Setting up a heart and lung transplant center in Sri Lanka: Slam-dunk or Daydream
Last week there were reports of a plan to setup a 'world-standard' heart and lung transplant center in Sri Lanka ('World standard heart and lung transplants here' – Sunday Times, Nov. 29, 2015). This is great news. In fact, if we are able to establish such a center, it will not only benefit Sri Lanka but the entire South Asian region. After all, only a couple of institutions in India are performing this kind of procedures in the region right now. Therefore such a center would undoubtedly be a huge boon to the entire region.
But the shortage of such centers in itself should be a red flag. If setting them up were as easy as importing a few doctors and getting some new equipment, why have such centers not become more prevalent throughout the region? Surely, with so little competition, one would expect such ventures to be extremely lucrative for the private sector. But despite such apparent commercial potential, the number of heart and lung transplant centers in the region has remained conspicuously low. What could be the reason for that? What else—besides experts and equipment—could possibly be needed to make such a center successful?
A combined heart and lung transplant is one of the most complicated medical procedures in the world. It is supposed to be several degrees more difficult than the transplant of any single organ (such as a kidney or liver or even the heart and lung separately). The degree of difficulty is not caused simply by the complicated procedure per se, but also by the complex pre assessment process and the sophisticated aftercare that is required to manage and monitor the patient throughout the remainder of his/her life. In other words, for a heart and lung transplant to succeed, a long-term and unwavering commitment by an entire multidisciplinary team (including the doctors, technicians, nurses, physios, dieticians and other allied health professionals) will be mandatory. This cannot happen in an environment where doctors are busy ‘nickel-and-diming’ their patients or are distracted with their car-permits.
But unfortunately that happens to be the exact environment in which the medical practice in Sri Lanka is operating right now. Doctors seem to act with absolute impunity with no accountability towards their patients or anyone else. For instance, the widely reported story of Shavini Fernando—the young girl from Kandy who was pushed to the point of requiring a heart and lung transplant due to sheer medical negligence—is a case in point ('Be heroic, save a life' –Ceylontoday, December 6, 2015). Despite many telltale symptoms, doctors had repeatedly failed to identify a large hole-in-the-heart that she has been living with her entire life. Instead, they had gone about treating her symptoms in an ad hoc manner without ever connecting the dots. For instance, they treated her fatigue and shortness of breath with inhalers thinking it was Asthma and her pain in the abdomen (a give-away symptom of heart disease) with very strong antibiotics. And when her overworked heart eventually started going into palpitations, they treated her for heartburn—with antacids!
At no point were efforts made by the different specialists to talk to each other or to triangulate these various symptoms to identify an underlying root cause. And at no point, until it was too late, did the doctors pause to re-think their original diagnoses—despite their treatments having little or no impact. In the meantime, any questions that Shavini or her family members posed from the doctors about their course of treatment were met with hostility and browbeating. And after their stubbornness had damaged her heart and lungs irreparably, they had the temerity to inform her smugly that there was nothing they could do and that she was on her own. Worse still, when she requested a prescription for oxygen to fly abroad to get a second opinion, they flatly refused, incensed that she dared to second-guess their verdict.
Sri Lanka will never be able to establish a 'successful' heart and lung transplant center in this kind of environment—where doctors do not communicate with each other and where they abuse their monopoly on information to bully patients. And Shavini just happens to be one case. Hospital corridors are replete with anecdotes of doctors acting with absolute impunity and where they walk away from any screw-up without answering to anyone. In this environment, how can we expect doctors to have the degree of accountability needed to perform such a high-risk and sophisticated procedure like a heart and lung transplant? Or to work in a collaborative fashion with a multidisciplinary team? And with the doctors seemingly not answerable to anyone, what guarentees do we have to ensure that they are not tempted by the high profits of the illegal organ trafficking trade? In general, who will guarantee the interest of the public?
While it is true that the planners are working with the Attorney General’s office to amend the Tissue Act to facilitate heart and lung transplants, the degree of governance reforms required here goes much further than the immediate regulatory environment sorrounding such a center. Instead, this would require the whole concept of doctor-patient relationship—as Sri Lankans know it—to be turned on its head. The doctors will actually have to be made accountable to the patients (not the other way round). The doctors will have to start being more receptive to the needs/concerns of the patients above anything else. Unfortunately, though the practice of medicine in Sri Lanka has kept up with the rest of the world in skills and techniques, it still lags way behind in terms of accountability.
Therefore, establishing a successful heart and lung transplant center will take more than just the skilled foreign surgeons and brand new equipment. Instead, it will also require broader governance reforms to foster a collaborative environment and to allow patients to hold doctors more accountable. Therefore, these reforms would have to include a full gamut of reforms relating to certification of doctors (around values of patient-centeredness and continued learning), delivery of services, payments, medical liability, medical malpractice litigation, and administrative simplification, among others. And the primary focus of all these reforms will have to be to enhance patients’ rights in relation to the doctors. If we are able to manage that, a ‘successful’ heart and lung transplant center may very well become a reality. But if not, this would simply become another ‘get-rich-quick’ scheme of a handful of businessmen, politicians, and doctors.