The BMJ contacted some of the journals in which Dr Singh's work has been published, including those in which versions of the rejected BMJ papers had appeared.
Dr William Roberts of Baylor University Medical Center, Dallas, editor of the American Journal of Cardiology, confirmed that two or three of Singh's papers had been published in his journal in the early 1990s: “Singh's articles in the [journal] received good reviews.” Once concerns had been raised by the BMJ, all subsequent manuscripts were declined, he said, but efforts to find out more about Dr Singh at the time were not successful.
Professor Lionel Opie of the Health Faculty of the University of Cape Town, South Africa, and former editor of Cardiovascular Drugs and Therapy, felt that Singh was guilty of disorganisation rather than any deliberate attempt to deceive.
Richard Horton, editor of the Lancet, believes that Western journal editors are so keen to publish research from developing countries, particularly if it offers cheap solutions to costly problems, that they tend to give the benefit of the doubt to aspiring authors.
Professor McKeigue says the BMJ is partly responsible for Singh's success. Cursory checks would have indicated that something was wrong with the 1992 paper, he says. “Publication in the BMJ opened up the floodgates.”
The difficulties of leaving things for a long time are that staff change, and papers slip through, McKeigue told the BMJ, citing the fact that concerns had already been raised with the Lancet about Singh under a previous editorship.
But the time lag also allowed Singh to polish up his presentation, he believes. “Every time the errors on [his] manuscripts were pointed out, they were cleaned up for the next submission. So in effect, the reviews were giving him a tutorial.” This made it harder to detect any anomalies, he contends.
The BMJ published a paper by Ram B Singh in 1992
Doubts were raised about that paper and subsequent manuscripts submitted by the same author
In the absence of answers from the author, the BMJ tried to find a legitimate authority to investigate and adjudicate on its concerns, and failed
The BMJ decided it had no option other than to publish an article documenting its efforts
One option might be to require authors to deposit a copy of their dataset in a secure archive, so that the data could be audited if questions arise, McKeigue suggests. Another might be that journal editors should seek at least one reviewer who is familiar with the local environment in which the research was conducted.
Richard Smith, who left the BMJ in 2004, accepts that it has taken far too long to bring the case of Dr Singh to light. “It is shameful that this case has been left festering so long,” he wrote to the journal after he had left. “The failure is in part mine.”
In his defence, he says that he made concerted efforts to force an investigation on the part of organisations with legal legitimacy, to seek help from other publications, and to find answers from the author himself, all of which ultimately drew a blank. And the evidence needed careful analysis.
“All of this was in addition to my day job, which is why it has taken years. It couldn't be a priority,” he wrote, adding that “the bigger shame lies with the scientific community that lacks means to investigate these international scandals and has to leave it to an individual journal.”
And Richard Smith resolutely stands by the decision to publish the saga, principally on the grounds that many readers of Singh's work will be unaware that major questions hang over his research, research which could then be used to inform treatment and health policies, to the potential detriment of patients and communities.
“This story has to be told in order to alert the world to the severe doubts around Singh's work,” he says. “More importantly, the story challenges the international scientific community to find a way to resolve cases like those of Singh and Chandra, where there are widely shared doubts about their work, but they simply go on publishing. The scientific community has an obligation to the public to do better.”