Palatial mansions, farm houses, multi-million ‘dollar’ bank accounts, expensive cars, real estate all over the country have been made in Pakistan through the business of ‘stents’. Stents are those little ‘wire mesh’ things that keep open narrowed heart arteries, mostly in the well-to-do who eat much too well and do too little physical work.

But the ones that will face the wrath of the anti-corruption gods will be some underpaid medical reps and poor technicians in Mayo Hospital who peddled some stents for a few measly rupees more than what they actually cost. All these ‘corrupt’ conniptions by these underpaid people brought barely enough for them to feed their families for a few months at best. The ‘big fish’ as always will get away.

The insertion of stents for blocked arteries in the heart and other parts of the body is a big business all over the world. Even in Pakistan, insertion of stents is probably the most frequently performed ‘expensive’ medical procedure following in frequency only the cardiac catheterisation needed to locate blocked arteries. The possibility that many stent procedures are done unnecessarily is a big concern and every year at least a few ‘busy’ cardiologists in the United States are investigated for such practices. The question whether stent procedures were medically appropriate is a different discussion from the problem brought up in Lahore.

The stents are implanted not by heart surgeons but by ‘interventional cardiologists’ and it is not heart surgery but a heart procedure. This procedure is made up of three parts or stages and certain problems are present in all three stages. The first question is whether the patient really needs a stent and if so, what type of stent. The second stage is of acquiring the appropriate stent and the third stage is the insertion of the stent in the patient during a cardiac procedure. But for the actual procurement of the stent, all other steps are under the direct supervision as well as actions of a cardiology consultant. The consultant decides whether a stent is needed and what type of a stent should be used and of course then puts the stent in the patient.

The only part of this entire transaction that the consultant is not necessarily involved in is the actual ‘buying’ of the stent. But the consultant is aware of the type, quality and the make of the stent that is bought by the patient and then actually used in the patient since the consultant can see the stent when putting it in. The consultant not knowing what stent is being used is like expert drivers not being aware of the make of the car they are driving. So, any major chicanery especially about the use of ‘bad’ or inferior stents cannot happen without the knowledge of the consultant performing the procedure.

Here it is important to point out that different stents have different prices. These differences are based on the quality as well as the manufacturer of the stents. It is quite possible that a less affluent patient will opt for a less expensive stent. So the major problem as reported by the press concerning stent usage in Mayo Hospital was that the stents were sold at a much higher price than they should have been. Different numbers were bandied about the cost and the sale price of these stents. Also there was mention that some of these stents were not approved for sale in Pakistan.

As I have said above, consultant cardiologists that implant stents decide the type of stent needed and then ensure that it is the right one when they put it in the patient. If the cardiologist does not put in the proper stent then he or she is committing malpractice. So in my opinion that is one of the major problems that emerges from the recent reports of inappropriate stent usage. The second problem is of price gouging. The cardiologist might or might not be involved in this part of the transaction but large scale ‘corruption’ really cannot happen in a hospital department without the knowledge of a competent head of the department.

As far as the quality, make and appropriateness of the stents are concerned, the consultant putting the stents in the patient has to be aware of all these things. That leaves the problem of price gouging. The people selling stents are in it to make money and like all good businessmen they will try and get the highest price for their products. And as reports in the press suggested, four different companies were involved and as such competition between them would have kept prices down. Unless there was collusion between these companies and their representatives, price gouging would be unlikely.

A little bit now about the Mayo Hospital Department of Cardiology where these ‘errant’ stents were bought and inserted in patients. First, Mayo Hospital is a very low volume cardiac centre. Fewer stent implantations are performed in a year in Mayo Hospital than are implanted in a few weeks in places like the Punjab Institute of Cardiology (PIC) or Doctors Hospital. Most high volume cardiac centres buy the appropriate stents and keep the on the ‘shelf’ so the patients do not have to buy them from medical reps hanging around the catheterization laboratories.

The only way to avoid any such problems for Mayo Hospital in the future is that the hospital should directly acquire these stents and then provide them to patients at cost. Of course, that creates a different type and level of corruption as has been reported on and off but never proven in high volume cardiac centres. But low volume cardiac centres offer a different problem besides the taint of corruption.

When I took over as the head of department of cardiac surgery in Mayo Hospital, I was surprised to find dozens of unused prosthetic heart valves that had been lying around for years. A large number of these valves were bought by the hospital at the behest of previous consultants but were never used because not enough patients came for heart valve replacements. I used as many of them as I could use but had to discard many because they were past their last use dates. As such the hospital suffered a loss of millions of rupees. The same could happen if the Mayo Hospital acquires a large variety of stents but these are never used.

The obvious way out of this problem is that all the government (Punjab government) owned hospitals and cardiac centres should have an adequate inventory of stents that can be shared as needed in different hospitals. There are five government-run hospitals that perform stent procedures in Lahore. There is absolutely no reason why they should not have a centralised, shared inventory of stents. The same can be done for most other ‘disposables’ that are used in different hospitals in surgery procedures. This will save money due to the ‘economy of scale’. This will not eliminate corruption but will cut down on it and at the same time assure that the patients receive the right thing for the money they spend.