MUCH is said these days about how unqualified ‘quacks’ are playing havoc with the lives of the undiscerning public in Pakistan. Doctors and their professional bodies, who miss no opportunity to highlight the presence of so-called quacks as a menace to society, drive much of this narrative. The following is another perspective, one that focuses on the interest of the patients rather than that of the physicians.
Healthcare practitioners working at the primary level who are typically labelled as ‘quacks’ generally belong to two main categories: 1) those who have served previously or are still working as paramedics in public or private healthcare systems; and 2) those who hold unrecognised diplomas with little or no training. Incidentally, many of these individuals enjoy the patronage of a doctor who comes to their rescue in case of punitive regulatory action. In return, such doctors receive patients referred to them by these quacks.
Before going any further, let us take a step back and look at Pakistan’s healthcare situation on the ground. Though a focus on primary care is widely acknowledged as the most cost-effective and efficient approach to healthcare provision, the situation across the country has one common factor: there is an acute dearth of personnel at all levels — especially at the level of primary care. A giant infrastructure of primary healthcare facilities, which was developed at colossal expense in the 1980s and 1990s, is today in a state of disuse, neglect and disrepair, ie suffering from outright official apathy.
The foremost reason for this decay is that doctors generally do not prefer to work at this level. I would have done the same, as the quality of life that I am familiar with, or aspire to, is not possible to maintain or achieve in remote rural areas. As a result, what little healthcare provision is left at this level of the public health system is managed by paramedics.
Non-physician workers serve the public where few doctors would.
In order to address this, Pakistan’s governing bodies ought to recognise paramedics working as primary-level healthcare workers, and authorise them to work at this level by the provision of proper training, guidelines and oversight. There are numerous examples of similar integrations, both within Pakistan and abroad, which serve as templates of how productive steps being taken in the right direction can result in positive outcomes.
For example, the role of traditional birth attendants (ie, illiterate village women called dais) has been recognised in maternal and child healthcare, and they are being trained and supervised by the relevant government programmes to very good effect. A hundred thousand Lady Health Workers across the country, with no more than a few years of schooling and departmental training, have changed the landscape of maternal and child health on the ground.
Looking at examples outside of Pakistan, Nepal and Indonesia have trained their semi-literate medicine retail shop workers to dispense anti-diarrhoea and respiratory infection medicines, thus enabling them to play an important role in saving children’s lives in both countries. In Europe, nurses and pharmacists alike are being trained to prescribe medicines, even for complicated cases like diabetes and hypertension.
I would refer critics of this recommendation to the Alma Ata Declaration of 1978 — the bastion, indeed the fountainhead, of the concept of primary healthcare — which mandated that primary-care positions be staffed by paramedics (and not physicians).
The medical community and the government should also see the second category of ‘quacks’ — ie local informal practitioners — as a resource, that ought to be offered appropriate and recognised courses in order to become legally qualified paramedics. Their value should be recognised, especially in a situation when we have such an extreme shortage of healthcare workers at the primary level.
Several critics of ‘quacks’ have rightly pointed out that there is a large number — approximately 600,000 — of non-recognised practitioners in Pakistan. Few would disagree, then, that if acknowledged, they comprise the largest health workforce in the country, or that these health providers are working mostly in areas where few doctors would serve — in the remotest of places and the poorest of neighbourhoods, in both rural as well as urban settings. Accordingly, we should reject the rhetoric of labelling their work as ‘quackery’ and instead focus on improving public health — especially the health of those who are underserved by the current system.
Research from Pakistan and overseas has shown time and again that, when it comes to irrational, unethical and un-Hippocratic practices, it is the higher-ups of the healthcare system that are most at fault. Doctors ought to re-evaluate and rise above their anti-quackery campaign, and focus instead on the best interests of patients rather than those of the medical profession.
The writer is a senior public health pharmacist.
Published in Dawn, November 23rd, 2018