Two basic questions remain unanswered over Anwar Ibrahim's much discussed medical condition: Who is paying for his care, and why has he been hospitalised this long?

If Anwar is paying, then he is entitled to his choice of doctors and hospital. But if the public is picking up the tab, then the standard of care should be one applicable to the average Malaysian, and not that of a sultan.

How much did it cost to bring in all those high-priced foreign consultants? Anwar has no right to hog the nation's scant resources (First Class Ward and 16 specialists!) when hundreds of poor rural students are unable to sit for their Standard Six examination for lack of money.

Anwar may be the former deputy prime minister, but today he is a convicted felon. We owe our nation a better use of our funds.

Unlike his earlier arsenic poisoning ruse, this time, Anwar's medical condition is straight forward - a prolapsed lumbar disc. It is a common malady, afflicting millions. Most are not even hospitalised; they are doing their regular productive jobs, with appropriate precautions.

The only time they need to be briefly in a hospital is during the initial phase, both for pain control and to rule out serious conditions; and of course for the surgery. To hear Anwar supporters, he is suffering from a rare life-threatening debilitation.

Sizable bounty

The algorithms of management too, are well defined. There is consensus when urgent open surgery is indicated (when bowel and bladder sphincters are affected), or when any surgery is unwarranted (minor pain and no nerve impingement).

In between are the vast majority of patients in which the decision as to the best form of treatment resides with both patient and physician. Even if surgery is entertained, questions remain as to the timing and procedure - the standard 'open' versus small incision surgery, to endoscopic and percutaneous techniques (using a needle inserted through the skin).

No matter what route is chosen, it is very expensive. In America, it costs in excess of US$50,000 (RM200,000), a huge sum especially for Malaysians who have to pay in depreciated ringgit. Anwar's estimate of RM25,000 for the surgery in Germany is unrealistic. That amount barely covers the airfare and accommodation.

If Anwar can afford it, let him go to Germany. The fear expressed by Prime Minister Mahathir that Anwar may abscond is unfounded. Make Anwar post an ample bond. If he fails to return, the government would then get a sizeable bounty. It would also be spared the huge expense of incarcerating him. If Anwar were to later return, charge him with bail jumping.

Letting Anwar leave would also prove to be a shrewd move politically. Apart from the immense goodwill from this humanitarian gesture, the government would have a convenient way out on the Anwar problem, akin to letting a thorn out of a festering sore.

It would also cripple Keadilan's leadership, for his wife Wan Azizah, the party's leader, would want to join him overseas.

Prohibitively expensive

Once abroad, Anwar's voice would soon be lost. Notice how quickly the West forgot the Shah of Iran and Philippine's Marcos, two unabashedly pro-Western leaders. When Anwar's foreign supporters discover that his chances of regaining power are slim, they too will quickly dump him.

Perhaps Mahathir fears that Anwar in exile would prove to be dangerous. The Shah found, much to his sorrow, that banishing Ayatollah Khomeini was a grave mistake. But Mahathir is no Shah, and more importantly, Anwar is no Khomeini.

The Ayatollah vehemently opposed the Shah right from the beginning, seeing the Shah's evil side long before anyone else did. In shameful contrast, Anwar was desperately ingratiating himself and sucking up to Mahathir right to the last moment.

I agree with Anwar's German consultant in not wanting to operate in Malaysia. This is no reflection on the standard of local surgical care, as alleged by some. It would be impractical to fly in the delicate instruments and support staff. It would be prohibitively expensive.

Even Jordan's King Hussein came to Mayo Clinic rather than have his American doctors fly to Amman. And the King had a lot more cash than Anwar could ever dream of acquiring.

Very safe

Anwar's supporters, especially those in the local medical profession, are disingenuous in suggesting that Anwar can only be safely operated abroad. The head of the Islamic Medical Association, in an open letter to Mahathir published here, intimated that Anwar risks injuring his spinal cord (and thus paralysis) from intubation with open surgery.

Endoscopic procedure, the proposed German technique, can be done without intubation. While this is a potential danger, the learned doctor overestimates the risk. Of the many complications from incompetent intubation, damage to the spinal cord is way down there, so far down that I cannot see it.

One is more likely to tear the airway or gullet instead, both potentially lethal complications. Intubation skillfully done is very safe. When operating on patients for neck discs, general anesthesia and thus intubation is routinely used.

Besides, open back surgery is the standard procedure even in the Silicon Valley-home of Stanford and University of California medical centers.

During Anwar's previous hospitalisation for suspected poisoning, I castigated his doctors, through 'Letters to the Editor' in a Malaysian daily for the unnecessary long stay and indiscriminate use of consultants. They were oblivious of the costs incurred.

Sadly, his present doctors are no better. Anwar is paralysed by the opinion of his numerous consultants. One for example, attributed his injury to the beating by the ex-police chief and another, to playing sepak takraw.

Interestingly during that earlier hospital stay, I criticised his doctors for doing too many unnecessary tests while neglecting an important one, an MRI (special imaging) of his neck. As Anwar had a previous horseback riding injury, I suggested then that he had neck disc disease rather than arsenic poisoning to explain the tingling and numbness of his hands.

This was evident by his stiff neck posture, long before his firing. I venture that the same mechanism that produced his neck injury also caused his present back problem.

Cost containment

Like before, a committee now manages Anwar! He must also be the only patient in the world with this condition to be hospitalised for nearly half a year. The reality is, all of Anwar's medical care, including his physiotherapy, can be done as an outpatient.

Prolonged hospitalisation is not without risks. It can lead to life-threatening blood clots and infections from drug-resistant hospital bugs. Patients also develop 'secondary gains' which would hamper their later recovery.

If Anwar were in an American hospital, his doctors would be hauled before an Utilisation Review Committee for abuse of expensive facilities. In this day of cost containment, that would be reason enough to yank their hospital privileges.

Anwar's doctors should treat him like any other patient. This, after all, is the hallmark of a true professional. Anwar should have been returned to his cell months ago.