Quo Vadis-Whither Dentistry?
( excerpts from the R Ahmed Oration delivered in Mumbai on feb 11th 2012)
Several people have asked me the meaning of Quo Vadis. For many people of my generation it was a popular footwear from the famous house of Bata. Quo Vadis simply means “Where are you going?”- in Latin. Simple as it may sound, it has a profound provenance. It has been used by hundreds of writers and speakers to ask a question that is both meaningful and rhetorical. There is an apocryphal story that this was a question put to Jesus Christ by St Peter. “To be crucified again” Jesus is supposed to have replied. This seems to be the predicament of dentistry in India.(1)
This oration will take you on a journey that saw the elevation of dentistry from a humble vocation to a respectable profession and then back again to an unwanted career.
Let me begin with a small story. In 1952 a young school teacher from a small village in the South of India travelled to several cities across the country in search of an opportunity to do a post graduation in botany. Unsuccessful, he was returning home via Bombay (now Mumbai), when he accidentally bumped into an old classmate from his village in the YMCA. The teacher was amazed to learn that his friend was doing a four year course in ‘dentistry’ in Bombay. It was at a time when Dentist or Dentistry was unheard of in the small towns and villages of India. The only dentist that the teacher knew of was a dubious gentleman who wore a black robe and pulled teeth at the weekly market. The teacher accompanied his friend on a visit to the Nair Hospital Dental College. After being surprised that dentistry was taught in a college for 4 years, he was further taken aback by the 5 storey buildings and the well dressed people going about in bow ties and white coats. On a whim, he joined the college. It was possible because there were vacant seats. Obviously, it was not a difficult task to gain admission into a dental institution. Certainly easier than an Msc in botany!! Four years later, the young school teacher became a qualified dentist.
This newly minted dentist was my father!
The story of my father Dr G Paulose, who passed away in 2008 after practicing dentistry for more than 50 years is more or less the story of modern dentistry. In his fifty years of practice he saw the establishment of dentistry as a specialty of medical science. It had grown into a sought after profession. As a Dentist he was recognized in society as an important health professional. He even saw the establishment of a dental college in his small city.
By the time of his death in 2008 he also witnessed the first signs of decadence and the dark side of the profession. Proliferation of colleges, cheap advertisements, unemployment, ethical misconduct and several ills had begun to creep into the once respected profession which he accidentally stepped into 50 years before. Dentistry had come a full circle. The period can be described best in the words of Charles Dickens “It was the best of times. It was the worst of times” Opening lines of Charles Dickens ‘A Tale of Two cities” (Opening lines of Dickens ‘tale of Two Cities).
From being a lucrative profession in the 1980s and 90s, dentistry is today crowded by mediocrity. As a profession it is losing its glamour. Hundreds of seats in Government Universities are going vacant. Dental education has moved back into the hands of the private sector where admissions are open to candidates with moderate scholastic ability. Thousands are jobless.
The number of dental colleges stagnated in the first 50 years of the twentieth century. There were just two colleges for a population of 350 million population in 1947 when India became independent. Forty years later in 1985 there were 21 dental colleges for a population of 750 million(2). This was a 10 fold increase in 40 years.( Figure 1) however, it was a necessary increase to meet the increasing demand for dental care. Over the next 20 years the increase became more dramatic. The number of college rose sharply to approximately 240 dental colleges by 2005.( Figure 2) This was an increase by 1200% in 20 years. A Government of India and WHO collaborative workshop on manpower resources in Delhi in 2006 concluded that the increase in the number of dentists had no impact on the dental health care in the country. Yet in the period from 2006 to 2010 the number of dental colleges went up to 291(3). This was due to the indiscriminate use of ‘need’ as a justification for issuing no objection certificates by the State governments and the DCI acquiescing to the increase. The amazing aspect of the increase in dental institutions was based on absolutely faulty data and projections. A significant data by Ahuja NK et al (4) shows a table which is equivocal. Titled as Growth in number of dental graduates from Indian Dental Schools, it shows a projection that there will be 30,000 by 2010. .( Figure 3) It is not clear whether this is per year or the existing dental graduates. We need to assume that it represents the total dental graduates as the number shown as 20,000 for 1990 is more or less the actual total number of dental surgeons in the country. Other reports showed that the number of dentists in relation to population may go down as expressed by S. Tandon (2004) that “ in the near future there may be a reduced number of people entering these colleges as the rapid growth in the number of dentists might tend to discourage some prospective candidates who may feel that the increased competition would limit their future earnings” (5). This clearly has not happened because by most conservative estimates there were more than 200,000 dental graduates by 2010. The fact of the matter is that nobody including the Dental Council of India actually knows how many dentists there are in the country. On what basis the planning commission reiterated that India needs 200,000 more dentists is a fact nobody can answer. Is it ignorance or turning a blind eye to unplanned growth?
The Times of India has reported in 2011(6) that “as per a Planning Commission study, the country is short of six lakh doctors, 10 lakh nurses and 2 lakh dental surgeons.” In fact Montek Singh Ahluvalia was repeatedly quoted in the past repeating that India needs 200,000 more dentists! Are we confirming George Bernard Shaw’s cynical comment that there are “lies; damned lies and statistics!” Is the planning commission ignorant of the fact that the number of dentists increased from 20,000 (approx) in 1990 to nearly 200,000 in 2011.(Figure 4) Are they not aware that there has been a phenomenal growth in Dental colleges in the period of 2002 to 2012 because the State governments have been issuing essentiality certificates for anyone wanting to start a dental college?
I have analyzed the existing and validated statistics of Kerala to indicate how badly manpower resources are determined in India. Kerala had only 2 dental colleges graduating less than 100 students till 2003. It went up to 8 dental colleges in 2005 students and the number stands at 23 dental colleges in 2010.( Figure 5) The number of graduating dentists is 1300 per year. ( Figure 6A &B)The dentist to population ratio in Kerala stands at 1:3380 because there are approximately 10,000 registered dentists (7)for a population of 33.8 million. The ratio is about 1:4500 in Tamilnadu and less than 1:3000 in Karnataka. This is significant, because the WHO requirement is just 1:7500 (4) &(8).
Growth of dental institutions and graduating dentists can be likened to cancer. A College once started cannot be closed down when it fulfills its need. They will continue to churn out students year after year, long after the requirements are met. It is a kind of Cancer and the carcinogen is money. Like cancer it continues to grow long after the removal of the triggering cause or need. Like cancer, the sheer weight of numbers will cripple the profession and eventually kill it. Since the population growth is several times slower than the rate of the growing number of dentists this end is inevitable.
Coming back to the example of Kerala, let us assume that no more dental colleges will be sanctioned. It is necessary to understand that the decadal population growth (10 years) in Kerala is only 4.8% ( Pop increased from 33 million to 36 million in the last decade)(9). Today several of these colleges have applied for increase in seats. Even if we did not count these increased seats, by 2020 the dentist population ratio will be 1:1500 (approx). By 2030 the ratio will become 1:733. ( Figure 7)The last figure is ten times better than that recommended by the WHO. With increase in seats or increase in colleges it may end up as one dentist for every street or even worse. Can a Dentist actually survive as a professional??? Will the Government be able to close down dental colleges started by businessmen who would like to squeeze out the last paisa before abandoning the dental college project and move on to something else? NO! Apocalypse for dentistry in Kerala will therefore happen sooner than 2030. Maybe in five years from now! This will be replicated in every state in India. The next on the chopping block is my own state of Tamilnadu. Dentist Population Ration 1: 4500. Karnataka, Andhra and Maharashtra will all be in the same boat very soon. The other states including UP, Haryana, Delhi, Gujarat, MP etc will follow suit.
India today has the most number of dental colleges graduating more students than any other country. Compare India with the USA and China. China with a population slightly more than India has only 106 dental colleges compared to our very own 290 plus.( Figure 8) Has this made dental health in India better than China? No!
The problem for dentistry has to do with the distribution of Dentists. Most Dentists (79%)reside and practice in the urban areas whereas most of the population (73%) resides in the rural areas.( Figure 8) This explains the anomalous phenomenon described by the GOI/WHO’s conclusion that increased dentists have not had a positive impact on dental care. (8)
Ahuja et al actually conclude that though the national average Dentist Population ratio is about 1:10,000 the real picture is bleak. By some complicated mathematics (statistics again) they say that in rural areas a single dentist services 250,000 persons (4). On the other hand in a dense city like Delhi the Dentist to population ratio might be close to 1:1000. This may be true. But the solution lies not in increasing dentists but in redistributing them sensibly. There are large tracts of rural India that has never heard of a Dentist. The dentists are rushing to the rich who have greater visibility due to their conspicuous consumption. This brings us to the next question.
So why don’t dentists start practices in rural India? There are two important factors. One is the cost of private dental education and the other is the inability of the poor to pay for advanced dental treatment. We will first need to understand and assimilate the fact that dentistry is expensive business and they can find a meaningful market for their skills only in the pockets of affluence in our country. Most Dentists today are the products of dental institutions that cost an arm and a leg to study in. 250 of the 291 colleges are in the private sector. Admissions to many of these colleges are invariably on the basis of capitation fees and/or exorbitant tuition fees. Students spend their family’s life time earnings to study in these colleges. How can you expect them to go out and practice in rural India, especially the remote inaccessible regions of Northern India where even basic health care is not available? ‘Go practice in rural India’ is an easy instruction to give. Most of these dental graduates pile into the cities creating glut and unemployment.
It is just another example of unplanned growth. However we also need to ask why so many dental colleges were sanctioned? After all it is not the crying need of this country because millions die for want of basic medical care including preventable diseases like diarrhea, Tuberculosis, AIDS and even starvation and malnourishment. India needs only a fraction of the dentists who are in circulation. They can effectively fulfill the needs of a growing middle class that has expendable incomes to support high end dentistry. Why then have so many dental colleges been sanctioned?
We also need to ask why dentistry was handpicked for expansion when India needs so many more doctors, nurses, village health workers. The answer is simple. In fact it has nothing to do with fulfilling manpower requirements. There are four fundamental reasons.
Business and money.
Reliance on false data- knowingly or unknowingly
Government apathy to the plight of protests from dentists.
Corrupt Government agencies, including regulators.
Dentistry was carefully chosen by business people venturing out into the business of education. They needed to make a quick buck and move on. The unscrupulous business people saw potential of better returns on investment in Dentistry. Better than medicine. Better than nursing. India is perhaps the only country in the world which has more dental colleges than medical colleges! It is an anachronism!.
The story of funding for dental education has an interesting and ironic twist to it. Dr R Ahmed (10) returned to India in the early 1900’s as a qualified dentist from USA, bent on starting formal training in dentistry. R Ahmed went ahead and started the first Dental College in 1920. Nobody would fund it. In a flash of ingenuity he started a Soda Fountain (Ice cream parlour) which was a novelty in Calcutta. It was called the New York Soda Fountain. The business did very well and he used the profits of the ice cream parlour to procure equipment and pay the staff of the new dental college. He donated the Dental College to the Government of West Bengal in 1949.
Today, it is a complete reversal of roles from the time when the likes of R Ahmed funded education through his own business to the present when dental education funds the wealthy life styles of business entrepreneurs in collusion with willing regulators and Government agencies. Inadvertent or purposeful reliance on skewed statistics and apathy to the plight of dentists is another reason. George Santyana (11)the philosopher once said “ Those who cannot remember the past are bound to repeat it” . It is emblazoned at the memorial for the genocide of Jews in Auschwitz. It is a lesson we can do with. The fact that in 2012, the Kerala government is planning to have more dental colleges is an indication that we may never learn from our past.
Adlai Stevenson the philosopher/ statesman once said “It is easier to fight for principles rather than abide by them”. I do not claim any great moral authority to prescribe for a better tomorrow. In fact many of us have knowingly or unknowingly been a part of the problem. That how ever does not exclude us from being part of the solution. I shall lay down my humble observances in the full knowledge that it needs more than verbal support for change.
I hope history will not judge me for the fault of not trying. What we may need now is
A major restructuring of the regulatory bodies. The NCHRH is already on the anvil. The checks and balances seem adequate. I do not believe that a bureaucracy will be necessarily above board. It is however the best we have. Graduating dentists have every right to make a decent living. However a non meritorious student who has obtained admission through money power is unlikely to uphold the values of a health care provider- which is a little more than just making money. It does not matter whether it is merit in Government Colleges or Private institutions. Admissions should be on the basis of merit. The classic case of the bar being lowered to allow mediocrity can be found in the 2007 BDS regulation of the DCI(12). Most people are unaware that the minimum marks required to gain entry into dentistry has been lowered to 40% for backward communities. It was previously only for Scheduled Castes. This was done insidiously to allow the children of the rich and powerful with low marks. Today Dentistry is the only professional course where backward communities can gain entry with 40%. Nursing, Pharmacy, Homeopathy and every other professional admission requires 50% in the qualifying examination for even backward communities. This is the same regulation that sought to scrap internship and which was thankfully restored in 2011. These nefarious regulations to suit some persons need to be corrected if dentistry is to be seen as a profession for achievers. Lowered standards of entry requirement and the role of ‘seats for cash’ has made dentistry the course for the intellectually challenged. It has become a profession for mediocre abilities. A body like the NCHRH is more likely to provide checks and balances at entry and exit level. It is at least accountable.
There has to be a rationalization of the number of dentists in the country. While calling for a moratorium on new colleges, I am also forced to recommend the closing or merging of several defunct dental colleges. Many believe that this is impossible. In that case the survival of dentistry will also be impossible beyond 3 decades. Here I would invoke the Flexner report prepared by Dr Abraham Flexner.
In 1900 a gentleman called Abraham Flexner was faced with a similar situation in the USA. There were too many Medical Schools and the standards were appalling. There was no uniformity or a level playing field. Abraham Flexner was appointed by the Federal Government with a grant from the Carnegie Foundation to study the matter in detail. In 1910 he recommended that 50% of the colleges/ schools did not deserve to exist.(13) The Government acted on this recommendation and closed down or merged colleges. It also imposed restrictions on seats and several measures including exit examinations to rationalize medical education.
The IDA as an agent for change
Several persons have advocated that the IDA and DCI work together. I partially agree that both these agencies have a common purpose. However it must be remembered that the statutory bodies are powerful law makers. In this the IDA must act to check the misuse of power. If the IDA is subservient to the dictates of unhindered power it may well be the end of dentistry. The IDA needs to act as a check and balance to guide the profession by voicing the wishes of the ordinary dentist whether in private practice or teaching. We need a greater participation from the dental community. Like the Arab Spring. Like the movement to ‘occupy wall Street’. I am forced to again quote Edmund Burke “All that is necessary for the triumph of evil is that good men do nothing. “
Only Tamilnadu and Kerala have come forward through their IDA to counter some of these issues.
We must rise as one and stand up against injustice. It is our profession. It is our future. If we do not speak up now it may be too late.
Demographics of India- http://www.google.co.in/#hl=en&sclient=psy-ab&q=population+of+india&psj
Ahuja N K, Demographics and Current Scenario with respect to Dentists, Dental Institutions and Dental Practices in India. Indian Journal of Dental Sciences, June 2011 Issue:2, Vol.:3
Tandon. S., Challenges to the Oral Health Workforce, Journal of Dental Education July 1, 2004 vol. 68 no. 7 suppl 28-33
Kounteya Sinha, Times of India, TNN Dec 13, 2011, 04.02AM IST
Kerala State Dental Council, Trivandrum
Proceedings of the WHO/GOI workshop on manpower resources in Dentistry, New Delhi 2006.
BDS Course regulation (as modified upto 25.07.07), Gazette of India, Extraordinary, No 182, New Delhi, September 10,2007