The label should have made it clear that the medicine was not for people.
With pictures of camels, horse and cows as well as the words “Veterinary use only”, there could be little doubt about the intended recipient of the vial of steroids.
Yet as far as the poor – and often illiterate – patients being given injections at Mohammad Kashif’s backstreet clinic knew, they were receiving the best of care.
His lucrative business was halted one evening earlier this month by the abrupt arrival of Dr Saeed Asghar, deputy director of Punjab’s Anti-Quackery Department.
As Dr Asghar burst in through the clinic door accompanied by an armed policeman, the bogus doctor appeared ready to bolt until the health official took his arm and his defiance wilted.
“Many times a quack shows violence and sometimes their nearby relatives come and join in,” Dr Asghar explained to the Telegraph later.
Dr Aghar and his anti-quackery cell are at the forefront of a crackdown on unregistered doctors in Pakistan who can wreak medical havoc on patients and who officials say are a public health menace.
The bogus doctors are not registered with their professional bodies because they are normally either totally unqualified, or are operating beyond their remit.
A census of healthcare providers earlier this decade estimated there were 70,000 “quackery outlets” in the province of Punjab alone – far more than real doctors.
The unregistered doctors not only cash in on and often harm their patients, but are also a significant threat to public health.
Sloppy hygiene and lax sterilisation, particularly among unqualified street dentists, is blamed for an epidemic in blood-borne diseases like hepatitis C. The slapdash prescribing of antibiotics is also thought to contribute to a dangerous wave of microbial resistance. Infectious diseases are not spotted and not recorded.
However the fake doctors are a symptom of a struggling healthcare system where too few people have access to a genuine doctor and legitimate medics have a reputation for aloofness and disdain.
“Treatment by quacks is a healthcare nightmare,” said Dr Mohammad Ajmal Khan, chief operating officer of the Punjab Healthcare Commission which oversees the anti-quackery unit.
The quacks range from those without any qualifications at all to those who are practising beyond any certificates they do have. Doctors’ assistants and dispensers also often set up on their own to masquerade as medics after a few years experience.
Faced with a barrage of questions by Dr Asghar, Mr Kashif at first tried to claim he was a qualified medical doctor, but later admitted his only qualification was in homeopathy. His backstreet clinic was full of drugs he was not allowed to prescribe, while the bins were full of used syringes.
His desk draw was stuffed with cash. The backroom of his clinic in a suburb of Rawalpindi contained shelves of veterinary steroids which are one of the most popular treatments given by quacks. The powerful drugs temporarily mask a patient’s symptoms, while providing no long term solution to their ailment.
Dr Asghar’s team have the legal authority to lock up premises and to impose fines of up to half a million rupees (£2,750). But quackery is a profitable business and with that money comes corruption and collusion. Many quacks operate with the blessing of registered doctors, using their name and qualifications as cover. The legitimate doctors in return receive a “rent”.
As the Telegraph accompanied Dr Asghar on raids across Rawalpindi, several of those caught tried to bluff their way out of trouble by supplying certificates and licence numbers belonging to real doctors.
Dr Asghar said it was not unusual for a qualified doctor to turn up soon after a raid and try to get the quack out of trouble. The potential for corruption also means the anti-quackery department must remain vigilant of its own staff.
Punjab Healthcare Commission is trying to enforce professional standards in a province of 110 million where treatment has until recently been a free-for-all.
Of 70,000 unregistered healthcare providers found in the census, the commission has visited 41,000 and closed down 18,400. Another 9,700 had abandoned their practice.
Without addressing the shortage of legitimate healthcare, however, the battle against fake doctors would never be won, Dr Khan said.
“Unavailability, non-availability or partial availability of healthcare facilities are a great incentive for quacks,” he said.
He said that people had come to rely on their local quacks and accept them.
“Because quackery is so prevalent, so rampant, if people are exposed to this kind of method of treatment, there comes a point where people have started accepting it as an okay thing and we have to fight this mindset,” Dr Khan said. “People think at least I am getting some service.”
The unregistered doctors are often well known and well-liked members of the community. Outside one of the clinics raided by Dr Asghar, crowds gathered to watch.
As the premises were sealed with a padlock, they appeared less than happy that the facility was being shut down. In one case last year Dr Asghar was temporarily taken hostage in Muzaffargarh after closing a popular clinic.
The Commission is adamant that the unregistered doctors do more harm than good however. Dr Asghar, a former hospital administrator, said he had often seen his hospitals have to clear up the mess left behind by unqualified treatment. He had particularly seen many amputations on patients who had received bungled treated for fractures at backstreet bonesetters.
Dr Khan said another problem was infertility caused by infections caught at unregistered maternity hospitals. The Telegraph witnessed one raid on an apparently well equipped maternity hospital.
The woman in charge at first claimed she was a fully qualified doctor, but when her certificates did not stand up to scrutiny, she admitted she only had midwife qualifications.
“I’m shocked because we have been coming here for three months,” said Mohammad Imran who was waiting with his heavily pregnant wife. “We thought she was a doctor.”
Dr Khan said his campaign against quacks was a continuing war, rather than a single battle that could be easily won.
“Unless we resolve this issue of access, it will be like trying to fill a bottomless bucket with water,” he said.
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