A Colonial Legacy and a Modern Health Crisis
In countries like Pakistan and India, the dental profession stands as both a symbol of aspiration and a mirror to systemic inequality. While formal dental education exists and is often fiercely competitive, millions remain untouched by its benefits.
This paradox is not accidental. Both nations inherited much from their British colonial past: the penal codes, administrative structures and crucially, the educational system. In dentistry, this meant a rigorous path: a four-year Bachelor of Dental Surgery (BDS) degree, followed by a one year clinical residency. Getting into dental school requires near impeccable grades, strategic planning and significant financial backing.
However once these qualified dentists graduate, urban ambition overrides rural obligation. Most dentists seek to work in the cities, where they can recoup their investment, build reputations and access private practice opportunities. The countryside? It is often left with vacant clinic spaces, unopened instruments and one of the most overlooked consequences of medical inequality: quackery.
A First Posting: My Story from the BHU
After graduating from dental school in Lahore, Pakistan, I applied for a government position through the Punjab Public Service Commission, a notoriously competitive examination system designed to recruit professionals into public service. I cleared the written exam, advanced through interviews and was officially appointed as a government dentist under the Department of Health, Government of the Punjab.
Then came the news of my first posting: a Basic Health Unit (BHU) located approximately 103 kilometers from Lahore.
I was excited. There is something beautifully symbolic about a first job, especially one tied to public service. Like many new graduates, I envisioned treating patients in need, easing pain and bringing dignity to an area where oral health was often neglected.
So I packed my bags and set out into the heart of rural Punjab.
When I arrived, the landscape was almost cinematic.
Golden cornfields rippled in the distance, the horizon dotted with mud-brick homes and fruit-laden trees. A tractor rested lazily near the edge of a field and women in brightly colored dupattas carried handmade straw baskets, collecting vegetables under the warm sun. The air had a freshness and clarity that felt alien after years of city smog.
The BHU itself was modest but functional. I was greeted by Noor, the assistant assigned to the dental unit. He welcomed me with warmth and sincerity, offering me tea before giving me a tour of the facility.
Inside, the floors had been freshly mopped and the waiting area had simple wooden chairs, nothing fancy but clean and cared for. There were rooms assigned to the physician, the nurse and then finally, the dental suite.
What I saw next caught me completely off guard.
In the center of the dental treatment room sat a brand new Belmont dental chair, still wrapped in its original plastic.
I gasped, “Why has it not been set up?” I asked.
Noor smiled, almost sheepishly. “Doctor sahib, no one has stayed. You are the first dentist who has actually reported for duty.”
He explained that dentists were regularly posted there but they would typically visit once, inspect the site and immediately request a transfer closer to the city. In their absence, Noor, a non-dentist had taken on the role of de facto provider. He had learned through necessity and repetition, how to perform basic extractions. People in the area, he explained, only came when they were in pain and they didn’t ask for root canals, crowns or restorations. They asked for relief.
“They want the tooth out, saab. They don’t know there are other options. I help the best I can.”
I stood in silence, absorbing the scene:
- A top-of-the-line chair, unused for years.
- A rural population, suffering quietly.
- And a kind, unlicensed man, filling the role that organized dentistry had abandoned.
This was not quackery in the traditional sinister sense. This was a patch in a torn system, a survival mechanism where infrastructure had failed and where the hierarchy of care was dictated not by degrees but by presence.
Rural Quackery: Born from Absence, Not Malice
In the Western imagination, the word quack evokes shady characters with metal instruments, lurking in alleys, promising miracle cures and delivering misery. But in places like rural Pakistan or India, the reality is far more complex and far more human.
What I saw in that BHU was not a fraud, it was a stopgap in a broken system. Noor was not masquerading as a dentist out of greed or deception. He had stepped into a vacuum created by:
- Policy that looks good on paper but fails in practice
- Dentists unwilling to serve in distant areas
- And a rural population with nowhere else to turn
The reality is, organized dentistry left first and quackery moved in, not as a competitor but as a response to absence.
These unlicensed providers operate out of:
- Makeshift roadside stalls with wooden chairs and umbrellas
- Small rooms attached to general stores or mobile carts
- Even abandoned BHUs, where the infrastructure exists but the manpower never came
Their instruments are basic, their sterilization is questionable and their scope is narrow. It is mostly extractions and crude partial dentures but they are present and in many villages, that alone gives them legitimacy.
Is it safe? Not often.
Is it ideal? Absolutely not.
But is it malicious? In most cases, no.
It is healthcare by necessity, not choice and when a child is crying with an abscessed tooth 40 kilometers from the nearest qualified clinic, a man like Noor becomes the only name that matters.
Urban Quackery: The Economics of Desperation
But quackery does not stop at the village border. In cities like Lahore, Karachi, Delhi or Mumbai, it thrives in the shadows of formal clinics.
The reason? Affordability.
In Pakistan and India:
- There is no concept of dental insurance through employment
- There is no standardized provincial fee guide, such as the Ontario’s ODA Fee Guide
- All care is paid out of pocket and fees fluctuate between clinics
A single extraction or filling may cost five times more in one neighborhood than in another, without justification beyond location or branding.
For millions living at or below the poverty line, formal dentistry is simply not an option and into this financial vacuum steps the urban quack:
- Offering deeply discounted services
- Running clinics in busy bazaars or under railway bridges
- Sometimes performing up to 20–30 procedures a day, in high-turnover settings
Interestingly, some of these individuals have become informal dental entrepreneurs. In a bizarre twist of semi-legitimacy:
- They contract actual dentists to work a few hours a week
- They invest in basic equipment to attract clients
- They operate with minimal overhead, high volume and just enough skill to avoid disaster
Their clinics may lack ethics but they do not lack demand.
These are not isolated anomalies. They are part of an informal healthcare economy that serves a massive segment of the urban poor, people who live in legal gray zones and for whom root canal vs. extraction is not a choice but a class divide.
The Ethical Paradox: When the Unlicensed Serve More Than the Licensed
This is where the discussion gets uncomfortable for formal dentistry.
How do you reconcile the reality that quacks often serve more people than licensed dentists in both rural and urban areas?
Is it ethical? No.
Is it dangerous? Often, yes.
But is it entirely unjustified? That is the uncomfortable part.
The system:
- Trains elite dentists
- Centralizes care in cities
- Offers no safety net for the poor
- And then wonders why the “quack problem” persists
But the quacks did not break the system. They slipped in through the cracks.
Conclusion: Bridging the Gap, Not Blaming the Gaps
It is easier to point fingers at the men on the roadside with pliers and powdered gloves but it is much harder to look inwards as a profession, as policymakers and as a society, to ask the real question:
Why does quackery still exist in 2025?
In countries like Pakistan and India, where British derived educational and legal systems created formal pathways for licensed dentistry, the blueprint exists. There are thousands of trained dentists, hundreds of dental colleges and advanced clinical knowledge rivaling that of the Western world.
And yet…
- Rural health units remain unmanned.
- Urban slums are overrun by informal clinics.
- A qualified dental visit remains a luxury for the middle and upper classes.
Quackery is not a rogue wave, it is the tide that flows in when the system recedes.
The solution does not lie in mass arrests or punitive campaigns. It lies in:
- Decentralizing care and incentivizing rural postings
- Subsidizing basic dental care for low-income populations
- Establishing mobile clinics and community education programs
- Providing formal training pathways for informal providers to upskill and register
- And creating fee standardization, so that fee variation does not become a wall between pain and relief
An Ode to Noor and the People Like Him
When I think back to my first posting, to the pristine Belmont chair still wrapped in plastic, I don’t remember a failed system. I remember Noor, with his mop bucket and his makeshift clinic, holding the line for an entire community in the absence of structure.
He did not wear a white coat.
He did not carry a license.
But he carried intent and in some of the darkest corners of public health, intent is what keeps the lights on.
It is time organized dentistry stopped only condemning the existence of quackery and started acknowledging the system that breeds it.
Let us bridge the gap.
Let us not just defend the chair.
Let us finally fill the one that has been empty for far too long.
