It is only over the last few decades that medicine has evolved into a modern scientific discipline. Today, most of us try and practise what is called ‘evidence-based’ medicine. What that means is that every accepted treatment must be tested to ensure that it actually works.

Even fifty years ago much of what we were taught in medical school was based on direct observation rather than a scientific evaluation of the disease and its treatment. Medicine was still considered as much an art as a science.

Over the last century or so, medicine evolved while there were other medical systems that were popular but eventually became known only by the names traditionally attached to them. We have osteopathic medicine, chiropractic medicine, acupuncture, homeopathy, and a few more new age type stuff.

In Pakistan, we have hakeems that practise unani tibb (Greek medicine) based on hippocratic theories from a few thousand years ago, and we have homeopaths, ayurvedic medicine practitioners, and then we have religious practitioners of medicine. But none of them can claim that treatments offered by them have not been tested and found to be effective.

Besides these, we have a large number of people that masquerade as ‘qualified’ providers of modern medical treatments. These are often referred to as ‘quacks’. I prefer to refer to them as non-formal medical practitioners. However for the sake of brevity I will refer to them as quacks.

Most of these quacks have some medical background. It could be in nursing, as lady health visitors, or as pharmacists or those that have just worked in a hospital or a medical clinic for some time. One estimate suggested that there might be more than forty thousand such non-formal medical practitioners in the Punjab.

The first question, of course, is why there are so many of them. The answer is simple. When real medical help is not available, people in need will go whereever such help is available and more importantly, affordable.

This is especially true for villages and small towns where qualified medical practitioners are just not available because they do not want to practise in such places. And the rural health centres (RHCs) and the basic health units (BHUs) that supposedly provide care for these places are often not appropriately staffed.

The second obvious question is if these quacks are truly incompetent charlatans then why are they so popular and continue to provide medical care to a lot of people? The answer here is that they actually provide some level of service that is acceptable.

This is of course a situation that is difficult for most medical bureaucrats to accept. As my late father, a physician who practiced general medicine in Lahore for almost fifty years used to say, ninety percent of what I do, I can train my nurse or my ‘compounder’ to do quite well.

Simple problems like the occasional headache, fever, sore throats, cough, upset stomachs, diarrhea, and other aches and pains are usually self-limiting and will get better by themselves even without medical care. All reasonably educated and experienced doctor ‘moms’ are quite good at treating many of these problems at home.

Most quacks with some medical background can take care of these problems quite well. The real problem is when some of these quacks start believing in their own abilities a bit too much and go beyond basic supportive care. Fortunately, that is rare since that can lead to bad results and serious legal as well as public relation problems.

The same is true to some degree for the ‘hakeems’ and homeopathic practitioners. If they stick to what are the basic methods of their treatment, they cause little harm. First something about the hakeems and the Greek system of medicine, it has been around for centuries and by now these hakeems have a pretty good idea of what they can effectively treat.

This system of medicine is based on the hippocratic concept of the four humours, namely blood, black bile, white bile and phlegm. Common English descriptions like sanguine, phlegmatic and bilious are based on the preponderance of one of these humours.

And, of course, all foods have properties that can affect these humours and produce symptoms associated with them. Cool as a cucumber is just one example but many in my parents’ generation and even some educated people these days will suggest that certain foods should not be eaten during certain times.

Generally speaking, what hakeems have to offer is not too strong and has few side effects unless taken in quantities larger that prescribed. The one exception might be the kushtas or concoctions often containing metals. Some of these metals when consumed can be absorbed and damage some organs.

There is a story I once read, probably apocryphal, about precious metal prescriptions consumed by Mughal princes and princesses. Servants would collect their excretions to extract the precious metals consumed and passed out by these members of the nobility. It seems unlikely from a biological point of view.

Homeopathy is also based on an interesting premise. A medicine that mimics a symptom if diluted can mitigate that symptom. For a fever, if a medicine produces a fever then if diluted it will counter the fever. Fortunately, homeopaths believe that less is more and the least is the best. That means that homeopathic medicines do not contain enough active medicine to be a problem.

However, a while ago it was reported in the United States that you could buy an over-the-counter homeopathic cough medicine that contained enough alcohol to get a child drunk. Reminds me of a favourite syrup fed to colicky babies some fifty years ago. It contained more alcohol by weight than a bottle of fortified wine.

Two medical systems that I saw being practised in the US are chiropractic and osteopathy. Chiropractic has found some use in patients suffering from longstanding lower back pain. While osteopathic medical schools now teach regular medicine along with osteopathy and their graduates go through the same post-graduate medical training as medical school graduates.

Now to the point I wanted to make all along; should all those medical practitioners that are not ‘qualified’ to practise modern evidence-based medicine be considered as quacks? If not, then why should only those that have some medical training and usually provide a useful service be targeted as quacks?

Of course, any person falsely claiming to be a qualified doctor is committing a crime and should be held responsible.

My suggestion presented in these pages before is that all those informal medical practitioners that are providing medical care should be identified, registered and then made to go through a basic medical education programme every couple of years.

And while we are at it, as I have suggested before, all physicians, including general practitioners working in rural and semi-rural areas, must undergo an intensive continuing education programmes every two years as a requirement for re-registration with the Pakistan Medical and Dental Council (PMDC).

Frankly, in my opinion, a physician who is out of touch with new developments in medicine is a greater danger for a patient than an ordinary quack.

The author has served as Professor and Chairman, Department of Cardiac Surgery, King Edward Medical University.