AN OPEN LETTER TO AUTHORS OF ARTICLE IN LANCET

  

 From:
Dr. George Paul
F-72, Brindavan Road
Fairlands
Salem – 636016
Tamil Nadu, India

To:
Dr. Manoj Murekhar
Dr. Balaji Veeraraghavan
Corresponding Authors,
Neuromelioidosis Outbreak in Tamil Nadu, India: An Investigation of Transmission with Genomic Insight
Emails: mmurekhar@nieicmr.org.in, vbalaji@cmcvellore.ac.in

Subject: Request for Clarifications on the Lancet Article on Neuromelioidosis

Dear Dr. Murekhar and Dr. Veeraraghavan,

I hope this message finds you well.

My name is Dr. George Paul, an Oral and Maxillofacial Surgeon based in Salem, Tamil Nadu. While I do not hold any governmental or statutory position, I am a qualified clinician and legal professional, with additional credentials in bioethics. I have previously served as the National President of the Association of Oral and Maxillofacial Surgeons of India and as Member Secretary of an Institutional Ethics Committee overseeing CRO-conducted pharmaceutical trials. I currently serve as Chairman of the Institutional Review Board of Salem Polyclinic, Salem.

I write this letter with due respect to the authors and institutions associated with the recent article published in The Lancet (2025), titled Neuromelioidosis Outbreak in Tamil Nadu, India: An Investigation of Transmission with Genomic Insight. I would like to request clarification on a few important aspects of the publication, particularly in light of the potential implications for clinical practice and public trust.

1. Seizure of Evidence:
   It is understood that a saline bottle, reportedly implicated in the findings, was obtained from a dental clinic in Vaniyambadi during a period when the clinic was under investigation and closed for approximately 45 days (April–May 2023). Could you clarify whether any receipt or documentation was issued to the clinic for the items seized for environmental sampling?
2. Source and Documentation of Allegations:
   The article references alleged use of the saline bottle for invasive dental procedures. Could you please specify the source of this information? Was this statement made by the dentist? If so, was it formally recorded in writing and signed by the dentist?
3. Author Contributions and Conflict of Interest:
   Several co-authors are affiliated with statutory bodies such as the ICMR, the National Institute of Epidemiology, and the Directorate of Public Health. Could you outline their specific roles in the study? Were they involved in the preparation and approval of the manuscript submitted to The Lancet?
4. Causality and Epidemiological Reasoning:
   The article suggests that a single clonal isolate was found in the "in-use" saline bottle. On this basis, can eight patient deaths be conclusively attributed to visits to the same dental clinic? Given the time gap—particularly the five-month interval between the dental visit and the death of the first patient in December 2022—is it accurate to infer causality, or should this be interpreted more cautiously as circumstantial?
5. Implications of Findings:
   If, as the article implies, there is verifiable evidence of contamination and direct harm attributable to dental treatment practices, was any formal action initiated by the relevant public health authorities? The article references eight deaths in connection with a dental clinic, which raises concerns about follow-up measures and legal or disciplinary proceedings.

I raise these questions in good faith and in the interest of academic integrity and responsible discourse. It is important that any commentary or public communication on this matter reflects the facts accurately and avoids unintended misrepresentation.

Thank you for your time and consideration. I would appreciate your acknowledgement and an early response.

Warm regards,
Dr. George Paul

 

PANATT MEDICAL RELIEF TRUST

 

Reg No: 143/2024

Trustees: Dr George Paul and Dr Bini George

F 72 Brindavan Road, Fairlands, Salem – 636016. TN.

A Project Proposal for Philanthropic Support

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Executive Summary

The Panatt Medical Relief Trust stands as a beacon of hope for those marginalized by the inequities of healthcare access in India. Founded by two dedicated healthcare professionals, Dr. George Paul and Dr. Bini George, the Trust is committed to making quality health services available and affordable for the underprivileged.

With a combined experience of over eight decades, the founders have seen the plight of the poor firsthand. Their tireless service — nationally and internationally — forms the foundation upon which the Trust is built. The Trust seeks to bridge the systemic gaps in healthcare by facilitating access to affordable treatment options, offering counseling, negotiating for subsidized services, and actively disseminating healthcare information.

Through data collection, advocacy, partnerships, and targeted financial assistance, the Panatt Medical Relief Trust strives to empower the most vulnerable with the dignity of choice and access to life-saving care. This proposal outlines our mission, operational plan, funding requirements, and the transformative impact we aim to achieve — inviting corporates, foundations, and philanthropic individuals to join hands in this vital mission.

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1. Introduction and Background

India’s healthcare system is a paradox of excellence and exclusion. While there are world-class hospitals and cutting-edge technologies, large sections of the population remain deprived of basic health services due to high costs, lack of awareness, and systemic inefficiencies.

In response to this urgent need, the Panatt Medical Relief Trust was founded by Dr. George Paul and Dr. Bini George, under their family name "Panatt." Practicing in Salem, Tamil Nadu, the founders have dedicated their lives to serving the community through their professions and beyond.

Both have a track record of extending free or subsidized care to those who could not afford it, often going beyond professional obligations to ensure that patients received necessary treatments.

Notably, Dr. George Paul’s humanitarian work includes:

• Serving in the UNHCR's First Asylum Camp for Vietnamese Boat People in Palawan, Philippines (1990)
• Volunteering in Montego Bay, Jamaica (1991 and 1993) for Rotary International
• Working with Claretian Missionaries in Parrochio San Antonio, Guatemala (1993)
• Serving in the UNHCR Detention Camp at High Island, Hong Kong
• Volunteering at Kilimangago Mission Hospital, Thika, Kenya

In India, he served gratis as Hon. Medical Director of Sharon Cancer Centre for over 15 years, performing hundreds of life-saving surgeries without charge.

Dr. Bini George has complemented this work with her own commitment, undergoing specialized training in Palliative Care from Pallium India and working with vulnerable groups such as children with mental disabilities at CSI Balagnana Illam.

Both founders continued their services during the height of the COVID-19 pandemic, demonstrating resilience, empathy, and dedication.

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2. Founder Profiles

Dr. George Paul

• Specialist in Oral and Maxillofacial Surgery
• 40+ years of practice
• Extensive volunteer work with UNHCR, Rotary International, and mission hospitals globally
• Hon. Medical Director, Sharon Cancer Centre (1995-2010)
• Chairman, Advisory Committee, Sharon Palliative Care Centre
• Chairman, Institutional Review Board (Ethics), Salem Polyclinic
• Director designate, Smile Train India, Salem (in the process of accreditation)
• Qualified Lawyer and Ethicist

Dr. Bini George

• Dental Surgeon with advanced training in Palliative Care (Pallium India)
• Volunteer Consultant at CSI Balagnana Illam
• Board Member, Palliative Initiative, Sharon Palliative Care Centre

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3. Need Statement (Problem Analysis)

Despite numerous governmental health schemes, a large segment of India’s population is still unable to access affordable, quality healthcare. Key challenges include:

• High out-of-pocket expenses for diagnostics, surgeries, and medications
• Lack of awareness of available government schemes and affordable options
• Cartelization and inflated pricing of medical services and drugs
• Limited access to trustworthy information on hospitals, infrastructure, and costs
• Bureaucratic hurdles in accessing welfare health initiatives
• Insufficient advocacy and navigation support for economically vulnerable patients
• Bottlenecks and impediments in Insurance claims
• Defensive medical practices due to mob violence against even genuine medical practices

Without intervention, millions are pushed into poverty every year due to healthcare expenses, perpetuating a vicious cycle of deprivation and ill health.

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4. Objectives and Mission of Panatt Medical Relief Trust

The Trust has a clear and targeted set of objectives:

1. Collect and disseminate data on healthcare costs across different sectors.
2. Provide counseling to patients seeking affordable healthcare solutions.
3. Employ a primary care physician / Health worker to offer navigation support to the needy.
4. Partner with hospitals to negotiate subsidized or free treatment packages.
5. Identify reliable sources for inexpensive generic medications.
6. Counter monopolistic practices that inflate healthcare costs.
7. Educate the public about treatment options and dispel health-related myths.
8. Apply ethical principles such as distributive justice to ensure equitable resource allocation.
9. Create a Dashboard/ Website for internet access and communication for doctors and patients.
10. Assist patients who are denied justified insurance claims by engaging with third party providers and regulatory bodies.

Above all, the Trust pledges to preserve the autonomy of patients in choosing healthcare providers, maintaining a neutral stance and avoiding preferential promotion.

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5. Project Description and Approach

The Panatt Medical Relief Trust will work on a multi-pronged approach:

• Data Collection: Mapping diagnostic centers, hospitals, and private practitioners with an analysis of pricing structures.
• Patient Counseling: A walk-in helpdesk and telephone service to guide patients toward affordable healthcare options.
• Hospital Partnerships: Collaborating with government and private hospitals to secure discounts or preferential rates for needy patients.
• Pharmaceutical Access: Sourcing generic drugs through government outlets or reputable pharmacies to lower medication costs.
• Awareness Campaigns: Conducting educational sessions, press releases, and social media campaigns to spread health literacy.
• Soft Activism: Engaging with government bodies to streamline access to welfare schemes and improve public healthcare infrastructure.

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6. Current Activities and Achievements (in one week of operation)

To be officially launched on 1^st June

Preliminary aid

• For free cleft lip surgeries in partnership with private donations
• Arranged subsidized pathology and biopsy for several patients
• Two free surgeries for head and neck tumours
• Free counceling
• Initiated data collection on healthcare costs and service mapping in Salem.
• Begun preliminary negotiations with hospitals for subsidized rates.
• A medical board is being constituted

The Trust’s growing network of volunteers and goodwill ambassadors continues to drive momentum even with minimal resources.

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7. Target Beneficiaries

• Economically disadvantaged patients requiring diagnostic, surgical, or medical care
• Patients unaware of their rights under government health schemes
• Low-income families vulnerable to catastrophic healthcare expenses
• Marginalized populations including children, elderly, and persons with disabilities
• Protecting the legal rights of health care providers

The Trust aims to benefit 500–1000 patients annually in the initial phases, scaling impact based on resource mobilization.

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8. Expected Impact

By empowering patients with information and facilitating access to affordable services, the Trust envisions:

• Reduced financial burden of healthcare for hundreds of families
• Increased uptake of government health schemes
• Improved treatment outcomes through timely interventions
• Greater public awareness about affordable healthcare options
• Advocacy-driven improvements in health policy execution at the local level

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9. Monitoring and Evaluation Framework

To ensure accountability and measure effectiveness:

• A database of assisted patients will be maintained.
• Monthly reports will track key metrics: number of patients counseled, surgeries facilitated, funds disbursed, discounts negotiated, etc.
• Annual audits will verify financial compliance and impact assessment.
• Beneficiary feedback will be collected to improve services.

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10. Sustainability and Scalability Plan

Sustainability will be achieved by:

• Diversifying funding sources (CSR, individual philanthropy, foundations). The CSR certificate application is still ongoing.
• Volunteer-driven operations to minimize administrative costs
• Partnering with other NGOs and government initiatives
• Gradual scaling into neighboring districts based on success metrics

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11. Funding Requirements and Budget

Monthly Estimated Operational Costs:

Item	Cost (INR)
Part-time  Medical Officer	₹20000 (honaraium)
Nursing Assistant	₹5,000 (honaraium)
Audit, Accounting and Office	₹10,000
Furniture, Electricity, Internet	₹5,000
Miscellaneous (Stationery, Printing)	₹3000
Total Monthly Running Cost	₹40,000–45,000

Financial Aid for Patients:

• Dependent on case-to-case need assessment
• Estimated initial disbursement: ₹2–3 lakh per quarter

Annual Operational Budget Requirement: ₹12-15 lakh (including patient aid)

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12. Governance, Compliance, and Transparency

The Panatt Medical Relief Trust is:

• Registered under the Indian Trusts Act
• We have obtained 12A, 80G certifications for tax-exempt donations and registered with all statutory requirements including Darpan
• Application to receive CSR- in process
• Committed to full transparency with donors
• Subject to annual financial audits
• Guided by a Board of Trustees comprising experienced voluntary medical and administrative professionals

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13. Appeal for Support                                                                

We invite corporates, philanthropists, foundations, and socially conscious individuals to partner with the Panatt Medical Relief Trust. Your support can save lives, restore dignity, and transform communities.

Together, we can ensure that the accident of birth or circumstance does not determine a person’s right to health.

Every contribution matters. Every life matters.

 

  

 

Continuing Medical/ Dental Education- Do the statutory bodies have jurisdiction?

 

The simple answer is NO! In my opinion any public notice to the effect by statutory bodies is probably ill- advised or a wrong understanding of the Dentist Act 1948 and the Regulations made by it as per 20 (1). It certainly must be ratified or challenged in a Court of Law.

Let me explain. Continuing Education is an absolutely necessity not only in health care but also in all professional arenas. I completed my post graduate training in 1986, nearly 40 years ago. What I learnt at college is not what I practice today. It has qualitatively and quantitatively evolved over the last 4 decades to keep pace with innovation, new skill sets and advanced technology. I am sure this is the experience of all professionals.

How did we acquire new skills? Obviously, by attending courses and workshops meant to upskill and adapt to newer methods. Continuing education also helps us fill in the gaps during training and produce better doctors. This is a boon to the public in accessing uniformly better and safer healthcare.

Recently more than one State Dental Council has issued a public notice prohibiting the conduct of continuing education by individuals or associations without taking prior permission of the Dental Council. This public notice is ostensibly based on the Code of Ethics regulation 2014 which was further amended to include CDE points as a mandatory requirement. The amended clause also provides direction to clarify the qualifications for the CDE provider. Let me quote the relevant provision of the gazette notified regulation no which came into effect in 2018.

Section 2 (b) defines a service provider to include all DCI /MCI recognized institutions having dental departments, government bodies and Armed Forces. Professional bodies such as Professional Associations and National Specialty Associations will need to apply to the DCI/ State Dental Councils for award of CDE points for meeting and conferences held under their aegis and this approval will be valid for a period of 5 years, subject to review.

The CDE points as per 6 (1) of the same regulation also says that there should a CDE credit system in India and each and every dentist shall inform the State Dental Council from time to time otherwise (SIC), it would amount to violation of the provisions of the ‘Revised (Code of Ethics) regulations 2014

For reasons best known to the DCI and State Councils the central theme of mandatory CDE points were never carried out in the last 7 years. In the absence of CDE requirements, where does the issue of the qualification for the provider arise?

Does this not mean that the regulation (DE-226-2017) is not implementable or was abandoned for the last 8 years? The old system of non –formal workshops and lectures can and should be continued in the interest of knowledge acquisition and continuing education.

Even if valid, a regulatory body can lay guidelines for acquisition of CDE points to fulfil regulatory requirements on those who wish to renew registration. The statutory body cannot prevent one qualified registered practitioner teaching another qualified registered practitioner any skill or technique or emerging treatment modality. Therefore, it is clearly outside the jurisdiction of the statutory bodies if no CDE points given or degree/ diploma is awarded.  The Dentist Act (the document of maximum reliance) only talks about recognized qualification. In fact, The Code of Ethics 3.2 encourages learning with the exhortation that “They should try continuously to improve medical knowledge and skills and should make available to their patients and colleagues the benefits of their professional attainments. and in fact encourages dentists to update their knowledge”. Implantology, for example, is not a recognized stand alone specialty. Dental surgeons became implantologists by learning it from the pioneers. Today it is a robust branch of dentistry, practiced by dental graduates, although it was not taught in dental colleges.  If the knowledge provider is spending time and resources on training, it is justified that they charge a cost towards imparting knowledge or skill.

In the final analysis it must be remembered that the Dentist Act of 1948 (with amendments) is to be relied upon if there is a conflict between the Act and regulations made by it. The Dentist Act  of 1948 and all amendments thereafter only refers to regulating registered qualifications like BDS, Dental Mechanics and Dental Hygeinists. If the Dental Council did in fact want to address the issue of non- registrable qualification it could have been done when amendments were instituted in 1992, 1993, 2016 and 2019. The issue was never addressed.

I sincerely hope that the National Dental Commission will address these issues more reasonably and allow flow of knowledge in the best interest of the profession and the public rather than drag these issues in court.

Caveat: the author George Paul has no vested interest in the matter as he does not conduct any courses or training.

The War Over Facial Aesthetics: Who Truly Holds Expertise?

 

Introduction

The question of whose domain facial aesthetics falls under is both a million-dollar question and a matter of professional identity. As an Oral and Maxillofacial Surgeon (OMFS) with a legal background, I bring a unique perspective to this debate.

Background in Oral and Maxillofacial Surgery

My training path has been through dentistry. To clarify, maxillofacial surgery is a specialty within dentistry, with varying international mandates regarding its scope and privileges. Contrary to popular belief, only about 10-15% of global OMFS practitioners require dual qualifications, mainly in Europe and Australia. In many countries, including India, a single qualification in dentistry is sufficient to practice this specialty. This is also true for many regions in China, Japan, South Asia, South America, Africa, and Russia. Any shortfall in the dental curricula is typically addressed through additional training in maxillofacial surgery.

It’s important to note that I do not perform aesthetic surgery and have no vested interest in this debate. However, I wish to emphasize the unique standards and requirements of Oral and Maxillofacial Surgery and its scope.

Evolution of the Specialty

At the time of my qualification, the core focus of my specialty included the surgical removal of stubborn teeth, jaw cysts, treatment of facial bone fractures, and surgery of the temporomandibular joint (TMJ). Over the decades, the field has evolved into a sophisticated specialty. Many practitioners, like myself, have exclusively practiced oral and maxillofacial surgery while remaining rooted in our foundational training in dentistry.

Dentistry itself is a demanding field, with a curriculum that includes essential medical sciences, enabling practitioners to treat patients safely and effectively. The culmination of this training results in a degree called Bachelor of Dental Surgery (BDS).

Interdisciplinary Perspectives

I have many talented physician colleagues, including dermatologists and plastic surgeons, who have also evolved their skill sets over the years. For instance, dermatologists have expanded from diagnosing skin conditions to performing cosmetic procedures. Although dermatology is a medical specialty that typically follows an MBBS degree, it now includes surgical interventions.

Defining Key Terms

A contentious issue is whether facial aesthetics falls exclusively under any one specialty. Before sharing my opinion, I would like to define some commonly used terms in our discourse:

1. Aesthetic Procedures: This term has sparked debate among specialties due to varying interpretations. Aesthetics, which emerged in English medical terminology in the 19th century, refers to the appreciation of beauty. In medical terms, it often relates to cosmetic beauty, including structural features such as the mouth, nose, eyes, and ears. It is much more than the just the skin.
2. Cosmetic Procedures: This broader term includes any intervention designed to alter or enhance appearance. It encompasses a wide range of practices, from eyebrow threading and makeup to surgical options like facelifts and orthodontics.
3. Plastic: The term "plastic" means "to mold" and is often misinterpreted as solely relating to plastic surgery. While plastic surgery has historical ties to specific specialists, many procedures—such as cranioplasty and urethroplasty—are performed by various medical professionals, including neurosurgeons and urologists. Pure dentistry itself has very challenging plastic procedures like gungivoplasty, mucosal grafts and use of botox and fillers.

Shared Responsibilities in Aesthetic Procedures

The National Medical Commission (NMC) and the Dental Council of India (DCI) have not defined exclusivity regarding individual procedures. Therefore, any assumptions about who performs what procedures are largely arbitrary and speculative, driven by a narrow view of ownership.

The ongoing "turf war" highlights the complexities of medical regulation in a country with diverse systems of medicine and multiple regulatory bodies.

1. Understanding Competence: The distinction in training and statutory competence between dermatologists and oral and maxillofacial surgeons is crucial. While both specialties have overlapping areas concerning facial aesthetics, the differences in their training pathways and regulatory frameworks must be acknowledged. This brings to light the need for a more nuanced understanding of the specific competencies each specialty brings to aesthetic procedures.
2. Regulatory Framework: The fact that the NMC and the DCI (soon to be NDC) operate under different legislative frameworks presents challenges for practitioners and patients alike. It raises questions about the clarity and consistency of regulations across different medical disciplines. There may be a need for inter-regulatory dialogue to establish clearer guidelines on who can perform aesthetic procedures, which could help mitigate conflicts.
3. Legal Interpretations: It is necessary to understand the absence of specialty registers in India. This is indeed significant. This gap in the regulatory framework allows for a broader interpretation of who can perform aesthetic procedures. However, it also raises the issue of patient safety and the quality of care, as not all practitioners may have the same level of training or expertise in aesthetic procedures. The deficiencies are addressed in the curricula whether it be knowledge of surgery or dentistry. The Role of Circulars and Notifications: The distinction between regulations and circulars is an important legal point. Circulars, notifications and guidelines, are often interpretative and do not carry the same weight as formal regulations. This creates an environment where practitioners may feel uncertain about their legal standing and scope of practice, which can lead to professional discord. Some state councils have placed too much importance to them and have exceeded their mandate in imposing restrictions without considering the possibility of competence by training.
4. Public Safety and Standards: The ultimate goal should indeed be the provision of safe and effective healthcare. Establishing minimum training requirements and standards for aesthetic procedures could help ensure that all practitioners, regardless of their specialty, possess the necessary knowledge and skills to perform these procedures safely. The health ministry and regulatory bodies should prioritize public safety over professional rivalry.
5. Future Directions: There is an opportunity for stakeholders from both dermatology and oral and maxillofacial surgery to collaborate rather than compete. Developing interdisciplinary training programs or joint guidelines for aesthetic procedures could promote a healthier environment for practitioners and enhance patient care.
6. Legal Action and Challenges: It is important to understand that India does not have specialty registers like in many other countries. The post graduate courses are ‘add on’ degrees used as essential qualification for teaching at graduate and post graduate levels in recognized medical and dental colleges. The essential and sole registration for practicing medicine or dentistry comes from being in the books of the MBBS/BDS register in the respective States or with the NMC. In the absence of a specialty register one cannot technically be restrained from practicing the full scope of medicine or dentistry. In other words, any registered graduate can practice the full scope of their basic qualification. The MCI / DCI has in the past issued notifications and circulars restricting procedures to specialists. These are arbitrary and has gone unchallenged. This aspect needs a judicial review.
7. Restricting practice privileges: I wish to reiterate that notifications, memos and guidelines by regulatory bodies are not actionable laws. These are mere administrative opinions. So the notices issued by state councils threatening to debar practitioners based on these memos or notifications can be challenged in a court of law. Qualifications and competence are two different things and need to be evaluated differently. The regulatory bodies have no right in law to prohibit teaching or upskilling courses because it is always in the best interest of the public that medical professionals, irrespective of their qualification, acquire greater competence through continuing education.
8. Patient-Centric Approach: Ultimately, the focus should be on patient welfare and informed choice. Patients should be educated about the qualifications of practitioners and the procedures they are considering, allowing them to make informed decisions about their care.

We need a collective effort to enhance healthcare delivery rather than restrict it. This collaborative approach could lead to improved outcomes for patients and a more harmonious professional environment for all practitioners involved in aesthetic medicine.

George Paul MDS DNB LLB Dip. Med. Law