Over the last month I spent much time in hospitals, in Lahore as well as Karachi. These hospitals were private hospitals and they charged a lot of money for their services. However the quality of medical and nursing care was quite good and the environment was clean and well maintained. What that makes more obvious is how inadequate medical care is for those that cannot afford the better class of private hospitals.

A majority of people in Pakistan and the Punjab depend on government-run hospitals for most of their medical needs. The problem with government-run hospitals and health centres is that they are overcrowded and underfunded. As such long waits and indifferent doctors and inadequate medical supplies force many patients to resort to local quacks that offer medical care that is at best dubious. Frankly for many of the poor, regular doctors in government-run facilities are no better or worse than quacks or marginally trained doctors in the private sector.

Those that can afford it will always get the best possible medical care money can buy in Pakistan and that can be quite good. But somewhere along the line ordinary Pakistanis also deserve to have decent medical care available to them. I have expended much ink on this issue in these pages so I am not going to belabour that point. However, there are two distinct issues that I do want to discuss.

The first issue is that of the so called quacks that provide care to a considerable number of people. Perhaps it might be a better idea to call these people ‘informal medical practitioners’. Estimates suggest that there might be forty thousand or so informal medical practitioners in the Punjab alone. This of course excludes all the ‘hakims’ as well as the homeopathic doctors practicing alternate forms of medicine. I do not wish to talk of the alternate medical practitioners but rather concentrate on the informal medical practitioners.

Many though not all informal medical practitioners have some sort of a medical background. Many have worked as pharmacists, nurses or as lady health workers before striking out on their own. The reason why so many survive in the market place and even make a decent living is because of one simple fact. A majority of medical problems are simple and essentially ‘self curative’. Common cold, flu, upset tummies, non-specific aches and pains will almost always get better with time, a proper diet and perhaps some aspirin or acetaminophen. The better among these practitioners are smart enough to know when they are out of their league and send the sicker patients to the local or tertiary care hospitals.

Clearly then these informal practitioners provide a service to many people living in villages and small towns. Here perhaps I differ from established medical thought. Instead of trying to make thousands of these practitioners stop practicing medicine, a virtually impossible task, it might be better to accept their contributions and bring them within some official control. Perhaps these people can be registered and provided some basic medical education and training on a regular basis so that they are better equipped to handle simple medical problems. Also the female workers can be trained to provide prenatal maternal healthcare. More importantly such practitioners can be the first line of defence against silent killers like high blood pressure and diabetes, two problems that are easy to diagnose and treat.

Indeed this would seem like a recommendation to create a two tier medical system, one for the rich and the well connected and one for the less fortunate in society. But then that dichotomy already exists and might as well use it properly. Ideally the vast network of the public health system spread all over should be improved and made more responsive to the needs of ordinary people. But that has never been a political priority among the ruling classes. Until such time that politicians decide to refurbish and improve the basic rural healthcare systems, informal medical practitioners will continue to work and provide a basic service.

The other issue I want to address is that of doctors and their reputation. It is always a source of considerable amusement to me that every so often newspaper articles are written about venal and corrupt doctors blaming them for all sorts of moral turpitude and medical malpractice. But when doctors go on strike, they suddenly become messiahs wandering off the path towards righteousness. Doctors are people too. They have families to support, bills to pay and a future to worry about. If history is any guide, messiahs usually end up rather badly. So let us treat doctors as we do other professionals. Rarely have I seen articles about lawyers charging large fees and then losing a case, or bureaucrats making a mess and having to pay for the mess they make.

More than most lawyers or bureaucrats I am sure that doctors by far try to do the best they can for their patients. Over the many decades that I have practiced medicine, I do not remember a single occasion where a doctor deliberately did something wrong. As I said above doctors are human too and as such they can make mistakes like anybody else. But that does not mean that doctors cannot sometimes make mistakes or do the wrong thing, not deliberately but out of carelessness. The major problem especially as medicine is practiced in Pakistan is the fact that many doctors never keep up with the latest information in their medical specialty. From my perspective, ignorance or inability to keep up with the latest developments in medicine is a worse crime than plain negligence.

That incidentally is one of the things that I learned during the last month that in our newer private hospitals, doctors are well trained and are aware of the latest concepts as well as practices in medicine. Does that mean all is well in the area of high priced medicine in Pakistan? Not quite. Certain important but narrow bases super-specialists are not easily available. One of the reasons that super-specialisation in different medical fields is possible in may western countries is that some form of ‘third party’ insurance pays for much of medical treatment. As such consultants taking care of narrow aspects of medical care flourish since they do not have to restrict themselves to taking care of just the rich patients that can afford such care. In Pakistan such super-specialisation is difficult since the number of paying patients needed to provide a consultant with an adequate livelihood is rather limited.

Our great public hospitals that once were at the centre of medical advancement in Pakistan are no longer in a position to lead. These days few well-trained physicians that return from abroad bringing with them the latest in knowledge and technology choose to work in places like the Mayo Hospital. Cardiac surgery in the Punjab was literally born in Mayo Hospital but today its department of cardiac surgery is on the verge of extinction. If you want the latest in medical knowledge, technology and technical skills then you will have to go to a well-equipped private hospital.