I am woman, hear me roar/ In numbers too big to ignore/ And I know too much to go back an’ pretend/ ‘Cause I’ve heard it all before/ And I’ve been down there on the floor/ And no one’s ever gonna keep me down again.”

---- I Am Woman, Helen Reddy (1972)

In 2013, Hollywood star Angelina Jolie made a shocking announcement: she had undergone a prophylactic double mastectomy, a surgical removal of both her breasts even though she did not have breast cancer, the usual reason for such a radical operation. She did it because she was diagnosed as having a gene called BRCA1 that significantly increases the chances of a woman developing breast and ovarian cancer (another gene BRCA2 also increases the chances of breast cancer in both women and men). Women who have at least two close relatives—a mother, sister or daughter—who have had breast or ovarian cancer are also at much higher risk (Jolie’s mother died of ovarian cancer at age 56). These women are good candidates for prophylactic mastectomy.

Jolie has been one of the most high-profile Hollywood celebrities of our era, and not just because of her performances on screen. Her life, more than most Hollywood stars, has been the stuff of drama, including related to mental health. Her Academy Award, at the age of just 22, was for her searing portrayal of girl with severe mental illness in the film Girl Interrupted, in 1999. She has been very open with her struggles with mental health issues and, in her own way, has helped bring a lot of much needed attention to mental health. In addition, as they say in show business, there is no such thing as bad publicity.

In Pakistan, breast cancer accounts for a third of all cancers diagnosed in women. This ratio is similar to other countries in the region. The number of women diagnosed with this life-threatening condition is much higher in Western countries. But this is partially because of higher education and awareness in the general population leading them to seek treatment sooner, and partially because of better screening and diagnosis methods. This means women are diagnosed and treated sooner leading to much better survival and long-term health outcomes.

Unlike the US and other Western countries, we struggle for different reasons, including the extreme fear and secrecy related to all things mental health, especially related to women. And when this is coupled with women’s reproductive issues, which are taboo subjects anyway, our task as doctors and healthcare providers becomes much harder.

It goes without saying that an illness like cancer will generate much fear, anxiety and depression, both because of the psychological impact of facing a potentially terminal illness and because of the effects of the illness (and its treatment) on the body. 

Asma* was a young mother in her thirties, brought in from her village by family members. Even though this was in the early 1990s, when I had just graduated medical college, her story has stuck with me. When she was brought in to the large emergency department of our public hospital, she was nearly comatose. Most of the family members, all villagers, had no clue about what was going on. When we finally located an older woman relative to help explain to us what was wrong, she told us in hushed tones that Asma had “something wrong with her chest.” Upon examination, we found her breasts wrapped in foul smelling, bloody bandages. We took her to our operation theatre and once we managed to unwrap the rotting, fetid bandages, all of us were horrified: one of her breasts had been eaten away. The wound around it was black and yellow, exuding pus and blood. When we questioned the family, it turned out that this had been going on for months, perhaps years. Asma was eventually diagnosed as an advanced case of breast cancer. She died shortly thereafter.

As a psychiatrist, I have treated countless women (and, at least, one man) with mental health issues related to breast cancer. Of course, my role as a mental health professional starts after adequate treatment of breast cancer, which itself is complex and daunting. Cancer treatment is expensive and grueling and the resources for it are pitiful. Government hospitals remain overwhelmed by the sheer numbers of people descending upon them. While treatment facilities are gradually being ramped up with private institutions like the Shaukat Khanum Cancer Hospital and Research Centre, much still remains to be done.

It goes without saying that a frightful illness like cancer will generate much fear, anxiety and depression, both because of the psychological impact of facing a potentially terminal illness and also because of the effects of the illness (and its treatment) on the body. It should be obvious that taking care of the mental health of someone diagnosed with cancer should be a priority. This has been proven in hundreds of research studies, which show better adherence to cancer treatment, better outcomes and improved survival in cancer patients if they are provided emotional support and psychiatric treatment along with their cancer treatment. In Pakistan, where awareness about mental health and the consequences of untreated mental illness is still in its infancy, especially outside large urban areas, our challenges are much greater. More than 30 years later, women like Asma* are still being brought to our hospitals. One can imagine what the impact of the death of a wife, a mother or a daughter can be on a family—an illness that is increasingly treatable if caught early.

We are making progress in breast cancer treatment but much more needs to be done, both for cancer patients and their families.

*Name has been changed for privacy reasons

The writer is a psychiatrist and faculty member at King Edward Medical University. He is the author of Faiz Ahmed Faiz: A Biography, Sang-e Meel Publications, 2022. His X handle: @Ali_Madeeh