Illustration: Paul Aitchison
Illustration: Paul Aitchison

Unhealthy reporting

Health journalism remains captive to commercial interests and government policy.
Illustration: Paul Aitchison
Illustration: Paul Aitchison
(This is an essay from our print quarterly 'Growing Media, Shrinking Spaces'. See more from the issue here.)
For much of the history of Indian journalism, reporting on health issues was not even considered a 'beat'. It was one of the many side beats or sub-beats of reporters covering more important beats like politics, governance, law, science and even sports. Health 'reporting' was often published in a column format, or, alternately, a page or two in a women's or general interest magazine would be given for a discussion on diet or some other ailment. This tepid kind of 'disease' and 'lifestyle' reporting has now been mainstreamed into news pages under the rubric of 'health'.
In the early 90s, when health reporting began to gain recognition as a separate beat, it was considered a soft beat, distinct from 'hard' news which was about more important issues. At the beginning of its evolution, health reporting was essentially concerned with the public sector – government health ministries and departments, hospitals and other public health facilities, along with some amount of disease reporting. Private sector coverage was almost non-existent, and the few journalists doing it were often sneered at as PR merchants giving free advertising to profit-making enterprises. A reporter writing about a private sector doctor or establishment had to contend with peer speculation as to whether the story was a 'plug' or real news. This might not have been entirely fair: considering that over 70 percent of the public accessed private sector healthcare, they could probably have used more information on it.

If reporters are reluctant to do their own reporting and investigation, the least they can do is read stories written by others who have.

Still, there had always been reporting on the healthcare market, most of which was done by business reporters writing about pharmaceutical and medical equipment companies, as well as on private health care providers such as hospitals and diagnostic chains. When filed by business reporters, these stories tended to lose their relevance to public health, instead becoming stories on health industry profits, stocks, shares and investment. By the beginning of the millennium, however, health reporting had come into its own, and had even established its own sub-divisions, covering policy, research, the market, and private and public services. Today, health has become a far more important beat, with most publications having full-time health reporters. Health stories are attributed more space than in the past, even if they're seldom front page news.
News you can use
As health journalism developed, so too did its coverage of the private sector. The rise in coverage kept pace with the growth of corporate healthcare in the 90s, when big hospital chains and corporate hospitals established full-fledged PR departments. This period also saw a mushrooming of PR companies, and a large number of these firms went on to specialise in health-related issues, establishing a clientele exclusively from the health sector that included individual doctors and hospital chains, as well as large international organisations such as the Bill & Melinda Gates Foundation and PATH.
While increased reporting on the private sector is to be welcomed, much of the coverage is problematic. Indeed, stories seldom concern themselves with the rising cost of healthcare in the private sector, the sector's lack of regulation, or the dubious habits that pervade private practices (such as forcing patients to buy medicines from hospital pharmacies, even if the same medicines or consumables are available at far cheaper rates outside the hospital; or how doctors in private practices direct patients to specific hospitals that pay them a commission for every patient referred). Instead of real reporting, most stories amount to gratuitous plugs at worst and subtle promotion at best.
The most common stories of this variety are those that claim a hospital or doctor as being the 'first' to perform a certain procedure. To this end, coverage in 2012 of the development of 'pin-less navigation for knee replacement' was typical. Reports appearing about two months apart in Times of India and DNA claimed that a doctor in Mumbai pioneered the cutting-edge 'pin-less navigation' technique. Hindustan Times, meanwhile, published a report around the same time stating that a hospital in Jaipur performed the first surgery of that kind in the country. But the articles had serious omissions: none discussed the cost of the surgery; none addressed the question of whether all knee replacement surgeries would benefit from this technique; and none asked whether there are drawbacks to the procedure that patients must be made aware of. Likewise, not one of the articles consulted more than two medical professionals, preferring instead to get the bulk of the story from the very doctor who performed the surgery. This is emblematic of a journalistic malaise in which every new surgery, device or diagnostic technique, is promoted with little perspective provided as to its cost, or indeed, its benefits relative to products and services currently available. Moreover, stories are rarely subjected to basic fact-checking that would establish whether the medical 'breakthroughs' are as revolutionary or 'new' as is being claimed.
Many of these stories fall into a category, now popular among newspaper editors, called 'news you can use', i.e. news that is supposedly useful to readers by giving them information about things they might not know, but might need to know. A recent article headlined 'Asia's first silent MRI launched' reflects this category of 'news'. The 200-word article fails to question the cost of the technology in relation to a regular MRI machine; neglects entirely to address the clinical advantages of the machine; doesn't make mention of other locations in the world where the new machine is being used; and fails to ask whether noise is such a huge problem for those who currently undergo an MRI screening. Indeed, the article might as well be an advertisement for General Electric's new MRI machine.
Reporting on robotic surgery has likewise been fraught with oversights: no matter which media house or publication, most of the stories read like advertorials. The coverage given by one health reporter, who has written four stories on robotic surgeries in just over a year, is symptomatic of broader failings. Peppered with phrases like "safest and almost painless method for surgery", "helps in early recovery of the patient" and "reduces surgery related risks", the articles shy away from discussing the escalation in the cost of robotic surgery, the risks involved and how it may not always be the best surgical option, or the higher training requirement for surgeons performing the procedure.
Most stories about robotic surgery are similar. Almost all papers have done at least half a dozen stories on robotic surgeries, and barring a few exceptions, none of the relevant issues have been raised. Many of the stories on the technology, for example, mention the Da Vinci robot sold by Intuitive Surgical, Inc, but fail to mention that the machine costs over INR 89.8 million (USD 1.5 million) and that its service contracts run from INR 5.9 million (USD 100,000) to INR 10.2 million (USD 170,000) per year while its disposable instruments – for which each procedure uses three to eight – cost between INR 36,000 (USD 600) and INR 60,000 (USD 1000) to replace. They also fail to mention the fact that the company has been on the receiving end of a warning letter sent by the US Food and Drug Administration (FDA) for the rising number of adverse incidents related to the technology, including 282 injury reports and 28 deaths in one year.
Given that a simple Google search on robotic surgery throws up a dozen stories on the procedure's risks and the controversy it has generated (especially in the US), there is little excuse for this lack of context and insight. It would certainly be of interest to Indian readers that the American College of Obstetricians and Gynecologists issued a statement saying that "Robotic surgery is not the only or the best minimally invasive approach to hysterectomy… nor is it the most cost-efficient." Likewise, one imagines some level of concern at an advisory published by The Massachusetts Board of Registration in Medicine discussing the "increasing number of reports of patient complications associated with robot-assisted surgery". If reporters are reluctant to do their own reporting and investigation, the least they can do is read stories written by others who have. Do reporters even do a cursory check before they file stories? Can they be condoned for not running basic checks in the age of Google, when verifying and researching a claim or topic has never been easier? Do editors ever hold reporters to account? The stories being published indicate that they don't.
Doctors in India are, by law, prohibited from advertising, making 'news' stories an invaluable avenue for medical practitioners to gain recognition and advertise their skills and services. Though they may not have to purchase ad space, most of them, or their hospitals, do employ PR agencies, or have paid PR professionals on their staff promote these stories. And such stories appear far more credible than any paid advertisement because readers, even today, believe that they have been vetted by a reporter. Earlier, even hospitals did not advertise. This convention is being eroded steadily. Hospitals – more so hospital chains or corporate groups of hospitals – are now pursuing direct-to-consumer advertising, as evidenced by the increasing number of hospital chains advertising on television, and in newspapers and magazines. With medical service providers becoming important sources of revenue for the media, one can expect it to become even tougher to pursue critical stories on private sector operators.

In health reporting, there is a need to ask questions – even seemingly stupid, obvious or superfluous ones – and ask them to the highest, most powerful bodies and people; both international and national, scientific and policymaking.

In this context, it is far easier to get promotional stories into print than those on policy issues, which are often buried in the inside pages, if published at all. Reporters are quick to get the message, and start filing more of the stories that 'sell' rather than the difficult-to-pursue and harder-to-make-interesting stories on public health policy. Too often, policy stories are restricted to the verbatim reiteration of government announcements and press releases, and are filed with almost no perspective or critical input given by the journalist. To provide a relatively innocuous example, newspaper coverage of the announcement that Delhi's public hospitals will have online registration for their out-patient departments (OPDs) amounted to the publication of the government's own press release. For the most part, published articles did not look at the relevance of the declaration in light of the percentage of patients that visited public hospital OPDs and had internet access, or address whether those lacking such access would be pushed to the back of the line by hospitals giving preference to those who booked online. Is registration the most pressing problem in OPDs? Did any editor ask reporters these questions? The kind of stories being published and the way they are reported seem to indicate that there is little or no editorial oversight.
Tough questions
In health reporting, there is a need to ask questions – even seemingly stupid, obvious or superfluous ones – and ask them to the highest, most powerful bodies and people; both international and national, scientific and policymaking. The example of the polio eradication drive is a case in point. By and large, the media coverage of polio eradication revolved around the relative successes or failures of the Pulse Polio Campaign – how many rounds of polio drops were being administered, how many cases were still surfacing and from where, whether the government's response each time polio cases surfaced was adequate, and so on. But there was little or no questioning of the very rationale of
the campaign.
Why anyone would want to cast doubt on an obvious good such as polio eradication is an understandable question. But journalists could approach the issue in more nuanced, insightful ways. Why, for example, was the polio campaign being run as a parallel and separate programme from the Universal Immunisation Programme? Why was the Pulse Polio Campaign, which is designed to eradicate a single disease, getting four or even five times the funds being allocated for routine immunisation that targets six diseases?
Indeed, if 100 percent coverage of polio drops administered during routine immunisation could be achieved, would it not help to eradicate polio and also prevent children from dying of other vaccine-preventable diseases by strengthening the infrastructure of routine immunisation? Why is it okay to ensure that not a single child is disabled by polio, but acceptable that thousands of cases of vaccine-preventable diseases like diphtheria, pertusis and tetanus are still occurring? Why does a sovereign government allow the World Health Organization (WHO) or the Gates Foundations of the world to set its health agenda? After all, foreign aid comprises just 1.6 percent of total health spending in India.
All of these questions needed to be asked, but seldom were. Nonetheless, there was some mention of the decline in immunisation coverage, which is said to have been caused by the intense focus on the Pulse Polio Campaign to the exclusion of all other public health services at the primary health care level. But the decline in routine immunisation could not be ignored: public health experts wrote extensively on it, and the impact of the decline was nationwide, affecting even high-performing states like Kerala and Tamil Nadu.
As a part of the tight surveillance of polio, cases of acute flaccid paralysis (AFP) have been reported as having no relation to the polio virus. But in the process of eradicating polio, India has become the country with the highest rate of non-polio AFP in the world – almost 55,000 cases in 2013 alone. While advocates of the polio programme have attributed the steady rise in AFP to increased surveillance, critics allege that the rise in prevalence could be a result of too many rounds of polio drops being administered to children. Nowhere in the world have so many children been given so many rounds of polio drops. Would it make a parent feel better if told that a child's paralysis is not from polio, but from some other cause? Does India have a public health system that can offer treatment to children afflicted with AFP, which is often reversible with treatment? If the public health system is not geared to do so, is it fair to expose children to increased risk of contracting AFP, if that is the result of getting more polio drops?
Rather than addressing these concerns and scientifically examining and responding to them, the media is told that pursuing such stories would jeopardise the Pulse Polio Campaign. Individual reporters are admonished about doing irresponsible journalism that could add to popular resistance to the endless rounds of pulse polio drops being given. Editors are contacted to prevent reporters from pursuing 'damaging and irresponsible' stories. A sort of uncritical buying in to so-called 'programmes for the greater good' is expected of health reporters. While no one is disputing the many great achievements of the polio campaign or begrudging legitimate coverage of such a massive public health exercise, it would be undesirable and irresponsible if reporters were to cover it uncritically.
The December 2011 introduction of the pentavalent vaccine in India provides another example of how health reporters are encouraged not to question government policy. The pentavalent vaccine is a combination vaccine for protection against five childhood diseases – diphtheria, pertussis (whooping cough), tetanus, hepatitis B and pneumonia, and meningitis caused by Haemophilus influenza type B (Hib). This vaccine replaced the traditional DPT (diphtheria, pertussis and tetanus) vaccine given to children at six, 10 and 14 weeks of age. By using a combination vaccine, children would get fewer jabs. However, DPT costs only INR 28 (USD 0.47) per vial of ten doses. The pentavalent combination vaccine is said to cost INR 525 (USD 8.77) per child and even with a subsidy of INR 145 (USD 2.42) from the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunisation) for the first five years, it would cost INR 380 (USD 6.34) per child. Several public health experts and civil society groups questioned how prudent it was to introduce a vaccine so expensive when India was failing to spend enough on its immunisation programme to ensure that the basic vaccines reached a coverage level of at least 90 percent. In large states such as Uttar Pradesh and Madhya Pradesh, the percentage of fully immunised children continued to hover at around 40 percent when last surveyed in 2012.

When controversial public health measures, such as the introduction of a new vaccine, are implemented, journalists are required to be aggressive in holding the government to account.

While there was criticism about how new, 'relatively useless' vaccines were being allowed to piggy-back on standard essential vaccines like DPT, many scientists in favour of the pentavalent vaccine dismissed this criticism, saying that the pentavalent vaccine's Hib component would help prevent pneumonia, which is a common killer of children born into poverty. However, critics point to an Indian Council of Medical Research study publicly available on the website of Cochrane Collaboration (an international network of health specialists), which claimed that DPT, given with the additional hepatitis and Hib components present in the pentavalant vaccine, was less effective than when the vaccines were given separately, while side effects were greater when the vaccines were administered in combination (as in the pentavalant vaccine). The fact that globally, at least 63 post-pentavalent infant deaths had been recorded added to the controversy. The result of this controversy was that the pentavalent vaccine was introduced in December 2011 only in two states with good immunisation infrastructure and strong adverse event monitoring mechanisms – Kerala and Tamil Nadu. There were at least 17 deaths in Kerala and three in Tamil Nadu.
Between the second half of 2012 and March 2013, before the data from Kerala and Tamil Nadu could be analysed, the pentavalent vaccine was introduced in Karnataka, Puducherry, Goa, Gujarat, Haryana, Jammu & Kashmir and Delhi. By the end of 2013, the reported death toll in India following consumption of the pentavalent vaccine had reached 54. Unlike medicines that are given to sick people to cure them, vaccines are provided to healthy babies and people in order to save them from possibly contracting a deadly disease. While side effects are often accepted as the price to be paid for making a sick person well again, the fact that vaccines are administered to healthy individuals should make the safety requirements extremely high: death and serious side effects are unacceptable. In the wake of the pentavalent deaths, the Indian government failed to carry out basic public health measures such as immediate investigation and the public diffusion of relevant information; instead it went into cover-up and denial mode. When controversial public health measures, such as the introduction of a new vaccine, are implemented, journalists are required to be aggressive in holding the government to account while being extremely cautious in how they cover the issue – particularly when strong arguments and counter-arguments exist on both sides of the debate.
It would be unfair to say that deaths associated with the pentavalent vaccine went unreported by the media. But reporting in relation to the hurried introduction of the vaccine was muted, and government officials went largely unchallenged when arguing that most of the deaths were unrelated to its immunisation programme. In such cases, it is often difficult for reporters to go against the government line, as officials may turn hostile. To gain access to the relevant officials and thereby ensure a steady supply of stories on health, reporters can become 'prisoners to access', and refrain from being antagonistic in their coverage.
To compound matters, journalists are often inundated by international experts who are roped in to support the science behind the government's line. It may help journalists to remember that the WHO, touted as an independent international authority on public health, is neither always above suspicion, nor always right. In 2009, the WHO declared H1N1 a pandemic when it wasn't one, and forced countries (via 'sleeping contracts' with pharmaceutical companies that become active upon the declaration of a pandemic) to waste billions of dollars in stockpiling the vaccine, providing a windfall for the vaccine manufacturers. Investigations by the British Medical Journal along with the Bureau of Investigative Journalism in London revealed that scientists who gave advice on which vaccines, and how much of it member-countries should buy, had financial ties to various pharmaceutical companies including GlaxoSmithKline, Novartis, Solvay, Baxter, MedImmune and Sanofi. Keeping a list of independent industry experts to consult, and checking for conflicts of interest within policymaking bodies, should be a basic, though crucial, part of reporting on major public health policies.
Even more routine policy-related stories suffer from similar deficiencies. Recent coverage of the Central Government Health Services (CGHS), which is supposed to cover the health needs of central government employees and their families, left many gaps. The story was about private hospitals, empanelled to provide healthcare under the CGHS, refusing to provide cashless service because of a dispute over the fixing of rates for various surgical procedures and the government's non-settlement of long pending bills. Generally, there were no details or examples of the rates fixed by government for procedures versus what private providers were bargaining for. The articles made clear that unpaid bills are pending, but give no details about the amount pending or how long they have been pending, or even the nature of the pending bills. One wonders how such stories get past editors, or whether any gatekeeping is done at all when basic facts are missing in a story.
A story that writes itself
A dearth of critical policy stories on health co-exists with an abundance of stories peddled by PR firms that represent all kinds of clients. For example, a pitch for a story about an in vitro fertilisation (IVF) clinic becomes packaged by a PR agency as a story about infertility in metro cities. The pitch is given as a 25 page academic paper on infertility, complete with charts, graphs and data on different aspects of the problem. The only catch is that the 'academic' paper is not published in any peer-reviewed journal. But it has plenty of quotes from doctors in the IVF clinic, and the PR firm could get the journalist more if required. If the reporter insists, the firm could even get them quotes from doctors in rival IVF clinics. For health journalists, this becomes a story on infertility, a topic of great interest to newspaper editors and readers, coming to them packaged and ready to be used with little effort.
As soon as an 'International Day' for this or that draws close, health reporters are approached by PR firms with readymade stories. And there is no dearth of commemorative days for various diseases and causes. On International Women's Day, for example, a public relations company pitched two different stories to health journalists. One was on polycystic ovary syndrome, a lifestyle disease, and the other was called 'Mommy makeover' – on the rising trend of body contouring after childbirth. The press release had three patient stories, a couple of quotes from hand-picked doctors, with a few trend marking percentages thrown in. The reporter, to soothe her or his conscience, could possibly make a couple of phone calls with the relevant doctors or patients, all arranged by the PR agency. Or, if even more conscientious, the reporter could talk to a doctor or two from other hospitals. Even photographs could be made available. If the reporter is particularly lazy, the story could be turned around by simply rewriting or rearranging the press release. These are the so-called trend stories, derisively referred to as 'more and more' stories. With a couple of patient stories and a few quotes from doctors, you have a trend-in-healthcare story that usually starts off with how 'more and more' women/children/teenagers/adults/elderly are doing something, or undergoing some procedure, or suffering from this or that condition. In such stories, it is mostly a case of laziness than anything more sinister.

Luckily for journalists in India, especially health journalists, there is little or no critical evaluation of their work and no one to call out shoddy reporting.

Whatever the case, PR professionals claim that reporters no longer take gifts like they used to (except, of course, 'the usual' gifts for festivals), and that they do check things out for themselves before accepting pitches from PR agencies. The stories that appear, however, do not bear this out. Indeed, are gifts the only form of bribery? What about the international and national conferences that take reporters on all-expenses-paid trips to exotic destinations? These abound in the industry. Fondly called 'junkets', they have been around forever. But media houses were once careful to check the stories filed by reporters upon return, in order to ensure that there was no bias, while it was made clear to junket organisers that if there was no story, nothing would be published. Today, there are few checks and balances to ensure that reporters who go on junkets don't end up plugging their benefactors.
Just as studies have shown that clinical trials of a drug sponsored by the pharmaceutical company producing it are four times more likely to give the drug a favourable result, a similar study on stories filed from junkets would, quite possibly, produce a similar result. Luckily for journalists in India, especially health journalists, there is little or no critical evaluation of their work and no one to call out shoddy reporting. Though several websites reporting on the Indian media have emerged, most of their content is restricted to critical evaluation of political reporting or even reporting on issues such as human rights, crime and so on. There is no one keeping a consistent check on what passes as health reporting, and hence no standards are being set for better health reporting.
It has often been said that "journalism is printing what someone else does not want printed; everything else is public relations." Though it may seem puritanical and old fashioned, this sentiment is a good place to start in building the credibility of health reporting in India.
~Bindu S is a freelance health journalist who has worked for various leading newspapers.
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