Thank you Kinner for accepting our " rendez-vous ". May I ask you to introduce yourself ?
I am a Surgical Oncologist in the city of Ahmedabad, with a population of 4 million.
My city is the largest in the State of Gujarat which is one of the larger states in India.
After my medical school I have done my masters in General Surgery and M.Ch (Master of Chirurgiae) in Oncosurgery from the Gujarat Cancer & Research Institute.
In Oct. 96, I left for Memorial Sloan Kettering Cancer Center, New York, USA for a three month travelling fellowship in the Head & Neck Service under Dr Jatin Shah. There I received a Clinical Research Fellowship at the completion of which I returned to India after visiting University College of London Hospital, London; Canniesburn Hospital Glasgow and the Free University Hospital Amsterdam for a short period of time.
In USA, I was exposed to the need for research both clinical as well as basic research.
Also senior colleagues familiar with the situation in my country stressed on the role of prevention.
They very rightly pointed out that for a huge (population wise) country like ours with a myriad of problems including poverty, illiteracy, infectious diseases etc. cancer comes way down in the list.
Because of the sheer magnitude of the problem, they suggested that PREVENTION SHOULD AND HAS TO BE STRESSED.
It would be very very difficult bordering on 'impossible' to tackle the huge patient population with trained doctors.
Instead, prevention strategies would give useful results in the short and long-term future of the country.
ESPECIALLY WHEN HEAD AND NECK CANCERS (WHICH ARE PREVENTABLE TO A VERY GREAT EXTENT) ACCOUNT FOR 30% OF THE CANCERS, ONE CAN IMAGINE THE IMPACT OF PREVENTION ON THE CANCER SCENE some years down the road.
This prompted my interest in Prevention.
On my return in May, I started work at the cancer institute, but left it in Sep. for private practice.
I get photographs, videos of all surgeries I carry out and show specimens/photos/videos to relatives as a counseling strategy to stop them from smoking.
This does work initially though the follow-up period is short.
I would like to expand my activities on a broader base because of the immense scope and realization that I CANNOT TACKLE OR CONTROL CANCER BY JUST OPERATING: removing tongues and buckle mucosae and larynges and esophaguses.
PREVENTABLE CANCERS HAVE TO BE PREVENTED.
1. Could you tell us about the tobacco problems in Gujarat and how different they are from what you experienced in New York and in Europe?
The tobacco problem in Gujarat is MAMMOTH, to say the least.
This is because of two characteristic features of my state.
One is the rampant use of BEEDIS which are extremely cheap thin "cigarettes" which are supposed to be very 'strong' and find a lot of appreciation even among 'foreign tourists'.
A pack of Beedis (25 in a pack) costs just the equivalent of 10 cents.
For a poor man also these are extremely affordable commodities which apparently 'help them' to cope up with the stressful hard life they live.
The second and very very significant scourge is CHEWABLE TOBACCO.
There are a whole lot of varieties of chewable tobacco available in small pouches which cost even less.
These are really horrible and have created a social problem over here with people moving around with their mouths full of this repelling substance and then throwing out the juices anywhere they feel like.
Difference in problem vis a vis to USA and Europe: there can be no comparisons of the situation.
The problem is of an entirely different magnitude.
Preventive Medicine in Cancer is fairly unknown entity in my state.
Few organizations if at all work against tobacco.
There are no smoking restrictions or awareness regarding the same.
You would require guts to ask a smoker under a no smoking sign to stop smoking.
In all probabilities you would be either punched or stared at without much support from anybody around.
You would rather go find a different place!
Extreme lack of awareness amongst people.
So many of my patients tell me that they really were not aware of the harm of tobacco and they just took to it because everyone around was...
Similarly quite a few casual contacts express surprise and thank me when I tell them about the harmful effects of tobacco.
Many do quit but.....how long before nicotine takes over...I do not know.
There are no restrictions on selling to minors.
As a matter of fact, smoking or chewing starts at a very young age as they often go to buy the stuff for their seniors and in the process they start smoking too.
Parents do not care.
Advertisement restrictions: Though technically advertisements are banned in the official media:
the most intriguing thing is ADVERTISEMENTS OF CHEWABLE TOBACCO IS NOT BANNED.
Also advertisements are not banned on other private channels like STAR TV ETC. which are getting more and more viewership.
Warnings on the cigarettes and chewable tobacco is just like a token warning with hardly any meaning, lacking totally in punch and just like a highway sign which we just ignore.
The Tobacco industry is strong but there is hardly anyone to confront it head on.
The only similarity would be greedy politicians who for personal benefits would allow the tobacco industry a free hand as seen by recent reports of allowing foreign companies into the market.
LASTLY AND MOST IMPORTANTLY IS THE CONCERN OF VIOLENT METHODS THAT COULD BE USED BY THE INDUSTRY IN TRYING TO PUT DOWN ANY RESISTANCE TO THEIR DOMAIN.
I hope this takes care of your first question.
2. As you noticed in a recent email, there are not so many surgeons involved (for the moment) in Globalink. Why is that so?
I recall an anecdote from Howard Koh, actual Massachusetts Commissioner of Public Health: during his medical studies he was -as you are- deeply shocked by the number and impact of tobacco related diseases.
He kept raising the point with his colleagues and the most frequent answer he got was:
"It's terrible, somebody should do something about it".
My question is: who do you think share your perception that tobacco is an important issue?
Is there an organization proposing measures to promote prevention?
I think the response of the medical fraternity especially surgeons is probably the same everywhere.
"You know its a terrible problem- someone better do something about it!"
That's about all you would find many surgeons exclaiming.
Interestingly enough I see quite a few surgeons over here using tobacco. The senior surgeons of olden times (I am told) used to be heavy smokers, smoking even during surgery!
But today see quite a few doctors, especially surgeons going for chewable tobacco and alcohol (which incidentally is officially banned in my state)!!
The reasons for this can be as follows:
a) Lack of knowledge about the harmful effects of tobacco.
They know it is bad, but how bad?????....They do not care b) It's not my job c) I am too busy with my clinical practice and hey man! look what if everyone stopped smoking then what would I do??!!!
d) I really do not care what the public does.
Its their concern e) Lack of efforts from the Prevention Community:
if they do not do their job how the hell am I, a surgeon going to do this?
About the political scene in my state or my country:
to be frank I am not aware of any figures.
But tell you what; with the situation described above; with hardly anybody to fight in a organized way against the tobacco industry; with the funds available with the industry for influencing politicians what do you expect?
Conversely it would be expected that the funds for Tobacco Control would be absolutely no match for doing anything and again the priorities lie in infectious diseases and so on.
There is no organization to fight tobacco in my state except the cancer institute which carries out some activities in a very subdued form.
There are efforts by certain Lions Groups and other clubs but they lack direction because of the lack of committed fraternity against tobacco.
There are individuals who share my views but how to start and sustain it is the question.
Again the fear of what the industry can do if there is just a single individual fighting against them is also pretty substantial.
Like one of my patients who has had a laryngectomy for his laryngeal cancer and supports my ideas and initiatives advises me often: grow big first before coming out in the open or else there are chances that you might be harmed!!!
My question to all of you would be in this regard too:
has the industry been involved in such acts against tobacco control activists?
I am in the process of creating an organization : one of the main themes would be to fight tobacco but that would be after probably we have some data on the incidence and prevalence etc of tobacco habits in my part of the country.
Not being a prevention person, I have no idea how to proceed with it and I would appreciate your help in that regards.
The WHO's Tobacco Free Initiative also sounds interesting but again my background as a surgeon ....
As I said there are departments of prevention in medical colleges but they are pretty subdued.
Herein I feel lies the role of a cancer surgeon in taking up leadership against this menace.
Why? BECAUSE OF THE SIMPLE FACT WE SEE THE DEADLY EFFECTS OF TOBACCO SMOKING OR CHEWING AND WE CARRY OUT THOSE HORRENDOUS DISFIGURING MUTILATING FUNCTIONALLY DEBILITATING SURGERIES AND THUS I FEEL WE MAY BE USEFUL IN BEING FORCEFUL TOBACCO ANTAGONISTS IN WHATEVER TIME AND WAY WE CAN SPARE.
Again I am not sure how much time I would be able to devote full time as my professional responsibilities do come first.
BUT I do not consider tobacco fight as a different work.
3. Can you identify the measures needed in your country to decrease tobacco use?
Are they on the political agenda or not?
As far as the political agenda is concerned, I am sure there is something on it.
Good things are always there on the agenda after all.
But how much has been done ...God knows..
Measures needed to decrease tobacco use:
Health education and Strong Prevention strategies.
Banning all forms of direct and indirect advertisements and support of sports or other activities.
A radical approach would be required like prohibition.
I do not want to enter into the definitions and arguments about the pros and cons of prohibition.
As a cancer surgeon I feel this cancer is in such an advanced stage that even with a radical approach aimed at total abolition what would be achieved would be perhaps just a fraction of it.
Again people in Australia or Europe or USA would frown that another radicalist has sprung up: but remember we are talking of a situation in a third world country where the situation is totally different and hence the approach also has to be tailor made.
How to tackle chewable tobacco?
Export it to USA and other countries where it is picking up!!!
If cigarette companies from abroad can come and wreck our setups with their then let the chewable tobacco go to such places and believe me they have an appeal which is difficult to resist.
I might have sounded a bit too aggressive:
Sorry if you feel so.
Just shows I really feel when it comes to removing peoples' tongues and larynges and esophaguses and so on.
In the villages tobacco is a way of life.
Just like you eat, drink, sleep, work etc.
beedi smoking amongst males and also to a lesser extent amongst females is a way of life.
Interestingly with the advent of chewable tobacco and cigarettes and its wide spread appeal I find more and more youngsters taking upto cigarettes and chewable tobacco. The old still go after beedis.
Now this is just a casual observation, which does look true, though I do not have any data.
4. You mention that tobacco use is a "way of life"in the villages. How do you think this way of life could change?
Wow that's the million dollar question!
Health awareness, difficult access to products, increasing the cost beyond their reaches, banning advertisements etc. A lot of approaches have been used successfully in the West and I believe with some modification should work out over here.
Before anything it has to be a united and concentrated fight with specific goals rather than a solitary effort being drowned into oblivion.
5. When you were in New York, or elsewhere in Europe, how many of the "colleagues" you met were "involved" (in a way or another) with tobacco control efforts?
In the West in general, what I feel is that you have so many well defined specialties and each specialty is busy in their own work (Publish or Perish adage) so tobacco control per se was not addressed by anybody.
But they did have chemoprevention trials going on Two doctors: Dr Jatin P Shah and Dr Stimson Schantz did stress on me the need for prevention and tobacco control and both are associated with an organization called International Institute for Head & Neck Cancer and Tobacco related illnesses.
I am planning to collaborate with them in the short future.
What you feel like adding :
Finally I thoroughly enjoyed my cyber interview.
I hope it is of help and useful and not too long.
I have been quite aggressive in my views and I would definitely like your and others input regarding the same.
I know it has been quite a long reply but I hope it is useful.
Thank you Kinner for taking the time to be with us today.
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