Ailing institution

IT is nearly a month since Prime Minister Manmohan Singh underwent repeat coronary bypass surgery, commonly referred to as redo bypass, at the All India Institute of Medical Sciences (AIIMS) in New Delhi on January 24. Significantly, this surgery was done on a beating heart, or off-pump as it is called. This is not very common, unlike the conventional mode of operating using a heart-lung machine, or on-pump, where the heart is totally arrested. The Prime Minister was discharged seven days later.

As per the latest reports, he is doing extremely well and his recovery is faster than expected. All indications are that he should be in a position to resume his duties in about two weeks time; he is already reported to be working more than what one would recommend for a normal patient. According to Dr Ramakanta Panda, the cardiac surgeon from the Asian Heart Institute (AHI) in Mumbai, who led the surgery, there will be no restriction on the Prime Ministers functioning and he can safely go back to his usual strenuous schedule.

It may seem ironical that Indias premier public institution for health care, which had done the first heart transplant in the country, had to summon the services of a private speciality hospital when it came to a complex cardiac surgery procedure on no less a person than the Prime Minister of the country. Considering that Panda had his grounding at the AIIMS, the irony would seem to be even more. Indeed, as the preparations for the surgery were under way, there were voices of opposition from certain quarters in the institute who said that outsiders were being brought in to spoil the institutes reputation. Even the decision to carry out a re-do bypass got into a bit of a controversy, with some experts opining that it would be safer to do angioplasty than surgery.

A combination of factors, which significantly included the total lack, in the AIIMS, of the required expertise in the advanced technique that the Prime Ministers condition demanded, resulted in a situation that has cast the countrys apex medical institution in a poor light. More pertinently, this evident decline of the institute has happened over a considerable period of time, which many would say is, in fact, irreversible. The reasons for this would seem to lie in the high degree of 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. Now that the Prime Minister is well on the course to recovery, one can analyse the various issues in an objective and dispassionate manner.

First, the nature of the Prime Ministers illness. Manmohan Singh, who has undergone a bypass surgery earlier in the United Kingdom in 1990 and subsequently angioplasty in Delhi in 2004, complained of physical weakness and chest pain in early January. So a medical check-up, which included some cardiac function tests, was done on January 20. An angiography done the next day indicated the development of some arterial blockages that required a cardiovascular intervention, and surgery was not ruled out.

The 1990 surgery was actually a triple bypass surgery; that is, three arterial blockages were bypassed with three grafts, one arterial and two venous. In 2004, angioplasty the minimally invasive ballooning of the artery was done on one of them that had narrowed (stenosis) and a stent put. Though alternative channels had opened up, and there was no risk, this was apparently done to be on the safe side. The other two grafts were, however, working. Even now, the functioning of his heart was fairly normal and there was no immediate problem, according to Panda.

While an arterial graft can last up to 20 years, venous grafts last 10-12 years. Over time, therefore, all the grafts had developed blockages (sclerosis). One of the three arteries that had been grafted in 1990 was actually supplying blood to two branches. It was found that one of the branches too had developed a blockage, which had to be corrected. In addition, an original artery on the right side of the heart, which was not blocked either in 1990 or 2004, had narrowed this time. So, in all, the Prime Minister had five arterial blockages, three old and two fresh, that required intervention.

The medical question arose as to what should be done an angioplasty or bypass surgery. Since Manmohan Singh had already undergone a bypass nearly 19 years ago, the latter option would mean a redo bypass. Besides his personal physicians cardiologists Nitish Naik and Ambuj Ray from the AIIMS the Prime Minister has a health panel headed by K. Srinath Reddy, an AIIMS cardiologist who had been the personal physician of former Prime Minister P.V. Narasimha Rao. The crucial decision on the question of angioplasty versus bypass essentially rested on the panel.

The Prime Ministers health care is governed by the Blue Book meant for VIP security. There is also a separate manual that details all the things that must be done for the Prime Ministers health care, including the point that AIIMS is the designated unit for finitive care (ongoing inpatient hospital care beyond emergency treatment). But it also says that the Prime Minister can still be taken anywhere for treatment if required and the best available medical care in the world should be obtained, thus giving full freedom to take Manmohan Singh abroad or get any doctor from abroad to attend to him.

In my opinion, says Srinath Reddy, angioplasty would have been risky. It would also have had very short-term benefits and imposed a lot of restrictions on his travel. Surgery, despite the so-called initial risks, was certain to give much better long-term results. And knowing Pandas surgical results (see interview) and I have seen how good a surgeon he is I was in favour of surgery. Incidentally, Panda had successfully operated on Justice Chinnappa Reddy for his third bypass operation, which means a second redo, at the age of 79, which Srinath Reddy apparently witnessed.

Besides the fact that the old bypasses were 19 years old, the other factor that favoured surgery was re-blockage. The stent of 2004 had re-blocked. When the stent is re-blocked, the chances of success with angioplasty are less, points out Panda. According to him, the chances are that in a year or even six months there would be a re-blockage in the stent. There was also stenosis inside the stent. Both of them put together, the probability of his coming back for treatment within six months was fairly high. Thats why we decided that it was better to do surgery, where the risk is less, says Panda.

It is true that a number of eminent cardiologists in the country did not agree with Srinath Reddy. But he points out that most of them had not even seen the angiogram to give their opinion. I could have easily played safe, says Srinath Reddy. On the day of the angiography, four cardiologists had recommended angioplasty. I could have easily gone along. If things had gone wrong, the blame would have been equally shared because a panel of five had recommended. But I was convinced that surgery was the best option and I stood my ground, he adds.

The Prime Minister, after he and his family were informed of the various options, decided very quickly and apparently said: On the balance of probabilities, let us go for surgery. Once surgery was decided upon, bringing in Panda was entirely Srinath Reddys decision. I wanted to get a person who has excellent redo experience. I wanted a person who has extensive beating heart experience. I wanted a person with extensive redo on beating heart experience. And Panda is the one who scores on all three counts, he says. Reposing total faith in Srinath Reddys judgment, the Prime Ministers family did not question the decisions.

Apparently, some surgeons in Delhi, including Naresh Trehan of Apollo Hospitals, did offer their services. For me it was very clear, says Srinath Reddy. We [at the AIIMS] do a lot of redo bypass for valves and other things but coronary redo rates are two to three a year, whereas Panda does two to three a 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. So when we have these options why should we go in for some institute surgeon, which would have been a highly risky option? he asks. The mortality rate even for the first bypass surgical operation at the AIIMS is a high 4 per cent as compared with 0.3 per cent at Pandas AHI.

Once these decisions were taken, the Prime Minister preferred to get it done at the AIIMS even though he had the option of getting it done in Mumbai. The Prime Minister has high respect for the AIIMS, says Srinath Reddy. All his surgical operations as Prime Minister, he points out, have been done at the AIIMS except the one for a carpal tunnel syndrome (on his left wrist), done when the AIIMS was on strike during the anti-reservation agitation. At that time, he was taken to the Army Research and Referral Hospital, but it was the AIIMS doctors who operated on him. Every time the Prime Minister needed medical attention, he has always insisted on the AIIMS. He has a fundamental faith in public institutions and in particular in the AIIMS, says Srinath Reddy.

Panda, of course, would have been comfortable in his own environment. Also, given the increasingly evident institutional politics and the presence of the pro-Venugopal and anti-Venugopal factions in the Cardiothoracic Vascular Surgery (CTVS) faculty which have hardened in recent times in the wake of the feud between Health Minister Anbumoni Ramadoss and the former AIIMS Director and cardiac surgeon P. Venugopal there was every reason to be apprehensive about the extent of cooperation that the department would extend to Panda. But, with the Prime Minister having decided on the AIIMS, it became imperative to have the institute prepare itself to cooperate with Panda.

But as was feared, the divisive politics of the department did raise its ugly head. While the CTVS head, A. Sampath Kumar, who had got a raw deal during Venugopals days and who was well aware of the institutes limited expertise, was all supportive, he could do little to prevent his detractors from raising the outsider bogey. This, in fact, forced Sampath Kumar to cancel his scheduled visit abroad in order to ensure proper assistance to Panda and his team from Mumbai.

Neither the Prime Minister nor his family apparently ever asked about going abroad for the surgery. At some point, only the Health Minister seems to have made this suggestion during discussions with the Prime Ministers panel. According to Srinath Reddy, the only person with comparable statistics to Panda is Bruce Lytle from Cleveland Clinic with whom Panda had worked. The Minister then apparently suggested that Lytle be got. Lytle, when contacted, apparently said that he was too old to travel and that he would operate if the Prime Minister could be brought to Cleveland. But given the Prime Ministers decision to get operated at the AIIMS, this was not possible. Even if Bruce Lytle had come, I would have asked Panda to operate and have Lytle stand by. Panda is the best and I had full confidence in him, says Srinath Reddy.

Assisted altogether in different phases by 14 members of the AHI, Panda performed the beating heart, or off-pump, redo bypass on the Prime Minister over an eleven-and-half hour marathon session. The surgery in all included five grafts replacement of the three old grafts, and two new ones. Actually, the old ones are left as they are; separate new grafts are attached to the areas in question. The earlier arterial graft had been sourced from the Left Internal Mammary Artery (LIMA), which apparently had got severely blocked. Panda, who uses arterial grafts to the maximum extent possible, used four arterial grafts and one venous graft. As arterial graft numbers are limited, we could not replace all of them, Ramakant Panda says.

The arteries that were used for grafting were the Right Internal Mammary Artery (RIMA) and the left hand artery called the radial artery. The vein used was harvested from the left leg. With two arteries we bypassed four, Panda points out. We did what we call sequential bypass. It is like a roadblock. If you have a roadblock, you take a side road and come back to the main road. What we do is bypass one or more blocks with the sides of the artery sequentially and the end of the artery to the last.

A sequential bypass does not restrict the blood flow; on the contrary it supplies more, according to Panda. The flow depends only on the diameter of the arterial graft, which, in fact, expands to allow greater flow if required, Panda explains. The grafts are also what are called free grafts. If there is adequate length, for mammary artery we keep one end attached to the original thing. But in the Prime Ministers case, even earlier the length was not adequate, because we are taking from one side to the other. So we cut it and joined it [to the aorta], explains Panda.

Although the AIIMS did extend support to this major operation with its team of cardiologists, an anaesthetist, a radiologist and laboratory personnel and necessary equipment with the overall supervision of the procedure by Sampath Kumar, it sharply brought into focus the fact that the premier institution lacked the higher level capability and skill required to carry out such complex surgery. This has served to reiterate the fact that the standards of academics and health care in the AIIMS have been declining over the past 15 years or so. Of course, as Srinath Reddy points out, the AIIMS does a lot of valve operations on poor patients and, unlike Panda, who is focussed on coronary surgery, specialisation in a particular area is difficult. For instance, the surgeon who does paediatric surgery has to do valve surgery as well. But such specialisation can come about only with more faculty and more facilities; perhaps a national heart centre can be established.

The AIIMS is a gold mine of clinical cases and is one of the best training institutions. This could easily be exploited to make it a high-class research and public health care centre if there is functional and administrative (including financial) autonomy and less political interference in the selection of doctors and in governance. This has resulted in the flight of expertise and skill in recent years to private hospitals for monetary gains though many would prefer the AIIMS even with lesser pay if only the institutes academic environment would improve. Even today there are quite a few very capable people at the AIIMS but this may not last long.

According to insiders, the politicisation of the AIIMS began with Health Minister B. Shankaranand (in 1993) and, except for a brief period when Salim Sherwani headed the Ministry, it has only increased with every subsequent Minister. As a result, cultivating political influence to achieve personal gains, particularly favoured entry-level appointments, has become part of the institutes culture. Moreover, the divisive politics of caste and other conflicts have become deeply entrenched, as is evident during every anti-reservation agitation; it had actually peaked when Venugopal was the Director. Direct political interference is also the reason why the AIIMS is still without a Director after Venugopal, who served as Director for six years, retired in mid-2008.

Recruitments too have been frozen at the AIIMS in the past five years. This is a fallout of the highly irregular appointments made during 1993-2003. A five-member committee constituted by the Ministry in January 2007 to go into faculty selections during this period found that no regular selections were made because of agitations and litigation by the faculty regarding recruitments to 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, 762 candidates, from India and abroad, appeared for the interview for the 170 advertised positions. These included 151 earlier ad hoc appointees and 611 others, including 209 from the reserved categories. The selection details of 161 candidates available to the committee revealed that 131 of them were filled from the ad hoc pool only. The committee found that many highly meritorious candidates, both in the reserved and general categories, were not selected.

This was done primarily to regularise the ad hoc appointees in large numbers [which] was unlawful, the committee observed. In addition, the committee also found that the institute had promoted 64 ad hoc appointees even though, as ad hocs, they did not meet the eligibility criteria. The committee also concluded that none of the appointments made during the 2003 selection could be considered final. The absence of in-house expertise can perhaps be directly traced to this irregularly selected faculty who continue to function in the institute at the cost of far better candidates.

The CTVS, according to AIIMS sources, has been particularly been guilty of biased dispensations during Venugopals long term as its head even earlier. They point how life was made difficult for many capable young people including Panda himself incidentally who were forced to leave. The legacy of that period became glaringly apparent when the AIIMS found itself lacking in the necessary expertise to treat the head of the country.

Shyam Prasad, a former cardiac surgeon of Christian Medical College, Vellore, and currently the vice-president of the National Board of (Medical) Examinations, said: In Venugopals time things should have been consolidated. That was when medical technology was improving and everywhere things were improving. But while others were going up, the AIIMS went down then. Today merit has been slowly reduced to a myth at the AIIMS.