New CDE regulations- another avenue for institutions to make money??

Continuing dental education- will be it another avenue for profiteering by institutions??

In 2007, the Dental Council of India came out with an ambitious but poorly drafted, half hearted and ambiguous attempt to make continuing education compulsory for practising dentistry. In 2011, a new regime, struck it down as non implementable due to several reasons. Five years later it has now emerged again as a rehashed version of the original regulation, by the same dispensation that struck down the earlier version.

There are two things that strike me.

1. Why is it that the already beleaguered and over produced specialty of dentistry alone require such compulsory updation as a pre requisite for renewal of registration when critical health bodies like MCI, AYUSH and other bodies have not imposed such compulsions?

2. Why has the onus of providing such updation been placed almost exclusively with Dental Colleges which have been variously described as ranging from very good to very bad. In other words, why are other private organisations and skill providers been excluded from accreditation?

Before anybody gets me wrong, let me explain that I am in full support of doctors and dentists being fully updated on advancement in their science as a matter of public safety and quality treatment. However, there are too many glaring holes in the structure of the current regulation, though most of us will concede that it is a significant improvement over the last attempt, a decade ago. My position on the matter is simple. Make learning a more open process where people can gain knowledge in less expensive ways provided by modern communication technology. We do not need another regulatory body breathing down the backs of the poor struggling dentist who has to reckon with one more 'bully' in the form of the state dental council. Here are some of the objections

1. The primary task of providing continuing education has been offered to the teaching institutions. Are we looking at a bail out package for Dental Colleges that are sinking for want of students taking up dentistry? Going by the new regulation, it seems that the statutory bodies are providing them with another opportunity to make money. It is completely presumptuous to think that teachers in dental colleges are better placed to provide skills and knowledge. On the other hand the need for continuing education and updation is precisely because many of the sub standard colleges have failed to provide good training in the first place.

2. Even more presumptuous is the fact that teachers do not need continuing education. They are exempt!! This could be true, if they were pure teachers who did not do private practice and their work is restricted to the dental colleges. Let me give you an example. How can a teacher in Oral Pathology, who neither sees nor treats dental patients in a dental college be allowed to practice dentistry after college hours without the mandated CDE points?  Does teaching Oral Pathology give the person knowledge about Infection control, Ethics, Crown and Bridge preparation or Oral Surgery. Absolutely not!!! The only way that this major anomaly can be addressed is by preventing dental college staff from private practice or by making it compulsory for them to undergo CDE like every body else, if they wish to practice after their working hours.

3. By introducing a self assessment protocol we are giving too much of discretionary powers to the regulators. They can pick and choose their victims. Most of us see the enormous possibility of some of these powerful persons venting animosity by targeting those they have professional or personal rivalry with. If made compulsory, CDE as a compulsory requirement, should be used universally against all those who do not comply by a process of due diligence exercised by the regulatory bodies. Any attempt by regulators to exempt anybody from statutory action for non compliance, should be considered as a corrupt practice and criminal action should be initiated against the regulators. This is the only way to prevent selective harassment.

4. There is a discord in the rules for obtaining CDE points. It says one should have 100 points in 5 years but not less than 20 points in a single year. Going by this rule, a person who gets less than 20 points in the first year, already faces disqualification. Why wait for 5 years to take action? Another clause also says ' not more than 25 points in a year'. What will the DCI do? Punish those who learn more? We will ignore that as oversight or stupidity!!

5. The notification says it comes into effect immediately. Does this mean that a dentist cannot register on the 1st January 2019, if they do not have 20 points? Are all the oversight mechanisms in place or is it going to be arbitrary. Is my next CDE programme this weekend valid? Is the next National Conference of my specialty valid? Too many gaps, if you ask me.

There are several more vacuous discrepancies in this incomplete regulation. 

My bottom line is that while the DCI has the powers to make sub ordinate legislations, it cannot legally refuse re -registration on the grounds of this new regulation. The Dentist Act only requires a recognised qualification and a prescribed fee for registration. In any conflict between the Act and regulation, the Act will prevail. I hope the DCI is prepared for litigation, unless they amend the Act and even then it cannot be used retrospectively. It cannot be used for those who are already registered.

The DCI should remove draconian consequences for not updating and encourage CDE as a positive way to remain relevant in the profession. In as much as that is concerned, I appreciate the provision in the new regulation for certifying those who achieve the recommended CDE points. That alone should be an incentive. Not punitive action!

George Paul

Oral and Maxillofacial Surgeon

Salem

An open letter to the Secretary of the Indian Dental Association

Dear Dr Dhoble,

First, let us affirm that this letter is not ad hominem and it should not be taken personally. At the end of our careers, we have no interest or ambitions to any post or privilege in IDA. But as members or past office bearers of the association we have deep concern about the way the Indian Dental Association ( IDA) is being run.  We have brought this matter to your attention in a personal note and have not received a credible reply or explanation about several issues being raised. We also wish to assert that we are not being influenced by any group as is being perceived by some of your friends.

Therefore this open letter. While we acknowledge the fact that you have made the IDA into a gleaming corporate structure, we are also concerned about the meagre benefits the contributing dentist members around the country are getting out of their association. The matters of immediate concern are ( but not limited to)

1. The concentration of power in the hands of a few. The Hon. Secretary's post is a time bound one as per the constitution but we have seen just 2 secretaries in the last 36 years. By the end of the present term in 2022, the secretary would have served 20 years. The general body meetings for election of the HGS are somehow arranged to always be in the incumbent secretary's home city or at least state. This seems more than a coincidence as it has happened two times and we will not be surprised if it is scheduled again in Mumbai / Maharashtra in 2022 for the next election.

2. The IDA Head office is run like a corporate office at enormous cost to the association. We see from the balance sheet/ statement of accounts that the HO spends about ₹6-8 crores a year ( 4 previous year statements available to us). The rent for running the office and salaries run way beyond 1 crore each. In your communications you have claimed to have 80 employees. The annual electricity bill is ₹ 15 lakh , there are humongous expenses for travel in India and abroad amongst other things. This does not seem to be helping the contributing dentist from various parts of India in any meaningful manner. Today's offices, nationally and internationally, are run with paperless administration and e- governance. Major International Associations with larger memberships and handling greater logistics are run at far lower costs and manpower ( calculated on purchasing power parity). More over, this is not a permanent office and it is meant to be rotated from time to time. Can this kind of expenditure on resources be justified, particularly when the members do not even get a quality journal free of cost. What does a dentist shelling out ₹1400 a year in these hard times get for their contribution?

3. The sponsorships from toothpaste and other companies, received and disbursed through the HO, seems to be too centralised. Current government and statutory regulations frown on corporate sponsorships and the money received itself is questionable. Let us assume that it is a 'corporate social responsibility' ( CSR) and there fore justified because the profession and public has after all benefitted in some small ways by their schemes. However the centralised receipt and disbursement of these sponsorships call into question the manner in which the finances are being spread across the branches. If at all sponsorship as CSR can be received, the dentists are concerned about transparency and fairness in its distribution for conduct of continuing education or knowledge dissemination programmes. In fact the ethical conflicts raised by such sponsorships itself should be scrutinised.

3. A recent development suggests that the IDA is being turned into a professional service provider for a statutory body, namely the Maharashtra State Dental Council. This is being viewed sceptically by many members. We understand that the IDA is providing logistic and data management support to the Maharashtra Dental Council for a fee of ₹45,000 a month and ₹5 lakhs as development fees. We have reservations on this matter for 4 reasons

a. Whether the General Body of IDA was consulted before involving the IDA as a business service provider. Business outsourcing is not a function described in the IDA constitution.

b. Whether it is correct to use the services of employees of the IDA head office for business purposes as they have been employed ( at enormous cost) for administration of the association.

c. Whether the company Dentsoft, which developed the software, belongs to any office bearer of the IDA. 

d. We understand that the Hon.secretary general of IDA is canvassing for the post of DCI member under 3 (a). Since the IDA secretary will have access to the data of the prospective voters for 3(a) in the State Dental Council elections, there seems to be a conflict of interest and an unfair advantage to the Secretary? This model will be misused across the country if we allow this to happen. 

There are several other issues pertaining to the democratic running of the organisation. We strongly feel that the association would be better run by employing a highly qualified executive secretary ( as is done by several international associations) with adequate pay and perks rather than have a professional dental practitioner running the affairs of office as Hon. Secretary General with no pay.  Alternately, the term of of the secretary should be limited to one term. The association should be run by a President and executives elected by the members for a fixed term and preferably in a centralised city where the real estate is not so high and the human resources are more rational. We need an association that can work towards the welfare of the dentists who are going through a rough patch, rather than build plush corporate offices and initiate programmes that have no impact on the practising dentist for whom the association was created in the first place.

As a beginning, I hope the members will strongly gather together and bring change in the constitution so that we can have a more democratic and decentralised organisation working towards the welfare of the dentist, his profession and the public. Despite the requirement that the constitution and amendments be circulated, there is no public access to it.

We do not want World Dental Shows and pomp. We need welfare for the members at a time when dentistry is going through some bad times. We need representation in the Clinical Establishment Act. We need social security and indemnity. We need free continuing education, not just in Mumbai but in the remotest parts of the country. Mostly, we need absolute transparency and free and fair elections.

We need change! It can only come with new and younger faces of a bright new generation. As a secretary, you can still make it happen and salvage your position by engineering change and passing on the baton after serving for 20 years. The gray beards must retire gracefully. 

This letter in its authentic original format is available on the blog site www.maxfaxgp.blogspot.com . Any variation in its dissemination is not the responsibility of the authors. It is being published in the interest and welfare of the profession.

George Paul- Member IDA, past Hon. Gen. Secretary and President AOMSI, TN State Legal Cell Convenor

Viswanath V- past State IDA president, Kerala State and CC member.

Murali Venkataswamy- Member IDA, past TN State Legal Cell convenor.

 

SOCIAL MEDIA AND THE MEDICAL PROFESSION

There is a message circulating on the social media that is a cause of great concern and brings into focus the dark side of this new media phenomenon. I am trying to make a balanced statement on why the social media should not and cannot be used to settle personal scores between doctors and patients, especially when it can do unjustified harm to the reputation of the other.

The issue in question refers to the travails of a retired army officer living in coimbatore who claims to be the victim of medical negligence. The message expresses with angst his sufferings with an implant supported denture, done and redone, by two dentists in Coimbatore for which he spent a large some of money. I had the opportunity to see the letter written by the patient on several Whatsapp groups, expressing his angst. I also received a copy of an X-ray ostensibly of this patient's jaws. As a dentist who has been in Maxillofacial surgery for the last 36 years and as a qualified lawyer and ethicist I have a few comments to make. This does not purport to defend or vilify anybody.

1. I do not wish to comment on the treatment per se because I am not an implantologist although I have a working familiarity with the process. Implants are done by another specialist in our practice. However, I can say that the patient's claim about the cost is irrelevant. Implant dentures are costly fixtures and I am sure the patient was informed  about the same. The number of implants and how it is engineered are purely technical details and can be justified based on the prevailing situation of bone and nature of prosthesis. There is no such thing as an exorbitant professional fee unless it is sprung on people without notice. That does not seem to be the case.

2. I fully empathise with the patient who is obviously frustrated because some of the teeth on the denture where constantly chipping off. If I had paid 6.5 lacs for a treatment, I too would be frustrated. I am close, in age, to the patient and can fully understand the despair one feels as we grow old with multiple medical problems. However, one cannot justify the act of using social media to name and blame the medical/ dental care giver based on personal opinions.

3. For the lay persons benefit, let me explain what an implant supported denture is. Implants are titanium devices that are planted surgically into bone. They can fail if improperly placed or if the bone condition is unfavourable or due to various other situations. These days, 95- 98% of implants  do not fail. 

This is followed by loading the implants with a functional denture after 3 to 6 months or sometimes even immediately. These dentures are fabricated in dental laboratories and the teeth on them is made of a costly material which is expected to bear normal bite forces.

4. Having seen the X Ray and CT scans, it is obvious that in this instance the implants have remained intact after 2 years. However, the patient's teeth on the denture were supposedly getting chipped. It cannot be seen on a radiograph but it is a possibility. This can happen due to improper fabrication or by sub standard material used by the laboratory etc. Since the patient complains that it has occurred twice with two different dentists and labs it is unlikely to be due to the laboratory procedure. This can also happen if there are excessive forces acting on the dentures. These forces maybe due to para functional activity of jaws, due to movement disorders like Oro facial dyskinesia, bruxism ( night grinding) or simply hyper function. I cannot comment on what the cause for the chipping of teeth was or on the engineering principles that required the number of implants he had. This is because of my limited knowledge on the nuances of implantology and full mouth rehabilitation. However, I can comment on the line of action the patient chose to publicise this issue, either because of ignorance or despair or both.

5. If the patient assumed that there was negligence on the part of the dentist, he may well be right or wrong. That needs to be decided by experts on the direction of a legal or statutory authority and should be based on evidence based science. There are several provisions within the legal and statutory system to get relief and a due process of law to ascertain medical negligence. I, as the author of a book on medical law and having written several articles on the subject of medical negligence, feel strongly that the gentleman has used the social media as a tool to defame the dentist on the basis of his personal opinion. Medical negligence can only be decided based on evidence that a practitioner has caused injury by failing to meet the standards of care prescribed by evidence based medicine. The Supreme Court has repeatedly reiterated that mere dissatisfaction or the development of a complication does not constitute medical negligence. 

6. Under these circumstances the decision to take the matter to the public without any technical input and premised purely on the basis of personal experience or dissatisfaction amounts to subverting the provisions of law pertaining to medical negligence. Directly putting up complaints on the social media drawing attention to the professional abilities of their doctors and imputing motives to their actions amounts to civil and criminal defamation. This is particularly so because the nature of the post appears to be ad hominem ( personal).

My comments are a reaction to an increasing tendency of people to express their angst and targeting medical professionals in a way that affects their profession and standing in society. To do so, if they are indeed found negligent by a court of law, is different from making unqualified judgment based on personal experiences. 

The patient, in the above situation, can always go to court or approach the relevant statutory body to obtain relief. It must also be remembered that the doctor who has been vilified has the option of going to court for civil and criminal defamation against the patient for using the social media with the obvious intention of causing loss of face and reputation which the professional might have built up over several decades. This amounts to extra judicial vigilantism in the name of warning the public. 

Both doctors and patients must act within their remit, realising that both have rights, duties and responsibilities.

George Paul

Oral and Maxillofacial Surgeon

Consultant in Medical Law and Ethics

Attention members of DCI

AN OPEN LETTER TO THE PRESIDENT AND EC MEMBERS OF THE EXECUTIVE  COUNCIL OF THE DCI

Respected sirs and madams,

I happened to see a memo from the office of the DCI restricting the conduct of any kind of course not pre approved by the Dental Council of India ( No De-110(186)(complaint)-2018/457. This obviously sponsored notice, coming as it does at this point of time, seems to suggest that all programmes aimed at providing knowledge or refreshing skills must have the approval of the Dental Council of India. 

Respected president and members, I beg to differ, like thousands of others, because the DCI has no such powers to curtail the improvement or renewal of knowledge and skills from qualified persons with or without the sanction of the DCI. The notice cites sections 10, 10A, 10B, 51 and 52 to make the fallacious argument that the DCI is the custodian of all clinical learning or updating. It has freely and wrongly interpreted the meaning of the term ' qualification' to mean competence or acquisition of knowledge and skills. I hope the statutory body had spent a little more time taking a legal and grammatical opinion before coming out with such an ambiguously framed memo hindering the fundamental right to learn and benefit society.

Sirs and madams, the heading of section 10 of the Dentist Act refers to registrable qualification. I am sure that you are aware that the medical and dental statutory bodies regulate only registrable degrees which indeed are qualifications. The prime registrable degree in dentistry is BDS . A registered dentist with a BDS is allowed to practice dentistry including all specialties depending on their interest, ability and training. The postgraduate qualification is only an additional or add on registration. Add on Registration for post graduation essentially permits one to become a teacher in a college approved or recognised by the DCI. It does not provide exclusivity of clinical practice in a specialty, as India ' DOES NOT HAVE' a separate specialty register.

In other words, the members of the statutory body must understand, that a qualified BDS graduate can do Endodontics, Oral surgery, periodontics or orthodontics according to his expertise which is achieved through experience, practice and skill enhancing programmes. Where they obtain these additional skills within the purview of dentistry is not the business of the DCI . This is made clear in the definition of 'recognised dental qualification' in chapter1 (j) which includes only 'qualification in the schedule'. In which part of the schedule are there references to refresher courses recognised by DCI, sir??? 

Section 10(2) requires all these qualifications to be entered in the schedule. Which courses other than those offered by recognised dental colleges are included sirs? Are the courses conducted by IDA or Specialty associations part of the schedule? Does the DCI have powers and guidelines to include them? NO! Quoting section 51 and 52 in the aforesaid  memorandum/ notice is at best a wrong interpretation and at worst an attempt to mislead. These sections only refer to practice of registered dentists and has nothing to do with acquisition of further skills and knowledge by them. 

In fact the code of ethics regulation ( of which I was one of the draftees) encourages the acquisition of knowledge without conditions. It exhorts dentists to continuously upgrade skills in Chapter I, 3.2 and subsections. Nowhere does it say that imparting knowledge and giving a certificate of experience is unethical as implied in your notice.

Let me try to cite an example. Several hospitals provide Basic and Advanced life support training for a fee. The same with Trauma Life Support. Does the DCI have to whet every certificate programme in every hospital or institution in India and abroad to have a current training record in BLS, which you will agree is an essential part of safe practice. Skill renewal and enhancement can be provided in formal and informal settings with and without certification from a person with established skills. Dental practitioners get trained by other practitioners in the use of new techniques and materials. They attend courses conducted by industry pioneers and manufacturers of new devices and equipment. What has DCI to do with these?

Medical science has advanced only because of these courses which cannot be or has not been provided in teaching institutions during their limited course of study. In fact the need has arisen because many recognised dental colleges have not been able to provide the knowledge and skills as prescribed in the curriculum.

Sirs and madams, I request you to withdraw the memorandum which was issued in haste. If indeed the Dental Council wishes to bring in regulation for accreditation of providers of knowledge and skills, please create terms of reference, guidelines and make amendments to the constitution rather than issue fiats which retard the continuous enhancement of knowledge and skills by imposing unreasonable and unconstitutional bars on the dissemination of information.

Thanking you,

Your sincerely

George Paul

Reg No 10285 ( TNSDC)

Past President AOMSI

Sharon palliative centre- dignity in life

It has been said that "Death with dignity is better than life with humiliation". It is an affirmation of what most of us secretly hope for. In India, a dignified death is a difficult proposition. A TOI report says that of the 9 million deaths every year in India, nearly 6 million need some kind of palliative care. The fact that most do not have access to it, is altogether another matter.The same article throws up a shocking reality- 80% of the palliative care centres in India are situated in one state, Kerala ( with 3% of the nation's population). 

Sharon Cancer Centre in Salem, TN, has just been renovated to serve as the largest palliative centre in our region. Most Doctors, over the years, have been obsessed with strategies and means of prolonging life without actually considering the quality of life. Palliative care focuses on providing care for the hopelessly sick by helping patients and family to cope with their physical pain and disability. While palliative care can sometimes be given along with their treatment, most patients admitted for end of life care will receive very little in the form of therapeutic interventions.

The staff at Sharon's palliative facility have been carefully chosen, keeping in mind the special needs of patients with advanced disease. The doctors, nurses, counsellors and social workers form a tight and empathetic group of specially trained personnel committed to making the life of terminally ill patients comfortable and dignified.

The premises have been carefully structured and planned keeping in mind the special needs of our patients. The verdant campus, situated in sylvan surroundings at the foothills of the Shevarayan hills, is a pleasant blend of natural beauty and functional efficiency.  The buildings are disability friendly and well equipped to handle the unique needs of our special patients.

Sharon palliative centre was conceived as a non profit establishment committed to egalitarian principles that will not discriminate on the basis of type of diseases, social status, race, religion, language or ethnic background. 

However in the absence of any external funding the management will strive to run it at a minimum fee to cover actual expenditure. A percentage of the beds will be reserved for indigent and extremely poor patients who will be screened by a select panel. Sharon palliative care currently provides clean and airy housing, bed and linen. Diet plans and pain medication is provided on an actual cost basis. Specially trained palliative nursing is covered in the base costs. Surgical or medical interventions are generally not curative and meant only for alleviating pain and discomfort through licensed narcotic medications and limited toilet or pain relieving surgeries. Special requirements including visits by external consultants can be obtained on request through the administration. Special needs like private rooms, air conditioning etc can be made available at cost price but all general services are charged on a flat affordable fee structure. We look forward to volunteers from the public, who can provide solace, comfort or mere companionship.

Sharon will also expand its services to include domiciliary care where nurses and social workers will make periodic visits to homes to counsel, advice and intervene for terminal patients needing home care. Placement of trained male or female nurses for continuous home care will eventually be rolled out later to meet in -house domiciliary care needs.

Those willing to offer their services on a voluntary basis are requested to contact Dr Karthik Rajaratinam 9894027274

IF YOU KNOW ANYBODY WHO NEEDS HOSPICE, PAIN OR PALLIATIVE CARE PLEASE CONTACT Dr Kartik Rajaratinam 9894027274

An open letter to the Hon. Minister for Health and Family Welfare - Shri J P Nadda

Sir,

This letter is a reflection of the angst that has preoccupied the minds of thousands of professionals in the field of dentistry. Over the last decade and a half, dentistry has suffered enormously at the hands of several persons who have been running the Dental Council of India and the Health Ministry. The profession has become a burden to thousands of young people who have chosen it, believing that it would give them a meaningful role in society and a means to a stable economic career. The unprecedented and totally unplanned increase in colleges and seats has caused an irreversible glut in the profession leaving hundreds of unemployed dentists and specialists. Many have abandoned the profession resulting in an unforgivable waste of human resources. All this was done to feed the business interests of certain persons who run private institutions as a pure business with the help of the statutory bodies- indeed an unholy nexus!

We appreciate the initiatives being taken by the government and the judiciary to revamp the medical statutory bodies. Dentistry is perhaps the worst.  In this regard I wish to bring to your notice the fact that the Dental Council of India continues to be run through the agency of corrupt members, nepotism and poor governance. It is a sad reflection on the Health Ministry that despite numerous petitions pointing out the illegal membership of the President and several members, no action has been taken against them. The nomination of the President of DCI Dr Dibeyendu Mazumdar to is flawed ab initio as also that of several others. Despite overwhelming evidence produced by several persons and pending cases challenging such nominations, the health ministry has done little to correct the situation. Nothing short of disbanding the DCI and reconstituting  it anew will solve the continuing problems faced by the profession. 

Sir, there has to be 

1. A complete moratorium on new dental colleges and increase of seats in under graduation and post graduation, because of the super saturation by poorly qualified dentists. 

2. The quality of students entering and exiting the institutions have to be monitored through appropriate examinations in the interest of public safety.

3. The complete administration of the profession has to be revamped to remove illegal members and prevent concentration of power in the hands of a few. This has to start by sacking all the illegal members, starting with president. It is after all the Health Ministry that has been tasked with the job of constituting all the statutory bodies. It has to be their responsibility to dissolve and reconstitute when it becomes unbearable.

Looking forward to a speedy reaction from your ministry.

I remain

Sincerely

George Paul

A half ticket to Heaven!

The in-flight newspaper on the Kenyan Airways flight from Mumbai to Nairobi announced that hundreds of people were dying of malaria in the rift valley. The rift valley is endemic for rift valley fever and malaria which kill hundreds of humans and animals annually.I never imagined that malaria took its toll in such a dramatic way until I saw a child die in his mother’s lap. I had just landed at the mission Hospital in Kilimongogo, where I was to spend the next one-month as a volunteer dentist. A little boy with cerebral malaria lay on the lap of his mother, his eyes rolled up to reveal only the whites. He was delirious, muttering words and making incomprehensible noises. The mother sat mute and helpless as the young doctor examined the boy and drew blood. “Cerebral malaria” the doctor informed me “do you see it in your country?” The doctor was himself a refugee from Rwanda- A Tutsi, who fled massacre in his own country. “ I am sure there are cases” I replied “ I haven’t seen one though.” Later that evening he informed me that the child died and they were keeping the boy till morning so that the mother could take him back home- somewhere in the rift valley, I assumed. There was no public transportation. The hospital had just one ambulance and several people were dying. I wondered how the mother was going to deal with it. She was gone in the morning, carrying her dead son !This incident brought back memories of something that happened many years before that incident, in my hometown of Salem in India. A little boy with an ulcerated growth on his palate was referred to me from a village.  As an Oral surgeon I often encountered these conditions. The father explained that he was an extremely poor sharecropper. They were unable to get any treatment at the government hospital and were referred to me by their village doctor. The growth was surgically removed under local anaesthesia and sent for a biopsy. The report was inconclusive. A couple of months later the same boy was brought to me again. The surgical site in his mouth had healed completely but he now had an ulcerated lesion on his leg, quite similar to the one he had in his mouth earlier. His leg was grossly swollen, as were his genitals. I had the boy admitted and asked for my friend Dr Ranjan David, a general surgeon, to see him. Despite Ranjan’s best efforts the boy died of septic shock a day later. We never found out what the problem was. The hospital was gracious enough to waive all the expenses except the drug bill. As the little boy was admitted in my care, I went over to complete the formalities. The boy’s father was extremely distraught. He was inconsolable and kept wondering how he was going to tell the boy’s mother in the village. I realized he did not have the money to pay the drug bills. We passed the hat around and collected some money to pay it off. I then asked him how he planned to take the dead boy home. His brother in law had enquired at the local taxi stand and was told that they charged a hefty sum to carry a dead body. Virtually no ambulances transported corpses those days, as there was a stigma on such vehicles. A couple of taxis parked around the general hospital did transport dead bodies, but they charged exorbitantly. He told me that he could not afford the transportation costs and that he would manage somehow. I watched helplessly as he thanked me and heaved the boy onto his shoulder and threw a cloth on to his head. He told me that he was going to take a one-hour bus ride to his village. When I asked him if the conductor would allow it, he answered simply “ I will say the boy is sleeping and take a half ticket for him.” The picture of a father carrying a dead child on his shoulder in a bus was imprinted indelibly in my mind and it comes up every time we consider the inequities in our health system.