Aasim, it’s lovely to have you here to talk about the situation in Pakistan because it’s a bit different from, say, the United States of America, isn’t it?

Very much.

What are the big differences and, to begin with, is there a lot of cancer in Pakistan?

There is, there is a great deal of cancer in Pakistan. We estimate that there are about 150,000 new cancer cases each year.

What happens to these cases?

Well, many of them never get diagnosed because of a paucity of diagnostic and treatment facilities throughout the country. Of those that are diagnosed a significant proportion will actually succumb to their disease because they will present late or will have been treated for other conditions first. There is a great disparity in the sorts of treatment facilities that we have; we have some which would rank with the best anywhere in the world but the vast majority of places do not have adequate diagnostic or treatment facilities for cancer.

I don’t want to sit here and just simply criticise Pakistan for that, many countries in the world will have similar problems, won’t they? What typically are the challenges that arise in a situation comparable to Pakistan?

Well, similar to Pakistan, many countries spend very little on health. As a nation we spend a very small proportion of our GDP on health and the majority of what is spent is spent on primary care, so diagnosis and prevention of infectious diseases which is very important; measures to reduce maternal and child mortality which again are very important and which have borne great fruit. As a result of which over the last fifty years or so average life expectancy in Pakistan has gone up from 35 to close to 60.

And the bonus of this is you get more cancer. People have long enough to be exposed.

Yes. People survive longer and then they get other illnesses which they wouldn’t have got if they’d obviously died in childhood or infancy. Also we have, with regard to your earlier question about the United States, for instance, we have a number of cancers which are more prevalent or which are caused by infectious diseases. So hepatocellular cancer caused by hepatitis B and C virus is much more common in Pakistan than elsewhere; oesophageal cancer, which may be related to human papilloma virus infection. However, other cancers such as cervical cancer are less common in Pakistan, possibly because of male circumcision.

So how do you advise people to tackle a situation where there are insufficient health resources and where, quite understandably, the emphasis has been made on primary healthcare?

A number of things. We’re trying to push for greater teaching and training of oncology at the undergraduate level in the medical curriculum because we feel that primary care physicians are not adequately trained in oncology, in the diagnosis and treatment of cancer at an early stage. We’re also trying to improve facilities to train people in the diagnosis and treatment of cancer at the postgraduate level. Currently there are probably less than 150 trained oncologists in Pakistan with a population of 175 million, or close to it. That’s clearly insufficient. There has been some improvement in facilities such as radiation machines and so on but the number of technologists and physicists and so on needed to run those machines has not increased in parallel. So there’s a great deal that needs to be done, both in terms of training of manpower and in provision of diagnostic and treatment resources and facilities.

So there is a huge challenge, must this be faced up to by funding, more money, more prioritisation of cancer and can you justify this? What are the approaches that you would suggest?

It’s difficult to say, it’s difficult to tell the government, for instance, that we don’t need to concentrate on primary care, clearly we do. But there needs to be a two-pronged approach, I think the government does need to do more in terms of funding the diagnosis and treatment of cancer and in funding research into the causes of cancer in our country which may be different from other places. There’s also a role for the private sector, the hospital I work in, for instance, is funded by a charitable trust. Pakistan has one of the highest ratios of philanthropy in the world. People often don’t trust the government, they’re loathe to pay taxes, but they’re very happy to pay charity to reputable organisations and a lot of healthcare in Pakistan is delivered through the private sector and through the charitable sector.

Equity is a big issue, though, isn’t it? If you can buy good care you can get it in Pakistan. What do you do about the disparities in Pakistan and other similar countries?

Again, it’s two-fold. The government sector obviously needs to improve; the government healthcare facilities provide free treatment in the sense that admission and doctors’ fees and so on are paid for by the government but often medications will need to be paid for by the patient. In the private sector again you pay for everything but then if you can afford it then you get excellent care. So the hospital that I work at, for instance, provides free treatment regardless of your ability to pay. Once you’re in the system you get all your treatment completely free but then that means that we can only treat a certain number of patients a year. We are expanding our network and will be building new hospitals in Peshawar, we’re based in Lahore and we’ll be opening new hospitals in Peshawar in three years and in Karachi in about five years. So these are all steps that are being taken to try and improve the spread of the cancer care throughout the country.

What should the cancer community take home from the experience that you’re having in Pakistan?

I think various things. We have a great deal of cancer, we have opportunities for research. Generally we’ve looked at our cancer statistics and most cancers occur between one and two decades younger in Pakistan than elsewhere so there are tremendous opportunities for the international community to collaborate with us in research. We need help from the international community in training. Many of the traditional avenues for training of our physicians overseas have dried up over the last 15-20 years, the UK, the US and so on, and we need help in training more people from the international community.

And looking at other parts of the world are there one or two lessons that could be drawn from your experiences? You’re doing very positive things at the moment in Pakistan, are there some messages that finally you would like to pass on?

Yes, I think one important message that we feel we’ve learned and we’re trying to teach others as well is that you can’t rely on the government to do everything. We are a poor country, we have a number of priorities, including healthcare but others as well, and we can’t sit back and wait for the government to do this. We need to be more proactive, involve industry, philanthropists and others in trying to fund this.

So co-operation all round, you put your faith in that rather than taxation, for instance?

Well, yes, I think so. As a nation we’re rather loathe to pay taxes.

And you’re not too keen on government either?

Not unkeen but we need to be realistic and if we wait for the government to do all this it’s going to be a very long time.

Aasim, thank you very much, it’s great to see you.

Thank you.