Holding a chunk of ice wrapped in a handkerchief firmly to his right cheek, Saleem Jawad, 34, looks rather pleased with himself. From time to time he turns away to spit out a stream of red blood, before sipping from a glass of cold water beside him.
Saleem, a car mechanic, has just had a molar removed in Lahore, capital of Pakistan’s eastern Punjab Province. The roadside dentist, Siraj Saeed, who performed the task, has the extracted tooth in a steel bowl next to an array of instruments spread out on a small, stained mat where he receives and treats his patients.
"The problem has gone now. I will be able to sleep properly and eat again in a few hours," Jawad told IRIN.
But while the roadside tooth removal - carried out without anesthetic and with only the most primitive, unsterilised tools - was obviously painful, there could be dire consequences for those who use the services of roadside dentists.
Recent studies in Pakistan have shown that roadside barbers, dentists and doctors are responsible for the rapid spread of diseases such as hepatitis, as well as HIV/AIDS.
Dr Anwar, who is considering moving back to Pakistan, cited an acute shortage of qualified practitioners - effectively encouraging such practices to thrive.
Shortage of qualified dentists
According to Pakistan government figures for 2006, there were 6,761 dentists in the country for a population of at least 155 million - roughly one dentist for every 23,000 patients.
This ratio had improved somewhat over the past decade, but the number of qualified practitioners remained dismally low.
This also means fees charged by trained dentists at private clinics tend to be high, while government medical facilities are often poor and involve long waiting periods.
"I know people say one can get sick by visiting roadside dentists. I have seen a programme on TV about this, and something about boiling instruments," said Jawad.
 When the same instruments are used on one patient after another, and only dipped in a pail of water to clean them, there is an immense danger of passing on all kinds of disease, including HIV. |
Roadside dentists charge between eight US cents and $3 for their services, while a visit to a private dentist will cost more than $8. Even treatment at public sector facilities often incurs larger costs.
Such costs are beyond the means of many people in Pakistan who earn less than $100 a month.
As a result, thousands of people each year visit roadside practitioners, who usually depend on lessons passed on from elders or simply first-hand experience, for their expertise. Moreover, most have little or no awareness about the need for hygiene, let alone sterilisation or the dangers of HIV/AIDS.
"These things are in Allah's hands; we do what we can," says Saeed. "I wash my tools with soap each evening."
Hepatitis, HIV/AIDS
But with the prevalence rates for hepatitis stated by the Pakistan Medical Association to be at least 11 percent and rising, such practices also play an inevitable role in the spread of the disease, which claims hundreds of lives each year, as well as HIV, say specialists.
Pakistan is now ranked in the “concentrated epidemic” stage of HIV/AIDS, according to the World Health Organization (WHO). Pakistan's National AIDS Control Programme (NACP) officially confirms only 3,198 HIV/AIDS cases across the country, but NACP experts concede the "number of sufferers could be higher".
Speaking to IRIN, Naveeda Shabbir at the NACP said prevalence among the general population was below 0.1 percent, but added there was a higher prevalence among specific populations, most prominently injecting drug users (IDUs).
| I wash my tools with soap each evening. |
According to WHO, the number of HIV-infected persons in Pakistan could be as high as 85,000.
Epidemics have been reported among IDUs in the town of Larkana in Sindh Province and also in other major cities. The high prevalence of sexually transmitted diseases, the large number of female and male sex workers, inadequate checks on blood transfusions and high levels of illiteracy and lack of awareness about AIDS also place Pakistan at high risk.
Following a month-long anti-AIDS campaign, the NACP country director, Asma Bokhari, said that in several Punjab districts, the re-use of syringes was found to be a major cause of the spread of AIDS, and that "unsafe medical practices" posed a grave risk.
Yet despite this, across Lahore, and other major cities in Pakistan, dentists - as well as barbers who traditionally also lance boils, ear doctors and other quacks - continue to carry on their unsafe practices.
Their numbers are unknown but it is estimated to be in the tens of thousands. To date, campaigns to tackle such unsafe practices have failed to achieve any results, despite the obvious risks.
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This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions
