The All India Institute of Medical Sciences (AIIMS) is one of the premier medical research and hospitals of the country. For the past 60 years, it has been painstakingly built by the leaders. Unfortunately in the last few years it has been over politicized and pushed to the fringes. This institution of national eminence should be preserved at all costs.
P. Ramachandran writes in The Hindu, 24.2.2009,
The coronary bypass surgery that Prime Minister Manmohan Singh underwent on January 24 at the All-India Institute of Medical Sciences is evidently successful as there does not seem to be any post-operative complication. His recovery is stated to be quicker than expected and, by all accounts, he should be in a position to resume his duties in about two weeks.
For Dr. Singh, who underwent a bypass surgery in 1990, this was what is referred to as a ‘redo’ bypass. Significantly, this was done on a beating heart — or off-pump as it is called — which is relatively less common than the on-pump mode where the heart is totally arrested but blood circulation is maintained with a heart-lung machine.
It is, however, an irony that India’s premier public institution for healthcare had to summon the services of a private specialty hospital for this apparently complex surgery. The fact that Dr. Ramakanta Panda, from Mumbai’s Asian Heart Institute (AHI) who led the surgery, had his grounding in cardiac surgery at AIIMS adds to this irony. Indeed, there were protests from certain quarters of the institute against bringing in “outsiders” as it would spoil its reputation. Even the decision to do bypass became controversial with some experts arguing that it was safer to do angioplasty, the minimally invasive ballooning of the artery.
A combination of factors, which significantly included the lack of the expertise in the AIIMS in the surgical procedure that Dr. Singh’s condition demanded, led to the situation that has cast it in a poor light. The decline, which many believe is irreversible, has happened over a period of time. The reasons lie in politicisation of the institution and the deeply entrenched attitudes of sections of the faculty that have bred nepotism, favouritism and sycophancy at the cost of merit, academic excellence, specialised medical skill and professional ethics.
Dr. Singh’s 1990 surgery was a triple bypass, in which three arterial blockages were bypassed with one arterial and two venous grafts. In 2004, he underwent angioplasty in Delhi on one of them which had narrowed and a stent was put. Angiography done on January 21, following the Prime Minister’s complaint of chest pain, indicated that there were five blockages — three old and two fresh — which required cardiovascular intervention, not excluding surgery. The medical question that arose was: should it be angioplasty or bypass? The latter would mean a redo bypass. The crucial decision essentially rested on the Prime Minister’s health panel headed by K. Srinath Reddy, an AIIMS cardiologist who was the personal physician of P.V. Narasimha Rao.
The Prime Minister’s healthcare is governed by the ‘Blue Book’ for VIP security and a separate healthcare manual that sets out details. The latter specifies that the AIIMS is the designated unit for ‘finitive’ care (inpatient hospital care beyond emergency treatment). But it also says the best available medical care in the world be provided, thus giving full freedom to take Dr. Singh, or get any person from, anywhere including abroad.
“In my opinion,” says Dr. Reddy, “angioplasty would have been risky. Also it would have had very short-term benefits and a lot of restriction on his travel, etc. Surgery, despite the so-called initial risks, would give much better long-term results. And knowing Dr. Panda’s surgical results, I was in favour of surgery.”
“The earlier bypasses were 19 years old and the 2004 stent too had re-blocked. When the stent is re-blocked, the chances of success with angioplasty are less. It could again get re-blocked in 6-12 months,” points out Dr. Panda. Also there was narrowing inside the stent. “Both these put together, the probability of his coming back within six months was fairly high. That’s why we decided on surgery where the risk is less,” he says. When Dr. Singh and his family were informed of the various options, the Prime Minister too opted for surgery.
Bringing in Dr. Panda was entirely Dr. Reddy’s decision. “I wanted to get a person who has excellent redo experience, a person who has extensive beating heart [surgery] experience, a person with extensive redo on beating heart experience. And Panda is the one who scores on all three counts,” he says. Apparently some surgeons in Delhi, including Naresh Trehan of Apollo Hospitals, did offer their services. “For me it was very clear,” says Dr. Reddy. “We [at AIIMS] do a lot of redo bypass for valves and other things but coronary redo rates are 2-3 per year, whereas Panda does 2-3 per week. And most of his redos are on beating heart whereas even some of the best centres of the world do it on-pump. And beating heart definitely has this advantage of less bleeding and less damage to the tissue,” he adds.
The mortality rate even for the first bypass at the AIIMS is four per cent as compared to 0.3 per cent at the AHI. The only person with comparable statistics is Dr. Bruce Lytle from Cleveland Clinic with whom Dr. Panda has worked.
Though Dr. Singh had the option of getting operated on in Mumbai, he preferred the AIIMS. Dr. Panda, of course, would have been more comfortable in his own environment. “The PM has high respect for AIIMS. Every time he has needed medical attention he has insisted on AIIMS,” says Dr. Reddy. All his past surgeries have been done at the AIIMS except for the left wrist carpal tunnel syndrome when an anti-reservation agitation was going on at the AIIMS. He was then taken to the Army Research and Referral Hospital but it was AIIMS doctors who operated on him.
With Dr. Singh having decided on the AIIMS, it became imperative for the institute to cooperate with Dr. Panda. But there were apprehensions about the extent to which it would cooperate given the increasingly evident institutional politics. Following the constant feud between Health Minister Anbumani Ramadoss and the former AIIMS director and cardiac surgeon P. Venugopal, the pro-Venugopal and anti-Venugopal factions of the Cardiothoracic Vascular Surgery (CTVS) faculty had, in fact, hardened in recent times. Indeed, as was feared, the divisive politics did raise its ugly head. While the CTVS head, A. Sampath Kumar, well aware of the institute’s limited expertise, promised all support, he could do little to prevent his detractors from raising the outsider bogey.
Though the AIIMS supported the operation with its team of cardiologists, anaesthetist, radiologist, laboratory personnel, associated equipment, and the overall supervision of Dr. Kumar, it sharply brought into focus its lack of higher level capability and skill. This has reinforced concerns of declining standards of academics and healthcare in AIIMS that has been evident for nearly two decades, which the recent flight of talent to the private sector has only accentuated.
Of course, as Dr. Reddy emphasises, the AIIMS does a lot of poor patients’ valve cases and a surgeon doing paediatric surgery also does valve surgery. So specialisation, like Dr. Panda, becomes difficult. But such specialisation can come about only with more faculty and more facilities. The AIIMS is a goldmine of clinical cases and is one of the best training institutions. It can be made a high-class research and public health centre only if there is functional and administrative (including financial) autonomy and less political interference in selection and governance. Political interference is why the AIIMS is still without a director after Dr. Venugopal retired in mid-2008.
Recruitments too have been frozen for the last five years. This is a direct fallout of the highly irregular appointments made during 1993-2003. A five-member committee constituted by the Ministry in January 2007 found that no regular selections were made because of agitations and litigation resorted to by the faculty to recruitments in reserved categories. “Instead,” the committee said, “the vacancies at entry-level assistant professors were made through ad hoc selections and appointments … characterised by a series of arbitrary in-house decisions and procedural violations.” As many as 152 faculty positions were filled in this manner.
In 2001, the court dismissed the anti-reservation petition. When the regular selection process was resumed in 2003, for 170 advertised positions, 762 candidates appeared for an interview including 151 earlier ad hoc appointees and 611 others. The details of selection of 161 candidates available to the committee revealed that 131 of them were from the ad hoc pool itself. The committee found instances of highly meritorious candidates in both the reserved and general categories not being selected. “This was done primarily to regularise the ad hoc appointees … [which] was unlawful,” the committee observed.
The absence of in-house expertise at the AIIMS in many areas can perhaps be traced to the irregularly selected faculty who continue to function at the cost of far better candidates. The CTVS is, in fact, guilty of biased dispensations even earlier during Dr. Venugopal’s long term as its head since the mid-1980s, say AIIMS sources. Many capable young people — who included Dr. Panda himself — were forced to leave then. The impact of that legacy is evident now when this famed institution finds itself lacking in the necessary surgical expertise to treat the head of the country.
The less political interference means the more better for AIIMS and the public. At the earliest AIIMS must be relieved from the clutches of the government control and made totally autonomous in all aspects. The union health ministers and other political heads should not even allowed to have even a single say in the day to day running of the institution.
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