Pakistan, May 25 -- The Nishtar Hospital inquiry should worry Punjab for reasons larger than the nine names now facing disciplinary action. The reported failure was not only that a patient was operated upon before mandatory HIV-screening procedures had been properly completed. The deeper failure was that a tertiary hospital could not reliably move a laboratory result through the chain of command before a patient entered the operating theatre.

The answer cannot be another round of suspensions followed by deafening silence. Disciplinary action may be necessary, but Pakistan's hospitals have perfected the art of punishing individuals while leaving systems almost untouched. Punjab needs more than a single inquiry at one hospital. It needs a ...