Ethics and social responsibility of scientists

As researchers of the observable universe, scientists often have a major impact on society through their work. Scientists drive progress by doing research to explain certain events, patterns and phenomena happening in the world. In doing so, they create new knowledge and established facts. At times, scientific research and discoveries can alter or even overturn preconceived notions about a particular subject. In this way, scientists are often perceived as commanding a special power and authority. Consequently, they have a special responsibility to consider the implications and consequences of their work. Especially where human subjects are concerned, scientists have a duty to be socially and ethically responsible in designing their research. A flawed or biased study design can lead to skewed interpretations, and subsequently, results which are misleading can create harmful negative social impacts.

The question I wish to raise here is related to an academic paper that was published by a group of researchers mainly from the Universiti Malaya, and widely circulated around the time of the heated debate on the “foreign cook ban” issue in Malaysia. The policy was announced by the Human Resources Minister M. Kulasegaran on 23 June to emulate a similar ban implemented in Penang back in 2016. The controversial paper, titled ‘Microorganisms as an indicator of hygiene status among migrant food handlers in Peninsular Malaysia’[1], was widely shared by supporters of the ban policy, as evidence to justify the rationale of the new government ruling.

On the same day, the Star published an article featuring an interview with lead researcher Assoc Prof Dr Siti Nursheena Mohd Zain[2]. Quoting the article’s first line: “Almost all foreign workers tested in a study were found to be carrying microbes which could cause food poisoning and even death, and a small percentage of them harboured antibiotic resistant bacteria, said researchers”. Even if it was unintended, many felt that the researchers had played into discrimination, by casting doubts on the hygiene standards of ‘almost all’ foreign workers in the food and beverage (F&B) industry. A majority of migrant-supporting organisations that I spoke to were understandably furious at the paper, especially for the fact that it had rapidly gained traction for supposedly ‘proving’ the need for the foreign cook ban policy.

However, even after a backlash of public criticism, the researchers staunchly defended their position, stating that their study was not meant to divide between foreign and local workers[3]  and was not served as a comparative study.

After reading the paper, I believe the main problem lies with the way the study was designed. Significantly, the researchers had not included control groups to offer parallel analysis and possible alternative explanations of the experimental results, such as local food handlers, migrant workers in non-F&B industry and/or restaurant patrons. Neither did they include negative control group (a group in which no response is expected) such as food handlers who had just performed proper sanitisation steps. 

Why are control groups so important in this case? First and foremost, from a social context, singling out foreign migrant food handlers solely as having ‘bad hygiene’ is both unfair and unethical.

Furthermore, it is also questionable to compare the workers based on their country of origin, as the study had done. Given the large standard deviation for each group’s result, it is unfair to assume that individuals from any particular nationality are more ‘unhygienic’ than others, since within each group there is already a big variation in individual personal hygiene. In other words, some cleaner individuals would be discriminated along with their countrymen, simply because the study highlighted the effect of country of origin.

On 14 July, Penang health committee chairman Dr Afif Bahardin issued a public statement confirming that a majority of the foreigners in the state had fulfilled the typhoid jabs requirement[4]. “Instead, it was a majority of the locals employed who did not get the typhoid jabs. This is a problem.“ he said. In fact, given that Section 34(g) of the Food Act 1983 and Regulation 31 of the Food Hygiene Regulation 2009 stipulate all food handlers to undergo medical examination to ensure the person is free from carrying food-borne diseases, local employees should theoretically not encounter such problems. His statement highlights the missed opportunity of the researchers for excluding local food handlers as a control group, since food hygiene issues are likely highly pervasive and personal, logically do not discriminate on the basis of nationality.

Interestingly, despite its questionable study design, the controversial research paper had in fact been funded by several government and university research grants, and had received full ethical approval. In this light, it is pertinent that we should talk about research ethics and social responsibility.

The following are four golden rules of research ethics that any responsible researcher should apply to his or her work:

i)                    respect for persons: obtained informed consent and the voluntary goodwill/trust from subjects before performing research

ii)                   beneficence: ensure the study design is robust and beneficial to study subjects

iii)                 non-maleficence: there should not be any intent of harm, either physically or mentally, to the subjects

iv)                 justice: the findings should be seen as just/fair to the subjects, not biased due to participant selection

In this case, the researchers should have considered how the results of their study would be interpreted, in light of the sensitive (or some say, xenophobic) sentiment against foreign workers in Malaysia. While there may not have been the intent to cause harm, the study’s highly publicised unfavourable findings have subjected foreign workers to public prejudice, in extreme cases, even hatred. Such sentiments are highly damaging, especially when they still have to carry out their duties day-in-day-out for a living. On top of this, the combined threat of impending stricter health regulations and higher frequency of spot checks by the authorities have created a cloud of fear looming over the foreign worker community. These are the social consequences of a poorly designed research.

It is high time that the Malaysian Medical Research and Ethics Committee (MREC) look into such scientific research ethical issues. The controversial migrant workers’ hygiene standards paper is a good case example highlighting the shortcomings in ethical evaluation of scientific studies. Perhaps the MREC should consider displaying all research study proposals (including those that have been approved) on an online domain for open public scrutiny. In this way, the public would be able to give feedback, objections, and suggest amendments, even after formal evaluation is done and approval given.

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[1] http://journals.sagepub.com/doi/abs/10.1177/1010539517735856

[2] https://www.thestar.com.my/news/nation/2018/06/23/bad-hygiene-offers-food-for-thought-govt-urged-to-check-practices-that-lead-to-health-hazards/

[3] https://www.thestar.com.my/news/nation/2018/07/09/researchers-study-not-meant-to-divide/

[4] https://www.thestar.com.my/metro/metro-news/2018/07/14/bad-hygiene-sees-eateries-shut-some-of-the-outlets-found-to-have-rat-and-cockroach-droppings/

The edited article titled 'Unethical to single out foreign workers as being 'unhygienic'' is published here at The Malaysian Insight, Voices, July 31, 2018.

Specialist brain drain a public healthcare woe

HAVE you ever wondered why private hospitals not only survive, but thrive, even though the federal government provides our people with close-to-free or highly subsidised public healthcare?

This phenomenon is largely observed in more urbanised, advanced states, where private care is highly concentrated, such as Kuala Lumpur, Selangor, Penang, Malacca and Johor. The question is, what is it that makes locals willing to look past the additional expenditure, and bear the brunt of paying expensive private hospital bills?

According to the 2015 National Health Morbidity Survey, Malaysians who would rather admit to private hospitals tend to belong to one or more of these groups: urban dwellers, aged 30 to 59 years, ethnic Chinese or Indian, private employees, tertiary-educated, and middle-upper household income.

Statistics indicate that private hospital clients are financially better off and at the career-development life stage. The survey also revealed several reasons why people are unhappy with public hospitals: long waiting time for doctors, not being allowed to choose a doctor, difficulty in choosing wards, among others.

When it comes to private hospitals, besides possessing an established reputation, a comforting interior design and space, and state-of-the-art equipment to treat patients, the largest “asset” is actually the line-up of medical specialists, or more accurately, experienced and well-known medical consultants. Once a loved one’s health is at risk or their life is on the line, most of us would go to all lengths possible to ensure our loved one gets the best possible treatment and the highest chances of recovery. Money might matter less when life is at stake.

Seen in this way, there is a certain impression that specialists are the faces – “brand recognition” – of the host institution (private hospitals), and a major factor in pulling revenue.

Paying more for private healthcare might not always be a rational decision, however. According to Malaysian National Health Accounts statistics, out-of-pocket expenses for private healthcare amounted to RM19.6 billion in 2016, and 78% of private hospital patients decided to pay in this way.

What can we make of the general public’s distrust of government hospitals? The following is my analysis, based on perspectives collected from practising specialists, and data on their movement and numbers.

According to a parliamentary reply from the former health minister, up to December last year, Malaysia had a total of 9,632 specialists registered under the National Specialist Register. Out of these, only about 50%, or 4,843, have remained under the Health Ministry (MOH).

MOH specialists appear to carry the burden of handling about 70% of nationwide admission numbers and a larger proportion of outpatient numbers, day in and day out.

Between 2015 and end-January this year, a total of 502 MOH specialists had quit the public service. A quarter of this number directly cited “transfer to private hospital” as the reason for their resignation.

MOH has admitted that the majority of the resigned specialists held civil servant rankings of Grade UD54 and above, meaning they had served the government for at least nine years and were considered relatively highly experienced. Assuming that these specialists did not emigrate to take up better positions aboard, this brain drain from the public sector almost directly translates into the private sector’s gain.

The widening experience and skills gap between public and private healthcare may explain why certain segments of the public have a poor perception of the public healthcare sector, when they see excellent and experienced specialists crossing over to private hospitals one by one.

Taking Penang as a case study, I observed that in 2016, not only was the number of specialists in private hospitals twice those working in MOH hospitals, but in terms of average career experience, private specialists also outstripped their MOH colleagues by seven years!

This was in spite of the fact that MOH hospitals in Penang provide 45 specialty and sub-specialty services, while private hospitals only cover 35 of the more “popular” specialties.

The public sector specialist brain drain must change, especially now, after the watershed 14th general election, and the dawn of a new government. If the government is serious about changing the public’s negative perception of and bias against public healthcare, it should first and foremost keep specialists in public service.

In my opinion, it is unreasonable to expect the government to raise the salary of its specialists to be on a par with those working in private hospitals. A better and more effective approach to tackle the issue is to adjust the emolument and promotion system. It would be better if MOH could decouple from the current rigid civil servant grading system, which is tied to salaries.

It is unfair to the government and taxpayers that while MOH commits considerable sums of money and time to train medical specialists each year, all this goes down the drain when private hospitals can easily lure away the top crop of experienced specialists.

To address this, I would like to offer a bold proposal, that the government impose a “transfer fee” on private hospitals that hire former government-employed specialists, according to the specialists’ experience and skills. The monies accumulated from these fees could go into a foundation to reward deserving MOH specialists, who have a track record of outstanding performance and service. This will surely generate positive recognition, and encourage them to stay and continue serving in the public sector.

Also, to circumvent the permanent loss of experience and skills of talent lured into the private sector, the government should encourage, perhaps, even mandate, specialists in the private sector to clock in a fixed number of hours in public hospitals. This would also enable them to widen their exposure to different and new case studies. 

Additionally, private specialists should help shoulder professional social responsibility, by training housemen and specialists or conducting clinical studies. This would be seen only as fair to their colleagues in the public sector, who are still struggling to keep up with their additional duties.

The article is published here at The Malaysian Insight, Voices, July 3, 2018.