Management of leukemia is expensive. In the developing world where there are significant resource constraints, how does the physician manage leukemia? Government health budgets need to put their money into areas where a small investment is likely to benefit a large proportion of its people and these would include immunization, sanitation, family planning and treatment of communicable diseases and the cost of expensive treatments would have to be borne by the patient and family. However, in many of the emerging economies in the developing world, society is three-tiered in terms of resources with a small proportion being able to afford the best treatment, the middle class with the ability to meet a significant proportion of the healthcare costs on their own and the poor who depend wholly on what the Government health budget can afford. Providing an accurate diagnosis is possible even with limited resources and this must be made available to all. Sometimes a precise diagnosis even at the molecular level is more important in the developing world so that resources are not wasted on inappropriate treatments. Choosing a protocol for management based on resources available for the individual patient would appear ethically unacceptable, but is probably the only solution when wealth is unevenly distributed in society. This paper illustrates an approach to the management of leukemia in the developing world that has evolved with experience over two decades in a tertiary referral hospital in India.