishedfrom the All India Institute of Medical Sciences which,although only a few years old, was indexed and publishedarticles of high quality. Dr Aranya did not agree with mycomment that the better Indian articles were sent to foreignjournals and whatever were left were sent to Indian journalsincluding the Indian Journal of Surgery. He said that theIndian Journal of Gastroenterology had good articlesprobably because it was also indexed.

On 29 December besides the parallel sectional scientificsessions, the symposium on 'multiple organ failure' high-lighted the management of a seriously ill patient. Mr S. P. F.Hughes from London in a guest lecture discussed 'thesurgical management of low backache', a problem of greatimportance to both general surgeons and specialists.

The Panch an an Chatterjee Oration on 'progress areas incolon and rectal surgery from lowly proctology to high-techsurgery' was delivered by Dr I. Khubchandani, a graduatefrom Bombay who is now a consultant in colorectal surgeryin the USA. He talked mainly about the progress madeover the years in colorectal surgery, and said that the rectumwas now becoming an organ for recreation as well as fordefecation.

In the surgical gastroenterological section, peritonitis,laparostomy and continuous peritoneal lavage in severely illpatients were discussed. Disorders of the pancreas were wellcovered.

Dr Mehta from Pune suggested that primary resection andanastomosis was the operation of choice in sigmoid volvulus

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in Indians, possibly because the bacterial flora in ourcolons is less virulent than in westerners.

A variety of other subjects of larger interest to generalsurgeons as well as to specialists in plastic surgery, cardio-thoracic surgery and trauma were also discussed.

The guest lecture in the oncology section by Satish Shuklafrom Indore was on early diagnosis and the results of treat-ment of breast cancer. This was well presented and heemphasized biopsy techniques to avoid painful scars.

Laparoscopic cholecystectomy seems to have taken overfrom the open procedure and now the laparoscopic procedureis being used for other operations such as appendicectomy,hernia repair, omental patch repair for perforated duodenalulcer and adhesiolysis. Practitioners of this new techniquerelated their experiences, provided tips and discussed theirdifficulties.

On the last day of the conference there was an authors'meet in which surgeons who had written or edited medicalbooks got together. However, sadly, this did not evoke anyinterest. Out of the six participants, only I, Dr Natarajan,and Dr Vittal (whose idea it was) were present. There wasno audience except for Dr A. P. Panda from Cuttack. Theconference came to a close on 30 December 1993.

Looking back many of us felt that the standard of scientificsessions at the conference had declined and there was a lackof academic content in the so-called research papers. Theorganizers of the conference also need to improve uponthe arrangements for handling such large numbers of par-ticipants. They should certainly pay more attention to thequality of the scientific sessions. A guest lecture shouldenlighten us about current advances or suggest modificationssuitable to our situation. Such large conferences should helpus improve our standards of patient care, otherwise they donot justify the vast expenditure of effort, time and money.

S. K. SRIVASTAVACharak Clinic

DaryaganjNew Delhi

People's Health in People's Hands: A Model for PanchayatiRaj. N. H. Antia, Kavita Bhatia (eds). The Foundation forResearch in Community Health, Bombay, 1993. 394pp,not priced.

This multi-author book is divided into four sections: 'Indianhealth sector', 'The voluntary health sector', 'Decentralizedhealth care' and 'The community health care system: Amodel for health in panchayati raj'.

All the authors agree that the present system of ruralhealth care is breaking down and has been intolerablyinefficient for a long time. There is also unanimity about thecauses of this decay, and it is useful to summarize thesebefore considering the various sections in more detail.

Historically, the present rigid 'top-down' system derivesfrom the traditions of the Indian Civil Service and the IndianMedical Service under British rule. Nonetheless, no one dis-putes the correctness of the recommendations of the BhoreCommittee of 1946, which initiated the setting up of primaryhealth centres and subcentres, even though they were toosparsely distributed in many states. So what went wrong?The whole system has been hijacked by the medical elite andthe drug houses, and has ossified into an inflexible structurewith a bias towards curative medicine on the western modeland a relative neglect of the rural areas. There has been anoverproduction of doctors, and private medical servicesare competing with inefficient state services in villages.The private sector is largely concerned with profit and the