"The poor have no memories" - Oral histories of women with oral cancer in Pakistan

This thesis explores how women with oral cancer in Pakistan make sense of their experiences. The social context of Pakistan is seen as integral to people’s meanings and experiences because it is intimately connected. Oral history interviews were conducted with fifteen women diagnosed with oral cancer receiving treatment at the Foundation University College of Dentistry, Pakistan. The findings suggested that the pathways to diagnosis with oral cancer could be direct or circuitous. These variations reflected the interplay of the social determinants of health, which included socioeconomic status, gender, beliefs in alternative medicine and religious influences. Socioeconomic status mediated access to diagnosis with some participants reporting extensive consultations with spiritual healers before accessing medical services. This contributed to late presentation for diagnosis. The diagnosis often left participants feeling that God had decided they would develop cancer. Cancer was interpreted as a death sentence and in some cases as a personal punishment. Participants also tended to resort to home remedies and alternative medicines before accessing dental professionals. Gender acted as a determinant by promoting the isolation of women from social participation in education and health. Participants interpreted the use of naswar, areca nut, chillum, bleeding gums, boils/ulcers and past sins as the main causes of oral cancer. Some women reported having to go through their husbands and complex private networks in order to secure diagnosis. This meant that they would often present late, which has implications for disease progression. The social position of women also affected how they made sense of their disease through their faith and talking more about its impact on their family. The findings of this thesis suggest that oral cancer diagnosis in the context of Pakistan develops within complex individual cosmologies and pathways, determined by the perplex interplay of the social determinants of health.