Two women, one with an infant in her lap, an oldie and a man in his 40s were all sitting in the waiting area at a ‘clinic’ situated in a narrow street of Dharampura, Lahore. The clinic charged Rs200 to acquire a slip number, something they were all carrying in their hands.

Meanwhile, a ‘doctor’ was examining an old lady in his open cabin who, it became clear soon, was suffering from a pain in her back. After five minutes, the old lady came out with the help of a girl and sat near the assistant’s chair. The doctor handed over the prescription to his assistant over the cabin and also gave him some instructions.

The assistant sent the next patient to the doctor before he started preparing an injection which was to be administered to the old lady. She was told the injectible pain killer would work faster but she had to take the prescribed medicine thrice a day for the next three days. She left with the girl but after paying Rs300 more for the injection and medicines.

Quick first aid, accessibility and affordability are the key attractions that draw the masses to quacks. According to Punjab Healthcare Commission (PHC) three million or more patients visit quacks each day in the Punjab. Excluding the street quacks, currently around 105,000 quacks are operating in the province and a conservative idea is that each quack caters to 25 to 30 patients daily, Chief Operating Officer PHC Dr Ajmal Khan says.

Essentially, the socio-economic condition, inaccessibility of doctors, and unavailability of necessary healthcare facilities are considered the prime reasons why quacks thrive. GALLUP’s January 2018 report shows concern regarding the doctor-patient ratio in Punjab: "Despite the 25% growth of MBBS doctors from 2006 to 2015, the number of doctors remains alarmingly low and unable to keep up with population growth."

Nonetheless, these deprivations and lack of health facilities are no justification to this unlawful way of treatment. Besides, quackery is one of the key factors in complicating the disease which can be cured at the first stage if patients visit qualified professionals. Therefore, on April 14, the Supreme Court directed PHC to eliminate quackery in Punjab and instructed the Punjab police to help PHC.

"Under section 36 of PHC Act 2010, the PHC has arrested 8500 since 2010 and sealed their illegal outlets, it has also collected Rs66 million as fine," Dr Khan tells TNS.

Unfortunately, 20 to 25 per cent of outlets were using the name plates of real medical practitioners or dentists which means they were also getting share, says Dr Ajmal Khan. "PHC cannot investigate doctors who help quacks in their business. That is why Pakistan Medical and Dental Council (PMDC) has been asked several times to investigate and cancel the license of those who are found guilty for running the quackery business. However, nothing has ever happened in this regard. Even some of the doctors have provided affidavits to the owners of illegal ‘clinics’ expressing that they are part of operational activities and this act of PHC of sealing these "clinics" is illegal. Therefore, the owners have gone to court against PHC and we are facing 306 such cases in district & session courts."

Representatives of Young Doctors Association (YDA) are also convinced that senior doctors do get their share from the quackery business by allowing them to use their names. "Apart from unethical support of our seniors, PHC, Pakistan Medical Association (PMA) and political administration never took serious steps to curb this menace permanently," says secretary general YDA Dr Salman Haseeb who is based in Lahore.

"The prime objective behind the establishment of Pakistan Healthcare Commission was to eliminate quackery whereas it has opted for a typical bureaucratic approach of putting blames on others; let alone perform its own assigned duties," says Central President Pakistan Medical Association (PMA) Dr Ashraf Nizami. "In addition, PHC looks more engaged in collecting money instead of abolishing quackery that is why the commission never tried to work on such laws which might have helped them eliminate quackery."

"The imposition of regulations since the formation of PHC in 2010 is frustrating for the doctors who were getting superfluous cash by giving shelter to quackery business," Dr. Khan states. "The doctors go on strikes several times in a year to coerce civic administration to fulfill their demands but none of them has ever come out on the streets against quacks."

"Though it is a non-serious statement without any solid proof, PMA has never supported such illegal involvement [of doctors] if there is any," Dr Nijami says, replying to Dr Khan’s charge.

Paramedics who are involved in providing private health services are considered quacks as well. Pakistan Allied Health Organisation and Punjab Paramedics Alliance have filed two dozen writ petitions in courts arguing that paramedics hold diplomas and they are skilled enough to provide first aid, therefore, they should have the right to private practice. "Many hospitals in the province do not have required number of pathologists, pharmacists, and radiologists which means that the paramedic staff is not only assisting in the hospitals but also fulfilling the jobs of those who are unavailable in the hospitals," says  spokesperson Pakistan Allied Health Organisation Muhammad Shoaib.

Office bearers of PMA and YDA believe that political government favours paramedics because of votes and political support. Current government has agreed to give permission to paramedics to practice privately, Dr Salman Haseeb states. However, Punjab Health Minister Khawja Imran Nazir denies such allegations. "Government does not approve such unlawful and unethical demands of paramedics. We are clear that paramedics who work independently also fall under the category of quacks and will be dealt with an iron hand."

PMDC Ordinance 1962 and PMDC Act 2012 explicitly elaborate that a medical practitioner or dentist must hold recognised qualification and shall be registered for one year internship in an approved hospital. According to PHC Act 2010, only those medical practitioners and dentists are allowed to work in the field who are registered with the four federal bodies. These bodies include Pakistan Medical and Dental Council, National Council for Homeopathy, Pakistan National Council for Tibb, and Pakistan Nursing Council.

The order of Supreme Court to arrest all quacks has made PHC the leading agency to seal all illegal medical outlets. It is confident that these cannot get stay order or relief from any court in future. They have to satisfy PHC regarding the legality of the business or they can contact the honourable Supreme Court.