Some more facts

We have still not analysed all the evidence available.

Look at the authors’ list. This study has, guess what, 31 co-authors [See Table 1]! A record of sorts. There are 19 authors from the UK, 2 from the School of Medicine, Cardiff University; and (mark this) 17 authors from the Health Authorities in UK – 16 from the Health Protection Agency Centre for Infections, London, UK, and 1 from the Northumbria Healthcare NHS Foundation Trust, presumably also a health authority related agency (all marked ^c and ^k in Table 1).

Such a large number of authors from the UK Health Authorities, 17 for a single paper, by their sheer numbers, must have ensured their viewpoint prevailed, in spite of there being 5 authors from India. One can understand how they managed to protect their health industry interests, and that of their citizens, incidentally maligning the Indian medical tourism industry in the process.

The corresponding author (marked * in Table 1) is from the Department of Infection, Immunity and Biochemistry, School of Medicine at Cardiff University, who probably got all the authors to collaborate with him. He is named third author here, but must have played a key role, as will be obvious in the next section. For, we have to look into some more facts available to piece the whole story together.

The study responsible

Let us trace the roots of this designated name, NDM-1. And here, we come to an interesting phenomenon.

The name was first used in a Dec 2009 paper (online Sept 2010) by Yong and colleagues (Yong et al., 2009) published in Antimicrobial Agents and Chemotherapy, another proper speciality journal (of the American Society for Microbiology) [see Table 2].

The genesis of the name is as follows. Yong et al. 2009 reported of a 59-year-old patient of Indian origin settled in Sweden. He had uncontrolled type 2 diabetes mellitus and had earlier had multiple strokes. While on a visit to India in 2007, he developed gluteal abscess and was treated with limited success in Haryana as also in a hospital at New Delhi. He shifted to Sweden where he continued treatment. Here, in January 2008, his urine sample tested positive for Klebsiella pneumoniae harbouring a new enzyme of the metallo-β-lactamase family.

Since this patient had earlier reportedly been in a New Delhi hospital, the sample was “designated” New Delhi metallo-β-lactamase, or NDM-1, probably by the microbiologist/s there, “1” probably being the number of the sample.

The interesting part

Look a little carefully at Table 2. You will find that three out of the seven colleagues in this 2009 paper happen to be none other than authors from the 2010 The Lancet Infectious Diseases(marked, ’ @ Common authors in both papers in Tables ​Tables11 and ​and22’).

And the corresponding author for both papers is the same (marked “*corresponding author common to both papers in Tables ​Tables11 and ​and2”),2”), along with another author from Cardiff, and the one from Karolinska, Sweden (who was probably responsible for the Swedish connection and the patient sample).

Also, the method of using author names for publication in this 2009 paper is the same as in the 2010 The Lancet Infectious Diseases paper. The lead author here is from the Republic of Korea, as are some others, just as the lead author in The Lancet Infectious Diseases paper was from India, as were some others.

In other words, the lead authors in both the 2009 and 2010 papers were the fronts while the control probably remained with the corresponding author in both cases.

This, incidentally, is what the lead author of The Lancet Infectious diseases study has also implied when he disclosed he was not consulted as regards the final draft, and did not agree with the alarm raised in the conclusions there – that those visiting India beware, for medical tourism or otherwise (Narayan, 2010; see http://timesofindia.indiatimes.com/city/chennai/Indian-author-says-superbug-report-is-fudged/articleshow/6302479.cms),because their health would be severely compromised in a country with poor asepsis and “high level of antibiotic resistance” (Yong et al., 2009). For, this is what the lead author is quoted as saying in the above press report: “I do not agree with the last paragraph which advises people to avoid elective surgeries in India. While I did the scientific work, correspondence [sic] author… of Cardiff University was assigned to edit the report”. Contrary to this is the statement from the section “Contributors” in the Kumaraswamy et al., 2010 paper: “All authors were involved in the compiling of the report and approved the final version”.

This means either the lead author is concealing the truth or the final draft was edited and prepared by the corresponding author and sent away to the editorial office, and accepted as approved by all authors at that office, without verification, in good faith, since the lead and other authors must have earlier given the corresponding author a blanket permission to do everything regarding the paper on their behalf.

Can anyone imagine a paper getting published without the concurrence of the lead author? Someone from the editorial department at The Lancet Infectious Diseases must answer for this. Either the corresponding author had ridden rough shod, or the lead author was backtracking to reduce the domestic heat on him. More on this later, in the last section on editorial responsibilities.

In other words, the main actor in this whole naming act remained the corresponding author, who continued to hold the threads, while the rest played to his tune.

Designated, and therefore, liable to change

To be fair to them all, Yong et al.’s 2009 paper, which named the original sample, called it “designated” NDM-1. Even The Lancet Infectious Diseases 2010 paper calls it “designated” NDM-1.

This means it was only so “designated” in both these papers. Designated means subject to confirmation/acceptance by others, which means there is a definite scope for change.

What happens to subsequent publications?

The legitimate question that comes up here is: If one even thinks of name change, what happens to papers published subsequently, since the name must have already been used in numerous papers published later?

Conducting a literature survey, one finds that papers which have subsequently appeared have been quick to latch on to this name [Muir and Weinberg, 2010; Centres for Disease Control and Prevention (CDC), 2010; Karthikeyan et al., 2010; Deshpande et al., 2010; Sidjabat et al., 2011; Bonomo, 2011; Poirel et al., 2010; Poirel et al., 2011a; Poirel et al., 2011b; Poirel et al., 2011c; Nordmann et al., 2011a; Nordmann et al., 2011b; Pillai et al., 2011; Samuelsen et al., 2010a; Samuelsen et al., 2010b;Woodford et al., 2010; Rodriguez-Martinez et al., 2010]. This is understandable as scientists usually do so unmindful of the repercussions of names giving, obsessed as they are with the technicalities of their work. What is understandable, however, is not necessarily justifiable.

Now, on closer scrutiny, one finds that most of the papers using this name have the same authors as the Yong et al., 2009, and Kumaraswamy et al., 2010 papers; and the rest are a small close circle of authors. Moreover, this name has been in use only from late 2009 to early 2011, i.e. less than 18 months.

So, it is not a fact that numerous biochemical/microbiological scholars have used the name rampantly for many years.

The rest of them who have used the name are the interested lay press and internet encyclopedias (e.g. Wikipedia, 2011), who would be quick to latch on to a new name as well, provided the broad scientific community agrees.

So, it is not the case that a scientific name change, if necessary, will cause a big reorganisation of the scientific record.

What is scientifically ominous about this enzyme and related gene?

As we are at the science involved, we must also understand why the interest in scientific circles in this enzyme and related gene. To understand this, we must know what is ominous about this enzyme. I will try and simplify it as much as possible. It belongs to the family of carbapenemases, which cause antibiotic resistance to carbapenems, one of the highest classes of antibiotics. Carbapenems are a special class of antibiotics used when the standard line fails. If they fail, one is left with very little option, i.e. only the polymixins (like colistin) and tigecycline. In fact, as late as the 1980s and 1990s, carbapenems were considered the “last resort antibiotics” used primarily against extended-spectrum β-lactamase (ESBL) or AmpC-producing gram-negative bacteria (Bonomo, 2011).

Here was a development whereby one more microbial mechanism was defeating man’s war against infectious diseases. What was further discomforting was that this enzyme caused genetic changes in bacteria whereby they could transfer immunity to other bacteria via plasmids. Plasmids are DNA type substances that can be passed on via horizontal transfer to other organisms, thus conferring immunity against higher forms of antibiotics. And not just to K. pneumoniae, but many others, rather the whole of the Enterobacteriaceae family (some as benign as Escherichia coli normally present in our intestines). Also, such horizontal plasmid transfer was potentially possible to other bacteria types as well. In other words, this genetic transfer could potentially make even the most benign organism the most virulent. This has not still happened, but it held such a potential threat.

Bacteria and their hosts (human beings) are in a never-ending battle. But this was one development that would give bacteria a clear edge, something science could ill afford to ignore.

The whole uproar and interest in biochemical/microbiological circles to understand this, and control it, is therefore, most legitimate.

Plasmid encoding as the important characteristic of this gene and carbapenem resistance as an important characteristic of this enzyme must be noted, for it has importance in our later discussion about a scientific name change.

Scientific names giving

Why the problem?

While a name can be appropriately connected to a scientist, place or institution, it can also be thoughtlessly so connected. The problem arises due to naming a gene, disease, bacterium, enzyme, etc. after a city/country, which some scientist presumes to be the city/country of its origin. It is the latter that we got to be wary of, and this has got highlighted in the present case. Names like “German” measles, “Australia” antigen, “Mexican” swine flu, “Delhi” belly, “Mongolism”.

Think about it this way. What is German about German measles? Or Australian about Australia antigen? Or Mexican about H1N1? Or Delhi about the so-called “Delhi belly”? Or “Mongol” about Mongolism? Or Haitian about the 4-H disease (the earlier name of AIDS, for those who are not aware)? All these are universally present conditions, but so named just because some scientist presumed they originated there, or some condition mimicked some race.

Graphic, true, but indiscreetly used words, since a convention allows for it (for there is one of using toponymous words for diseases). Why indiscreet? Because it can amount to names calling, unless the city/country is proud to own responsibility. If Germany, Australia, Mexico, New Delhi, Haiti and the Mongols felt proud of being named in such a way, could anyone object? But they do not. That is the key issue, and this incident has only italicised it.

It is time scientists stopped being naïve to names giving in science.

Names changing

The question that now comes up is whether a name, once given, can be changed. The answer is yes. Whenever names have been considered derogatory to a certain place or community, science has been persistent that the names be changed.

We just saw Down’s syndrome was earlier called “Mongolism”, Rubella was “German” measles, and HBsAg (Hepatis B surface antigen) was “Australia” antigen. Traveller’s diarrhoea was earlier called “Delhi” belly, and schizophrenia was earlier called “dementia” praecox. A patient with a psychosis was earlier called “insane”, “mad”, “lunatic”, etc. The “pandemic H1N1/09” (WHO) or “2009 H1N1 flu” (US Center for Disease Control) was earlier called “Mexican” swine flu. AIDS was earlier GRID (Gay Related Immune Deficiency) in the lay press, and even a scientific body like the US CDC earlier called it the “4-H disease” (the “Haitians”, “homosexuals”, “haemophiliacs”, and “heroin” users disease). And scientists did not consider it bad form when such names were first used, otherwise they would never have used it in the first place. Now they do, don’t they?

What was the essential reason why these name changes took place? It was to prevent science from, knowingly or unknowingly, indulging in names calling.

So, there are two conventions. One is naming after cities and countries. The second one is changing such names if it hurts a nation’s or race’s sensibilities. It is this other convention that concerns us here. Also, all name changes that have occurred have been based on their scientific characteristics, or in honour of a scientist. To the question “What’s in a name” (Nataraj, 2010), the answer is lots, if it has to be scientific. And to the contention, we avoid ersatz patriotism in science (Chatterjee, 2010), we need science in names giving to pre-empt precisely such ersatz patriotism.

There is a tradition to eponyms. True. But they were mainly used because they were a convenient tool to categorise an entity at a time when science and medicine lacked the tools to understand the underlying reasons and mechanisms behind diseases, bacteria, syndromes, etc. As an interim arrangement, and till we had the scientific wherewithal, it was a convenient designation. Now when we do have such means, eponyms must be avoided and consigned to the dustbin of medical history, unless it is an honour to institute it in some person, institution or country’s name. For example, if someone found the definitive treatment for AIDS or malignancy, or the aetiology of Schizophrenia, we would happily name them after that person, institution or even city/country, would we not?

The role of an editor: Scientific names giving

Some editors may hold the view that an editor has no role to play in the matter at all; he looks into the science of the paper and there his job ends. It is the scientist who needs to get educated about scientific names giving, if at all, and if he does not do it, popular or peer pressure could be exerted for change. But even to do so or not is not in the domain of an editor’s role. In any case, it is the sole prerogative of the scientist who first so named it to name howsoever he pleases, preferably following a tradition, and change it if he deems fit. It is like we do with our own names. In fact, there may be editors who would defend a scientist’s right to name an organism, gene, disease, howsoever he decides, and such a defence may be considered necessary to forward science. Otherwise, so the argument can go, anyone could start raising objections to names giving under some pretext or the other.

Now, to answer this contention. The job of an editor does not end with the science in a paper. It extents to ensuring that there is science even in names giving in a paper. In fact, this is part of the science of a paper.

In other words, an editor must ensure scientific names giving. If an editor ensures this, the need for popular or peer pressure to change names, or for scientists who first so named it to change names later, would just not arise. Prevention is better than cure. While it is necessary to defend a scientist’s right to name organisms, it is equally necessary to ensure that such names are based on science, not on an author’s whims and fancies. After all he is not naming his child or an enemy, to base it on a whim or a prejudice, respectively. Also, the name is not his personal property or domain, to dispose of, name, or alter as he pleases. The moment it is made public through a scientific paper, it enters the public intellectual domain and is the property of science, to be accepted, rejected or altered by fellow scientists. Also, since he is naming an object in science, that naming better be scientific, otherwise it will face censure, and needless arguments between peers, of which one manifestation is this very paper.

Think of it this way. If the editor of the Yong et al. 2009 paper had put his foot down and asked that the name after a city be changed to something scientific, the uproar that has followed and the need for papers like this would simply not arise. And scientists would be allowed to do what they do best, science, free from the burden of national and other such regional sensibilities hampering scientific activities. I would myself have been spared the task of unearthing so much evidence to just prove a point. It has been no joy, I can assure you, to find fault with peers. Biochemistry and microbiology are not my forte, either. It was done only to prevent further perpetuation of such mistakes, having realised what was happening.

This is what editors can ensure – preventing further perpetuation of such mistakes by simply rejecting “geographical” and “racial” and insisting on “scientific” names giving, since editors and journals are the primary conduits through which such names reach the public intellectual domain. They cannot absolve themselves of their responsibility under any pretext. When editors are meant to ensure objectivity in the rest of the matter that goes into a paper, how can they not ensure objectivity even in names giving?

Having been blind to this role till now, it is doubly important editors awaken and accept that it would be sound policy for editors to become sensitive to political and racial sensibilities in names giving in science, especially when they may even appear to be maligning a city, country, ethnic group, etc.

Moreover, editors cannot afford to immunise themselves from such considerations in the name of furthering science. It really does not further science; it only results in genuine scientific work getting embroiled in needless controversy, as this work did.

Scientists need not carry, or at least need not project, their prejudices about people on to our science. Editors need to be especially careful that this does not occur in the writings published in their journals; for writings may have a limited span, but journals have a legacy, and a reputation to protect, and project.

The Editorial Director of the publication in question has learnt his lesson well. I hope the broader editor community learns it too, before it is forced on to them by repetition of such incidents. His apology has been clear-cut and dignified. I propose editors find better ways to manifest such excellent qualities in the future.

Name, but not after a city/country

Therefore, Rule Number 1, both for a scientist, and an editor, is:

While a scientist has every right to research anything under the sun, he does not automatically have the right to name it howsoever he chooses, especially if he may appear to be hurting a nation/race’s sensibilities.

A scientist must know the difference between the two. For one right does not automatically ensure the other. But if he does not, an editor must at least know, and take care that the writings published in his journal are not immune to such considerations, as the Editorial Director of The Lancet Infectious Diseases realised, albeit belatedly.

To ensure this, Rule Number 2 to be followed by both scientists and editors is:

Names giving should be as scientific as the rest of the published work. By scientific we mean based on scientific characteristics, not on subjectivity, geography or race.

This simple rule just pre-empts all needless controversy and frees science for that it does best – science.

Answering the questions raised earlier

To answer, then, the questions raised at the beginning of this section:

1. Should editors learn from this incident, and see to it that researchers desist from naming bacteria, diseases, etc. after cities, countries or races, especially because (unintentionally perhaps) scientists may not be sensitive to sensibilities of countries and peoples?

   Yes. Editors must take up this role and avoid shirking their responsibility in the name of forwarding science and researcher’s rights to name an entity howsoever they please. They must ensure “scientific” names giving in place of “geographical” or “racial” names giving.

2. Will it be a good policy that henceforth, before accepting for publication, editors insist authors change any such names after cities and countries?

   Yes, they must, especially when they scent it can have fallout where peoples and races can be legitimately incensed, and names giving smells of names calling.

3. What should editors do so that corresponding authors ensure concurrence from all authors, especially the lead author?

Obtain written permission from all authors and especially the lead author (if he is not also the corresponding author) to the final draft of the paper before submission, or see to it that the corresponding author obtains it and submits it to them. This must be one of the preconditions to publication.