How do you get women who never talk about breast cancer to start opening up?
That was the question on the mind of Usman Saleemi, who along with colleagues Tiya Fazelbhoy and Jaison Ben created a bra designed to encourage breast self-examination among women in Pakistan.
According to Pink Ribbon, a national breast cancer charity based in Lahore, Pakistan has the highest incidence of breast cancer in Asia. More than 40,000 women lose their lives to the disease each year.
But while many cases of breast cancer can be successfully treated, the very topic is taboo in Pakistan. In this conservative country, a woman may be embarrassed to bring up intimate details about her body.
The taboos are especially strong in rural Pakistan, where women are valued for their ability to bear children and look after a home. A woman may ignore signs of a possible tumor and not say a word to family. She may fear that if she becomes sick she'll be seen as a burden. Or that if she has a mastectomy, her husband will no longer deem her attractive and will seek a divorce.
As a result, cancer is often advanced — stage 3 or 4 — when a woman is finally diagnosed, a common problem in low- and middle-income countries, according to Dr. Ophira Ginsburg, an oncologist and medical officer with the World Health Organization. Even if diagnosed, some of these women never return for treatment, Ginsburg adds: They either can't afford it or don't see the value if they believe that cancer is a death sentence.
The breast cancer cause is close to the heart for Saleemi and Fazelbhoy. Born and raised in Pakistan, they've each lost loved ones to the disease: Saleemi's mother and aunt, Fazelbhoy's grandmother and aunt. Both are now based in Dubai, working for Tonic, an advertising and branding agency — Saleemi as art director and Fazelbhoy as digital account manager. When the opportunity to do some pro-bono work came up, they began focusing on how to educate women in Pakistan about breast health.
They brainstormed ideas and traveled to Pakistan to do research, meeting with health groups and hospitals.
There they found a partner in Pink Ribbon, as well as Dr. Rufina Soomro, a breast cancer surgeon who works with women in rural villages.
They also teamed up with International Foundation & Garments, the leading manufacturer of women's undergarments in Pakistan, which produces prosthetic bras for women who have had mastectomies.
Like many women around the world, Pakistani women use their bras to hold money. It's especially common there because the traditional clothing — the shalwar kameez — is a tunic and loose-fitting trousers with no pockets. Inspired by the idea of a multitasking bra, Saleemi and Fazelbhoy came up with the Pink Bra.
The Pink Bra is a simple white brassiere with pockets to store money and raised pink outlines of fingerprints showing where to press for possible lumps during a self-exam. Instructions for breast self-examination are printed on the bra in Urdu along with illustrations (particularly important for women who are illiterate). Also printed on the bra is a hotline number for Pink Ribbon, which women can call for support and advice on what to do if they discover a lump and where to go for testing.
Then came the question of how to get the bra to women across Pakistan. Even though the goal was to keep production costs low, women in lower-income brackets might not be willing or able to buy one. So Saleemi and Fazelbhoy hoped to encourage women from the middle and upper classes to give Pink Bras to women on their household staffs.
"We filmed a video with a woman who had lost a maid [to breast cancer]. It was a very personal story and a difficult time for her," explains Fazelbhoy. In the video, she talks about gifting her staff with Pink Bras.
After several prototypes were made and tested with women, the final product was launched in May. A thousand bras were produced; around 900 were given for free to doctors and nonprofit health groups. The bras were also sold on the Pink Ribbon website and in some beauty salons for $9.50 (999 Pakistani rupees). The video of the woman talking about her maid's death got over 400,000 views on Facebook.
"A lot of influencers got on board, as well as some of the actresses in Pakistan, and radio jockeys were doing a weeklong educational series on the bra and breast cancer education," says Fazelbhoy. "Those were the primary mediums, but then really it spread by word of mouth."
At least 5,000 Pink Bras have now been manufactured.
And what do the experts think?
Dr. Soujanya Gadde, a breast radiologist working for the Prevent Breast Cancer charity in the United Kingdom, believes it's a good idea: "The Pink Bra project could be a lifesaving initiative in Pakistan. It encourages breast awareness and women to report symptoms early."
Lester Barr, chairman of the charity, urges caution.
"Breast awareness and breast-screening campaigns have done a lot to improve breast cancer survival here in the U.K. over the last 40 years," says Barr. "Maybe the Pink Bra project can do the same in Pakistan. We know how many locally advanced cancers present in Pakistan, so this campaign could help to reduce those numbers. But it will take a generation."
He also notes that self-exam alone is not effective unless there is mass screening and treatment available as well.
Dr. Ophira Ginsburg of WHO does not think the Pink Bra will make a difference: "There's a lot that needs to happen to improve access to care [in Pakistan] and none of it includes breast self-examination."
"For the women who are underprivileged, marginalized, rural, etc., you need to rapidly improve access to good quality, timely diagnosis and basic treatment. Diagnosis means biopsy, plus or minus an imaging modality such as ultrasound or mammogram if it's available, and pathology, which is shockingly under-resourced in many settings."