Teaching Global Asia
A Lecture Series to Understand Malaysian Case
Surviving Cancer in Asia: Cross-boundary
Cancer Studies, The University of Tokyo

Shigeto Sonoda
Norie Kawahara

Booklet GASINDEX
Lecture No. 1
Introduction: Signiﬁcance of interdisciplinary approaches to UHC for cancer in Asia
Shigeto Sonoda
Professor, Institute for Advanced Studies on Asia (IASA), The University of Tokyo
Lecture No. 2
Where is the road to realization of UHC leading for cancer in Malaysia?
Murallitharan Munisamy
Managing Director, National Cancer Society Malaysia (NCSM)
Lecture No. 3
Cancer in low- and middle-income countries in the context of global healthHajime Inoue
Advisor; Health, Nutrition and Population Program, World Bank Group
Lecture No. 4
Aﬀordable access to care in low- and middle-income Asian countries: Some lessons
from recent experience Cancer in low- and middle-income countries in the context of global health
Ajay Mahal
Professor, Nossal Institute for Global Health, The University of Melbourne
Lecture No. 5
Understanding the psychological mindset of a cancer patient
Lee Kah Yee
Clinical Psychologist, National Cancer Society Malaysia (NCSM)
Lecture No. 6
Understanding the perceptions of target audience to health education materials in Malaysia
Mandy Thoo
Manager, Health Education, Literacy, Promotion and Policy, National Cancer
Society Malaysia (NCSM)
Lecture No. 7
40th Anniversary of the Look East Policy
Katsuhiko Takahashi
Ambassador of Japan to Malaysia
Lecture No. 8
Disparities in the Malaysian Cancer Care Landscape
Saunthari Somasundaram
President of the National Cancer Society of Malaysia
Lecture No. 9
Introduction to the BEATY and Health Project
Murallitharan Munisamy
Managing Director, National Cancer Society Malaysia (NCSM)
Lecture No. 10
Believe in the power of BEAUTY (Bringing Education and Understanding To You): A community-based intervention
program aimed at improving cancer- speciﬁc health knowledge, literacy and risk-reduction practices
Norie Kawahara,
Representative Director, Asia Cancer Forum
Project Associate Professor, Institute for Advanced Studies on Asia (IASA), The University of Tokyo

Preface
Global Asian Studies (GAS) program in IASA started in 2022 to promote an “inside-out”
approach, which respects the agency of local scholarship to determine what should be studied,while engaging with global audience. This program has several missions, one of which is to think of
the teaching of global Asia.
This time, I’m very happy to announce the publication of the booklet titled “Teaching
Global Asia” which was designed and coordinated by Dr. Norie Kawahara who was a project
associate professor at IASA. Dr. Kawahara initiated a lecture series titled Surviving Cancer in Asia
in 2011 with late Prof. Hideyuki Akaza. As her attempts were very innovative, trying to combine
experts of a variety of disciplines to think of the importance of cancer prevention in global scale but
in concretely local context, I encouraged her to edit this booklet to let more readers know about
what she is doing in education.
Dr. Kawahara is now managing BEAUTY (Bringing Education and Understanding To You)and Health Project to tackle some difficult issues on the cancer prevention in multi-ethnic Malaysia.
The lectures offered in the class were structured so that students can understand the Malaysiancase and think of the possible solutions.
Though the number of registered students in the class was not so large, I hope this small
but innovative educational attempts will evoke people’s interests in understanding Asia frominterdisciplinary approaches from within.
Shigeto Sonoda
Chair of GAS Program1

Cross-boundary Cancer Studies within the Context of Global Asian Studies
Norie Kawahara
Since its inception in 2011 as a lecture series within the Japan-Asia Studies Program,
Cross-boundary Cancer Studies has maintained its focus on deciphering the current situation
across Asia, based on the shared challenge posed to humanity by cancer. The Japan-Asia Studies
Program represented the University of Tokyo’s university-wide collaboration in Asian studies, andwas also recognized as a lecture series that posed questions relating to how Japan has
approached Asia to date, and how it should best interact with Asia in the future. Although theprogram unfortunately concluded in academic year 2020, the questions it raised and tackled overthe course of a decade remain valid today, as the path that Japan took in the postwar years andhow it has interacted with Asian neighbors continue to provide lessons today. Taking on the legacyof the Japan-Asia Studies Program, a new lecture series has been devised under the leadership ofProfessor Shigeto Sonoda, and we are most appreciative to have the opportunity to be able topublish the lecture transcripts as a Global Asian Studies report.
Asia has been described as being “near and yet so far” from Japan, and wars of the pastremain embedded in Asia’s present. It has been said that there are two trends in Japan’sinternational cooperation during the postwar period. One is the “international line,” which aims at
international public interest in line with predominantly Western perspectives, and the other is the“domestic line,” which has its origins in postwar reparations. The Cross-boundary Cancer Studies
network traces its own origins to the Asian Cancer Registry and Information Network meeting heldin Nanjing in 2007 (the “Nanjing Conference”), and this network has continued to this day, following
in large part the “domestic line.” https://www.nature.com/articles/450772c#about-the-journal
In 2022, war revisited Europe for yet another time in its history, and the future of Japan’s
postwar relationship with China, which has long been questioned and considered, and which
Cross-Boundary Cancer Studies has dedicated much effort to nurturing, is now facing an uncertain
future. Could we really dare to hope that by facing together the vexatious challenge of cancer we
could transcend past hatred and suspicion and work together to share issues that are common to
all Asian societies, thus enabling pan-Asian solidarity? Can we create wisdom sufficient enough toovercome the foolishness and original sin of human existence through Cross-boundary Cancer
Studies?
It is with such hopes lodged in our hearts that since 2011 we have been conducting
interdisciplinary cancer research based on the late Dr. Akaza’s firmly-held belief that “cancer is amirror.”2

Cross-boundary Cancer Studies is a lecture series designed to decipher the present stateof Asia through both the uniqueness and universality inherent in cases of cancer, but it has proved
difficult in practice to share questions and devise a system through which to provide the lecturesduring the course of the academic term. The advantage of interdisciplinary research is thatexamining multiple areas at once may result in new discoveries that individual researchers had
previously been unaware of. However, when collecting and deciphering cases based on suchdiverse perspectives and specialties, we nonetheless felt the necessity for some kind of unifying
baseline perspective that would undergird our research and study.
Moreover, even within Asia, as medical care has become ever more sophisticated and thevalues being pursued are increasingly converging with those of the West, we struggled with thequestion of how to ascertain a real picture of Asia that would take into account both the highdegree of regional disparities, coupled with the high universality of cancer medicine.
It was with these issues and considerations in mind that from this year, the program
shifted focus to throw a spotlight on Malaysia, based on the BEAUTY (Bringing Education And
Understanding To You) Program, an actual program supported by the Sustainability Division of
Astellas Pharma Inc. https://www.astellas.com/en/sustainability/program-in-malaysia
In cooperation with the National Cancer Society Malaysia (NCSM), the goal of the learning
process was to provide the participants with both opportunities to learn and to make their own
suggestions regarding the BEAUTY Program.
The BEAUTY Program is targeting more than one million Malaysian residents andinvolves various processes, including the establishment of a database for cancer education, acancer prevention registry portal, and community participation sessions for raising cancer
awareness in the local community. These processes are focused primarily on beauty salons andbarber shops as community touchpoints. This community-based approach has real potential to go
beyond a narrow circle of researchers and truly involve local communities, accumulating the
combined power not only of medical science, but also of humanities and social sciences, todecipher and better understand the current state of Malaysia, and, more broadly, a fast-changing
Asia.
Forty years ago, around the time when the Look East Policy began in Malaysia, I was astudent at Waseda University. It was during my time as a student working for the Japan-side
partner organization of the ASEAN Council of Japan Alumni (ASCOJA) that I first started to be
involved with Malaysia. Later, I made a promise with Mr. Tanaka Nichijun, a Buddhist monk who
was a prison chaplain for Class-BC war criminal, to 'do our utmost to overcome the tragic legacy of3

war. That is what has driven me to continue the activities of the Asian Cancer Forum. Having
become deeply involved in the BEAUTY Program in Malaysia, I can now appreciate that neither of
the abovementioned traditional approaches to international cooperation are truly applicable to thecurrent reality. I understand most keenly that facing the realities of 21st-century Asia means morethan Japan simply trying to atone for a past war, or imposing Western logic in the course ofproviding poverty relief. We must find an approach that is imbued with an entirely Asian
perspective.
Seeking as it does to realize a world in which no-one is left behind, the concept ofUniversal Health Coverage (UHC) could also be perceived as a riddle: in a world in which theprogress of science has blessed us with increased longevity, but at the expense of increased
cancer incidence, how can humanity survive with limited and finite resources, while also giving freerein to human ambitions and aspirations?

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Acknowledgements

We would like to thank the people who provided support for this lecture series,
with their rich and valuable insights, comments and examples.

Angelique Lewis

Astellas Pharma Inc.

Shingo Iino

Astellas Pharma Inc.

Izumi Fujii

Astellas Pharma Inc.

Teppei Sakano

Asia Cancer Forum

Keiichi Ohwari

Asia Cancer Forum

Shigeru Matsui

Asia Cancer Forum

Marie Ishida

Asia Cancer ForumTomoko Matsushita Asia Cancer ForumZen-U L. Hotta

Asia Cancer Forum

Jane Aiko Yamano

YAMANO BEAUTY COLLEGE

Tetsuo Noda

UICC-ARO

5

Lecture No. 1
Introduction: Significance of interdisciplinary approaches to UHC for cancer in Asia
Shigeto Sonoda
Professor, Institute for Advanced Studies on Asia (IASA), The University of Tokyo(1) Introduction to the lecture series
One of the reasons Prof. Sonoda accepted the offer to host this lecture series on Surviving
Cancer in Asia is that he is currently chairing the International Grant Program of the Toyota
Foundation (since 2019). Applicants for this grant program have to submit a proposal topromote dialogue across disciplines and across national boundaries. The successful
applicants for the current year have recently been announced and cover a broad range ofareas. The reality facing research today is that professors have very limited opportunities
to encourage or introduce students to work with other disciplines, particularly acrossinternational borders. Just like the complexity of initiatives being implemented under the
Toyota Foundation program, the challenge of cancer in Asia is multifaceted and has
diverse aspects that change from country to country and region to region.
Prof. Sonoda explained that the aim of this class is to provide students with a variety ofknowledge about what has been done to prevent, cure, and care for cancer in Asia throughthe collaboration with Union for International Cancer Control (UICC) Asia Regional Office(ARO). This class will be held in an omnibus style, inviting many guest speakers including
medical doctors, experts on cancer studies, etc. Students will get to understand thatcancer is a “social disease” that has many dimensions to be considered in Asia. During the
program the case of Malaysia will be explored and Malaysia-Japan collaboration will be
discussed, focusing on the BEAUTY (Bringing Education and Understanding To You) and
Health Project.
The issue of cancer has multiple dimensions that need to be addressed, and it isprecisely this multidisciplinary style of lecture course that will help to grow understanding
about the issues and identify potential areas for collaboration.
Dr. Norie Kawahara is the coordinator for this class. She is the representative of the Asia
Cancer Forum and is the Japan-side leader of the BEAUTY and Health Project, which is
being supported by Astellas Pharma.

6(2) Introducing the BEAUTY and Health Program
Dr. Kawahara noted that Malaysia and Japan are celebrating the 40th anniversaryof the Look East Policy (LEP) this year. Cancer collaboration is also greatly influenced by
the power of diplomacy.
The BEAUTY and Health Project is designed to communicate the negative topic ofcancer in a way that is more accessible to the public. In addition to gaining knowledge andawareness about cancer, the smartphone app that will be used under this project aims toincrease the cancer screening rate and promote early detection and treatment. It aims tofuse the digital with the human.
The Asia Cancer Forum is fortunate to have IT partners in both Japan and
Malaysia and with them it is hoped to create a social networking platform to create UHC
for cancer and ensure that no-one is left behind.

(3) Structure of the lecture series
Prof. Sonoda introduced the structure of the class, noting that some lectures would
be provided live via Zoom, while others would be provided on demand. Question andanswer sessions would also be held during each lecture. The series runs from October
2022 to January 2023 and it is planned to invite many experts preeminent in their fields. In
particular, lecturers from Malaysia will be joining the class on a number of occasions,giving students the opportunity to take a deep dive into the realities of cancer care in
Malaysia, including the practical application of cancer care policies in the field in Malaysia,
as introduced by representatives of the National Cancer Society of Malaysia (NCSM).
Class evaluation will comprise of attendance and short reports submitted (40%)
and the final presentation and report (60%). The theme of the final report is to makecomments and suggestions for the BEAUTY and Health Project for further development.
Students explained their reasons for auditing the lecture series. Some of thesereasons include the rising awareness of cancer as a disease in Asia, and an interest inunderstanding how Japan and Malaysia are approaching cancer care. Students from Asia
expressed an interest in understanding about the costs of cancer and accessibility ofaffordable care. Other students noted that they had previously audited the lecture series
and it had proved extremely interesting and instructive. Other students explained theirinterest in the BEAUTY & Health Project in Malaysia from the perspective of healtheconomics.
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Prof. Sonoda asked students to evaluate the following statement: “Many areas ofresearch including cancer studies are said to be in need of interdisciplinary approaches.”
Students noted that historically fields have been in very specifically defined areas,
which is also important from the perspective of advancing knowledge. However, as
research becomes more advanced the boundaries that have been set historically can limit
the scope of research and therefore interdisciplinarity is necessary in order to improveapplicability and long-term impact. An interdisciplinary approach, however, requires aneffective team of people from different disciplines, which can be challenging. People with acertain set of expert knowledge tend to be very focused on their own specialty and it canbe difficult to get people to interact with people beyond their own fields. Other students
noted that interacting with people in certain specialized fields can be difficult due to a lackof expert knowledge, but with tolerance and mutual explanation and understanding it ispossible to advance interdisciplinary approaches. Other students stressed the importanceof interdisciplinary approaches in today’s world, particularly in such areas as public health.
The global COVID-19 pandemic was cited as an area where interdisciplinary collaboration
has been imperative, bringing together medical aspects (epidemiology) with IT aspects
and other areas. Whereas IT engineers are capable of analyzing data, they don’t have theexpertise to interpret the results, which is why the input of medical experts is also critical.
Another student noted the importance of interactions and sharing information,
acknowledging also that it is important to find the right person and facilitate connections
among people.

(4) History of the Surviving Cancer in Asia lecture series and the initiatives of Prof.
Hideyuki Akaza
According to Prof. Sonoda, The late Prof. Hideyuki Akaza was the main organizerof the Surviving Cancer in Asia lecture series from 2013 to 2021. His main concept was“Cancer as a Mirror,” or something that reflects social reality. He tried to use the lens ofcancer to look at many aspects of society. The combination of Prof. Akaza, an expert inprostate cancer and Dr. Kawahara, an expert in humanities, was very unique andfacilitated the formulation of the lecture series with its cross-disciplinary focus. Both Prof.
Akaza and Dr. Kawahara shared a strong aspiration to advocate a cross-disciplinary
approach and cultivate young talent.
Prof. Akaza used the metaphor of “cancer as a mirror.” By this he meant that the8cancer of individual persons often mirrors the culture of a country. Secondly, the figures on
the mirror may not always the same. Prof. Akaza stressed the importance of learning how
to see the right figures on the mirror. In other words, he wanted to tell students to use themirror in an appropriate way. A further message of Prof. Akaza’s metaphor is to understandwhat lies behind the mirror as the key to understanding the world and improving cancer
medicine. It was these imperatives that led Prof. Akaza to propose the “Surviving Cancer
in Asia” lecture series as a cross-disciplinary course.
Prof. Akaza highlighted the decision-making factors for the treatment of cancer,
bringing together knowledge, ethics and guidelines to come to a clinical decision. What
made him different from other clinical doctors is that he looked at the concept of a clinicaldecision in a much broader way.

Figure 1: Decision-making factors for the treatment of cancer

Prof. Akaza sought to go beyond exclusively clinical-oriented decisions, including
such constraining factors as formal policies, community standards, time andreimbursement of medical costs. He stressed that various factors are involved in cancer
treatment decisions, including science, politics, economics, philosophy, religion, education,and lifestyle factors. Prof. Akaza urged medical doctors to take an interest in and try tolearn more about these other factors.

9

It was this desire that led to the creation of Cross-boundary Cancer Studies. Prof.
Akaza invited a diverse range of speakers and activated discussions from various angles.
Professor. Sonoda provided his evaluation of the lecture series to date and futurechallenges.
He noted that previously there had been few opportunities for scholars of different
disciplines to discuss “cancer as a mirror,” which became a seedbed for new research andcollaboration.
In addition, a pioneering program at the University of Tokyo to teach “Global AsianStudies” also sought to position cancer as a common issue Asia is now facing.
However, through the years it has proven difficult to manage the cross-disciplinary class.
Very few speakers have seemed to realize in detail the common issues/challenges to be
tackled and the incentives for social scientists to join in what superficially at least appears
to be an issue in the field of science.
Another significant challenge experienced by the lecture series to date has been
the lack of an international collaborative network. This year’s lecture series seeks toaddress this challenge for the first time by engaging in joint lectures with Malaysia.

(5) Why is collaboration needed?
Prof. Sonoda mentioned that collaboration in any discipline is essential, particularly
in medical research, because one researcher cannot acquire all data alone. Furthermore,
one researcher cannot be expected to cover all aspects of a phenomenon. Finally, one
researcher cannot effectively describe the whole picture relating to that phenomenon. In
the case of this lecture series, it will likely be the case that researchers in Malaysia havedetailed knowledge about the situation in their own country, but may not be soknowledgeable about Japan. It is such deficiencies that the lecture series seeks toaddress.
However, it is also important for any researcher to find pointers for new ideas andinnovation. Some researchers try to create new areas of research by joining
interdisciplinary teams and finding new research questions. Through collaboration withscholars from different disciplines, researchers can find solutions to issues which should
be addressed by interdisciplinary means. Paradoxically, marginal questions from the eyesof single disciplines can become core questions in an interdisciplinary approach.
Collaboration presents various difficulties. The first challenge is that each research
10has their own research interests and it takes time to adjust them. Also, integrating thefindings of each research will not necessarily produce the expected results. Another verypractical problem is that it is difficult to find research partners, Prof. Sonoda said.

(6) UHC in Malaysia and the road forward
Even in terms of the concept of the UHC there are subtle differences among
countries and organizations. The WHO stipulates that UHC means that “all people haveaccess to the health services they need, when and where they need them, without
financial hardship.” However, depending on the levels of medical treatment, economics
and finance, education, public policy and engineering the interpretation of the UHC
concept may differ. Different countries face different realities and possess different ideas.
Moving across disciplines and across international borders presents daunting challenges
for researchers, but also eye-opening opportunities.
The issue of cancer and how to survive it in Asia is an extremely complex andthought- provoking topic. Prof. Sonoda concluded his talk by saying that it is hoped thatthe lectures in this year’s series will provide interesting insights and suggest new ways
forward.

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Lecture No. 2
Where is the road to realization of UHC leading for cancer in Malaysia?
Murallitharan M.
Managing Director, National Cancer Society Malaysia (NCSM)(1) Introduction to the lecture
Dr. Kawahara introduced Dr. M Murallitharan, noting that as Managing Director of National
Cancer Society Malaysia (NCSM) he is leading efforts relating to the BEAUTY and Health
Project in Malaysia. Dr. Murallitharan previously worked as a journalist and so has adifferent perspective to a purely medical background. Dr. Akaza, the founder of this lecture
series, once said that “cancer is a mirror that reflects society,” and it is to be hoped that Dr.
Murallitharan will help everyone to understand the current status of cancer in Malaysia.

(2) Overview of cancer in Malaysia
Malaysia is an upper-middle income country, and as with most countries of such a level
society is starting to age. As the population ages and become more economically
comfortable the issue of non-communicable diseases (NCDs) starts to become more
apparent, of which cancer is a notable example. Like other NCDs there are a lot of aspects
to cancer that go beyond clinical issues, which can be very challenging and problematicwhen seeking to care for cancer patients. This is why, within the scope of cancer, NCSM
has stopped using the term “patients” and sometimes, depending on the perspective,
starts calling them “survivors.” For a long time the term “survivors” was given to mean
people who had completed treatment, but now all people are termed “survivors” from thefirst day that they are diagnosed. Another term used is “people living with cancer,” and it
does not just refer to patients, but also their family members, close companions andcaregivers. This term tries to capture the depth of impact that cancer has on the overall
population. It is not merely a clinical disease, and that is what makes it different from otherconditions, and it imposes major social and economic impacts. Cancer also have
behavioral and cultural impacts. Cancer is therefore a very complex disease with farreaching implications.
It is very interesting that the University of Tokyo has been exploring for many years
through this lecture series the different holistic aspects that enable us to approach cancer
12

in a different manner to a purely clinical approach.
In Malaysia the most prevalent cancer is breast cancer, accounting for 17.7% of all
diagnosed cancers. Female cancers account for 54.8% of all diagnosed cancers, whichreflects the prevalence of breast cancer and also the tendency for male cancers to beunderdiagnosed. Males tend to only come and seek treatment when cancer is at a laterstage, and therefore also have poorer outcomes.
Cancers that are common to both males and females are colorectal, lung, lymphoma,
nasopharynx, leukemia, liver and stomach. Generally there are approximately 20,000 new
cases of cancer reported each year, which may seem low considering Malaysia’s overall
population, but this probably reflects a challenge relating to underreporting. In Malaysia it
is still the case that a police officer can certify a death without any medical input. Anyone
above 60 in Malaysia living in rural areas very often receives a death certificate with “oldage” being reported as the cause of death. This has a significant impact on healthstatistics.
Figure 1: Prevalence of cancer in Malaysia

In terms of the detailed breakdown of cancers by gender in Malaysia, the most common
cancers for men are colorectal and lung, and for women they are breast and colorectal.
Lung cancer in males is largely driven by smoking, but there are an increasing number of
non-smoking women being diagnosed with lung cancer, which may be related to the issueof second-hand smoke.

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Smoking is one of the modifiable risk factors for cancer, but for women who are being
exposed to second-hand smoke the risk is less modifiable, as it may be difficult to
encourage male relatives to stop smoking. Whereas smoking has been denormalized as alifestyle choice in western countries, and accordingly has led to reduced rates of lungcancer, smoking rates in Malaysia remain relatively high pending the introduction of newlegislation. In actual fact Malaysia has drafted a law that would ban anyone born after
2007 from smoking, but it is currently stuck in the parliamentary system. This smokingrelated bill has also become a political issue and raised discussions about the degree towhich people’s lives are controlled for health promotion reasons.
One area where Malaysia is doing poorly is the stage at which cancer is first diagnosed.

Figure 2: Stages at diagnosis of cancers in Malaysia

The success of cancer treatment is heavily dependent on the staging of the cancer atdiagnosis, therefore late diagnosis impacts the staging, which in turn impacts survival
rates.
People in stage 1 usually have a 80-90% chance of living past five years, but once
diagnosed in stage 3 or 4, five-year survival drops to 20-30% or worse. In the case ofbreast cancer in Malaysia, approximately half of all patients are diagnosed with stage 3 orstage 4 cancer, which is difficult to treat and survivorship rates are low. A similar situation
is witnessed in the staging of lung and other cancers. There are various social factors thatare driving this tendency towards late diagnosis in Malaysia.

14

In terms of international comparisons of five-year survival rates, Malaysia ranks low due to
its late detection of cancer (see Fig. 3 below). To put the reality into perspective, if you are
diagnosed with lung cancer in Japan, you have a 2.5 times greater chance of surviving
than in Malaysia.

Figure 3: Cancer survival, a country comparison

Some people may argue that Malaysia’s lag in terms of five-year survival rates is due tofacility and equipment reasons. However, increasingly the level of expertise and level oftechnology are similar to other countries, so this raises the question why cancer diagnosis
is so low in Malaysia and what can be done to improve it.

Many of the challenges for cancer control are systemic in nature. For example, in terms ofmanagement, there is no separate funding for implementation of the National Cancer
Control Plan. Also cancer is still managed separately, rather than as part of the NCD
spectrum. A further challenge is that preventive services and measures to emphasize
prevention are still underfunded. What is more, there is a lack of nationwide population
screening programs. In public sector hospitals, there is a lack of trained sub-specialists
including oncologists, due to the fact that many have moved to the private sector. There isalso geographic disparity in terms of service levels provided, compounded by overloaded
public sector hospitals and long waiting times. Access to innovations in treatment is also15

restricted and slow and can represent the difference between life and death in somecases.
In the private sector a challenge faced by patients is financial catastrophe due to the highcost of treatment. The price of innovator drugs, particularly for those paying out-of-pocket
is crippling, with long-term maintenance not covered by insurance.
Challenges for cancer control among patients included the following factors: i) low levels ofcancer health literacy, ii) Late detection skills makes up more than 50% of all cases, iii)
drop-out rates from treatment are high (up to 30% of cancer patients) due to the significant
influence of alternative medicine practices, and iv) there is a lack of non-clinical support, in
terms of psychological, rehabilitation and other psychosocial support services.
A further challenge is the non-governmental organizations (NGOs) are not effectively
incorporated into the national response, with all organizations doing their own activities
independently of each other, without any cohesive direction.

Discussion
Sonoda: I notice that your data included ethnic-related data, so could you perhaps say
something about the ethnic distribution of cancer in Malaysia.

Murallitharan: We have a diverse population in Malaysia, with three very distinct cultural
ethnicities: Malay, Chinese and Indian. The Malay population accounts for approximately
60% of the total, with ethnic Chinese accounting for approx. 25% of the total and theIndian population 8-10% of the total. According to cancer diagnosis data there are far more
ethnic Chinese people being diagnosed with cancer than Malay people, despite the factthat the Malay population is the largest ethnic population in Malaysia. There are cultural
factors driving this difference in the number of people diagnosed. Generally within the
Chinese population people have moved from a concept of strong religious beliefs to amore pragmatic world view rather than blind faith. Along with this pragmaticism ethnic
Chinese are becoming much more health conscious, because they are perceiving that thisis the only life that they have. More ethnic Chinese are therefore stepping forward forregular screening, which helps in realizing early diagnosis. Ethnic Chinese people are also
more inclined to follow instructions and continue with treatment.

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In contrast, the Malay population is largely Muslim and there is more of a focus on spiritual
aspects and preparing for the afterlife. They have a concept known as “redha,” whereby
rather than going to see a doctor, they adopt a more fatalistic approach and concentrateon making peace with God. It is due to such cultural practices that cancer is verysignificantly underreported in the Malay population.

Sonoda: At the beginning of your talk you mentioned that male patients are generally later
than females in visiting hospitals and are therefore later in being diagnosed. Another factor
that may influence diagnosis is the patient’s economic level. Medical literacy is also very
important, but if you try to identify the weighting of these different factors, among religious
belief, ethnicity, class, and medical literacy, which do you think is the most influential indelaying people in visiting the doctor//clinic?

Murallitharan: All these factors are more closely entangled than we might expect. Looking
from a very narrow medical perspective we tend to think that health literacy is everything,but there are other factors – social and economic, etc. that also have an impact.

Q: It was interesting to hear about religious and cultural beliefs and how they impact
cancer screening and care. Also, the use of the term “survivor” for people from their firstday of diagnosis is also an interesting concept.

Murallitharan: I helped to run a hospital on the Thai-Myanmar border, and interestingly
there was a high prevalence of HIV among the young female population. Rather thanfocus on treatment we were trying to focus on the cause. The region borders on theGolden Triangle and workers from this region would visit the town and infect the young
girls, who did not have information on practicing safe sex. There was prevalence of fullblown AIDS of about 80% and to tackle this issue we instituted a condom policy. The
incentive that was provided was that if people would take a condom home to use they
could buy their beer more cheaply. The hospital also worked in cooperation with the monks
at local temples, utilizing people’s religious beliefs to help to impact treatment.

Q: In China the only reason that prevents people from continuing treatment is economic. In
terms of the impact of religion, are there any gender differences?
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Murallitharan: Rather than purely religious, the cultural impact is also significant. I have
many patients who have to seek the permission of their husbands to get treatment.
Another interesting phenomenon is that the wives themselves are worried about getting
treatment because they are concerned that their husband might turn to other women.
There are these patriarchal cultural influences that can drive decisions.

Q: Many people do not have the opportunity to improve their knowledge about early
detection and treatment, and I would like to know how Malaysia is working to spread
information about cancer.

Murallitharan: In some countries, like Singapore, there are health promotion organizations
that specialize in promoting health information. However, in Malaysia there is very littleemphasis on awareness raising, so NGOs have to take up the slack in educating people
and raising awareness.

Sonoda: Today’s talk has been very comprehensive, touching on political and religious
influences on cancer care. Whereas some groups believe in the power of science, others
turn to other doctrines or cultural norms.

Murallitharan: As you noted, COVID-19 has shown us the power of health as a political
agenda. One of the big issues in Malaysian politics is that of financing for healthcare.
Politics is currently in upheaval in Malaysia, but it is interesting that one of the key issues
that interests the populace is how to pay for healthcare and the increasing cost oftreatment and medicines. NCSM has also started to create its own election manifesto for
health, setting out priorities for health in order to lobby all political parties and influencechange.

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Lecture No. 3
Cancer in low- and middle-income countries in the context of global healthHajime Inoue MD, MPH, Dr.PH
Advisor; Health, Nutrition and Population Program, World Bank Group(1) Cancer burden in East Asia
This talk comprises five components: epidemiological and demographic trends in cancer inthe East Asian region, the challenges of cancer treatment in low- and middle-income
countries (LMIC), the need for a comprehensive approach, ways of controlling risks, and aconcluding summary.
The Institute of Health Metrics Evaluation has devised a Disability Adjusted Life Yearsmodel to visualize the share of cancer burden in East Asia. In the figure the darker colors
indicate that the disease or condition is increasing, whereas lighter colors indicate thenumber of cases is declining. As can be seen below, diseases like diabetes andAlzheimer’s are increasing significantly in Asia, and various cancers are also increasing.
Highlighted in red in the figure below is the disease burden accounted for by cancer.
Cancer accounts for approximately 20% of the total disease burden, and specific cancers
that are increasing in prevalence include pancreatic cancer, prostate cancer, and ovariancancer. Cancer is generally a disease of the old, namely those in their 60s, 70s and 80s.

Figure 1: Share of cancer burden in East Asia (highlighted within red line)19

(2) Aging populations driving increase in cancer cases
In terms of cancer mortality, every year 10 million people die from cancer, more than halfof whom are in Asia. Asia is therefore the epicenter of the growing challenge presented bycancer. One of the highest risk factors for cancer is demographic risk, particularly giventhat the population in East and Southeast Asia is aging. When the population as a wholeages, the risk of cancer increases. The figure below shows the percentage of the
population aged 65 years or older. Currently the average in the Asian region as a whole isaround 13%, and in Japan it already stands at around 28 to 29%, more than double the
Asian average, although the proportion of people over 65 will increase rapidly throughout
the region in the coming years. In turn, this will be accompanied by an increase in cancer
prevalence.

Figure 2: Percentage of population aged 65 or over (East and Southeast Asia)

As of 2020 there were approximately 20 million new cancer cases each year, withapproximately 10 million people dying from cancer. The number of new cases is expected
to grow rapidly, reaching approximately 32 million cases by 2040, a 50% increase over2020 figures.
Cancer is also increasing more rapidly in low Human Development Index (HDI) countries.
In terms of the projected increase in new cases between 2020 and 2040, although cases
in very high HDI countries are expected to increase by approximately 30%, cases in high,20

medium and low HDI countries are expected to increase significantly, over 90% in the caseof low HDI countries. Most East Asian countries are categorized as either high/medium
HDI countries, hence the likelihood that cancer cases will continue to rise rapidly.

(3) Issues of access to cancer care
In terms of access to cancer care, it is a fact that treatment disparities are larger than forother diseases. Whereas comprehensive cancer treatments (surgical, radiological andchemotherapy treatments) are available in approximately 90% of cases in high income
countries, in low income countries access to comprehensive coverage drops toapproximately 15%. The majority of patients in low income countries therefore do not enjoy
access to cancer treatment.
Cancer treatment is challenging in that it requires various elements through the carejourney, including skilled specialists, heavy equipment for diagnosis and treatments,
intensive care units, non-generic medicines, and cross-disciplinary work. This is in stark
contrast to other increasingly prevalent diseases like diabetes, for which one medical
personnel member can make a significant difference on their own, using medicines
available.
Cancer treatment therefore requires strong social and health systems, in addition tocapable medical professionals. Key factors that are required can be identified as follows:
1) health literacy, 2) socio-cultural factors, 3) data to inform policies, 4) screening, 5) early
diagnosis and effective care, 6) transportation, 7) health worker capacity, 8) supply chains,9) financial affordability, and 10) health insurance coverage.

Figure 3: Social and health system requirements for cancer treatment

21

In terms of health insurance coverage, in many medium HDI countries in East Asia
universal health coverage (UHC) systems have been put in place, which offer coverage forcancer treatment to a certain extent. However, cost constraints mean that comprehensive
cancer treatment remains unavailable to many people in low and middle income countries.
Ensuring access to cancer treatment is not simply about costs and facilities, or thenumber of physicians. It also requires a certain standard of settings for treatment andseveral technical aspects. For example, the World Health Organization (WHO) andInternational Atomic Energy Agency (IAEA) are engaging in a joint program to develop
technical specifications of radiotherapy equipment for cancer treatment. These
specifications aim to set standards for what equipment is needed in middle and low
income countries and in so doing improve access to cancer care.

(4) Importance of a comprehensive approach to care
A comprehensive approach to cancer care is also critical in low and middle income
countries as a means of proactively reducing the costs related to cancer treatment.
Prevention, screening and early diagnosis are three key elements that could reasonably
be expected to be implementable in cost-constrained low and middle income countries.
In terms of prevention, it is a fact that between 30 to 50% of cancers are preventable byhealthy lifestyle choices. Some of the high-risk elements for cancer are obesity, alcohol,
infections and tobacco. Public health workers are engaging actively in initiatives topromote prevention, with a view to decreasing the burden of cancer. Preventing cancer
may also help to prevent other diseases.
In terms of infection-attributable cancer cases, including H. pylori, HPV, HBV, HCV andothers, the total number of these cases amounts to approximately 2.2 million annually,
approximately 10% of all cancer cases. Prevention of such cancers is already in theory
possible using relatively low-cost measures that would be applicable even in low andmiddle-income settings.
In the East Asian region, the incidence rate of infection-attributable cancers is the highest
in the world, with approximately 38 cases per 100,000 persons, in contrast to theworldwide average of 25 cases per 100,000 persons. Ongoing efforts to tackle infections
that can cause cancer have the real potential to reduce related cancers, such as gastriccancer.

22

In terms of the estimated number of cancer cases attributable to alcohol, the Asian region
records by far the highest number of cases, at around 430,000 cases per year. This highfigure is attributable to certain ethnic factors, including the fact that a high proportion of the
Asian population lacks an enzyme to digest alcohol. Alcohol control policy in Asia therefore
needs to be given thought, in light of the Asian people’s susceptibility to alcoholattributable cancers.
Tobacco-attributable cancers are another challenge, and the number of smokers is
estimated to be highest in middle income countries, many of which are in Asia.

(5) Conclusion
Cancer cases and deaths are increasing globally, but disproportionately in low and middleincome countries (LMIC). In addition, treatment disparities between high-income countries
and LMIC are also bigger in cancer care in comparison with other kinds of disease.
Cancer treatment requires stronger social and health systems and cannot be improvedby boosting the number of medical professionals alone. What is needed is a broader
scope that looks beyond treatment and includes prevention. There is a long way to go
before LMIC can achieve access to comprehensive cancer care, so in the interim it isimportant to focus more on prevention, screening and early diagnosis.
In East Asia, risks associated with infection, smoking and alcohol are higher than in otherregions and this is a challenge that requires public health policy interventions.

Discussion
Sonoda: One of the key words that Dr. Inoue mentioned is the necessity for acomprehensive approach. I wonder how much this concept is appreciated in different
countries, and whether LMIC share this focus on taking a comprehensive approach. Also,with regard to international collaboration, cultural factors may be difficult to deal with. How
important do you think it is to promote international collaboration, particularly with a view totransform the situation for LMIC?

Inoue: With regard to the level of recognition about the importance of a comprehensive
approach in LMIC, my impression is that there is not an adequate level of recognition due
to several factors. One is that the most influential groups in forming cancer policy,
including in Japan, is clinicians. Of course clinicians therefore have a tendency to focus
23more on treatment, rather than prevention and screening. People working on prevention
and screening have relatively smaller voices that clinicians. This power balance between
clinical and non-clinical areas needs to be taken into account and efforts made to achievea degree of balance.
Secondly, with regard to the need for international collaboration, it is imperative for all
areas of the global health agenda, not just cancer. My impression is that the level ofcooperation on cancer is less than in other areas, such as HIV or TB, for example. There isa higher level of exchange of views on these diseases compared to cancer. We are still ina suboptimal level of collaboration with regard to cancer.

Sonoda: Why do you think that there is a lower level of recognition on the need forinternational collaboration on cancer? Could it be a mindset that cancer is perceived as anindividual’s disease? Or could it be that Asia doesn’t have as loud a voice as other parts of
the world? What do you think are the explanations behind why cancer is paid less attention
than other diseases?

Inoue: There are various factors. First, that cancer is for many East Asian countries a
relatively new disease, in that it has rapidly increased over the course of a single
generation, which is unique in history. Over the last 20 to 30 years the number of cancer
specialists has increased rapidly in Asia in response to the growth in cancer cases. It is
expected that collaboration will increase in the future as the number of specialists
continues to grow.
Also, the actual level of treatment is very different among different Asian countries, whichraises questions about the value of collaboration among countries. For example, in Japan
all cancer care is covered under national health insurance, which guarantees access tocomprehensive care. This is not the case in other Asian countries, and therefore Japan
may not present an achievable goal under current circumstances. This is a challenge forcollaboration. It is imperative to first work to narrow the gaps that exist among countries in
Asia as an initial stepping stone to collaboration. This seminar series is one example of an
initiative that is working to close the gaps in Asia.

24

Student: I was wondering about whether early diagnosis can be achieved in LMIC.

Inoue: Early diagnosis is certainly important and is comprised of two elements, the first ofwhich is cancer screening, which in Japan is provided by local governments. In addition tothat many people also pay for additional cancer screening. The majority of people of acertain age (over 40) have access to screening, and this is an element that LMIC need toconsider introducing. There is a possibility here for Japan to share its experiences relating
to screening.
One more element that is also important is cancer literacy in the general population. Even
without diagnosis, in Japan when people feel that something is wrong, they recognize that
there is a risk of cancer, which motivates them to visit a clinic. Thisreadiness to visit a

doctor is a result of cancer literacy among the general public.
These two areas: screening and literacy, are areas where Japan could share its
experiences with other countries.

25

Lecture No. 4
Affordable access to care in low- and middle-income Asian countries: Some lessons
from recent experience Cancer in low- and middle-income countries in the context
of global health
Ajay Mahal
Professor, Nossal Institute for Global Health, The University of Melbourne(1) Introduction to the lecture
Dr. Kawahara introduced the lecturer, Professor Ajay Mahal, He is an economist in healthsystem and policy research and evaluation His experience will provide very useful
insights in the BEAUTY and Health Project.
Professor. Mahal noted that although very often the focus can be on transferringknowledge from high income countries to low- and middle-income countries (LMICs), it
should also be noted that there is much to be learned from the experiences of LMICs andhow these can be applied in high income countries. Some of the more adventurous andmore exciting research and initiatives are taking place in middle-income countries such as
China and Indonesia.
This lecture will focus on what we have learned from recent efforts to improve access toservices in certain Asian countries, and what that might mean for policy going forward. The
lecture will not be about cancer, but access to services more generally. Students areinvited to ask questions about cancer-related issues at the end of the lecture, but with the
caveat that Professor. Mahal himself is not a cancer expert. The definition used for the
purposes of this lecture of “affordable access” is: “People obtain the health services theyneed without financial hardship and without compromising quality.”
Professor.Mahal is part of a World Bank policy advisory project looking at governments’
health spending and suggesting what the main priorities should be for the next 20 to 30
years and where resources should best be allocated.

(2) Remarkable expansion in population health insurance coverage in Asian LMICs
The proportion of population covered by health insurance has increased tremendously
over the last 25 years, with some countries such as China seeing astonishingly rapid
growth in coverage over a very short time.
26

Figure 1: Health insurance coverage in Asia

The speed at which this coverage has been achieved is truly unprecedented. The
important thing to note is that insurance or access to services is not simply access to“formal insurance,” it can also be through a highly subsidized set of services as madeavailable by the government, the British National Health Service being one such example.
There are similar examples of such systems in Asia, and Malaysia is one. Public sector
hospitals and outpatient services in Malaysia offer a wide range of services for free to all
Malaysians and private insurance to those who can afford it.

Figure 2: Expenditure on public hospitals in Malaysia

There has been rapid expansion in population coverage in a range of major Asian LMICs,
so what are some of the lessons that can be learned from the experience of recent years?

(3) Lessons from rapid rollout of health insurance coverage in Asia
The first lesson is that the high share of informal work means that income-based premiums

27

have not been easy to implement in LMICs in Asia. This is because it is difficult to separate
poor from non-poor informal workers for purposes of premiums. If asked to voluntarily
contribute to public insurance, only unhealthy workers enroll. In some cases 80 to 90% of
the workforce is non-trackable, making it impossible to impose premiums on them. Thismeans that high levels of government subsidies are required to expand coverage toinformal sector workers, whether it be through public insurance or tax-financed public
services. Not every country is therefore in a position to cover all members of the
population due to the high cost involved. In such economically-constrained situations, insome countries the governments opt to provide only limited coverage. Others however
provide very generous services notwithstanding the limited funds available, Thailand andMalaysia being two examples. The key challenge for countries is therefore to decide
whether to charge all members of the population a fixed rate and risk penalizing thepoorest, or provide a smaller benefits package to cover all people.
In terms of the generosity of coverage and the expanding breadth of services that arecovered, out-of-expenditure has not fallen as much as might be expected, and in somecountries (notably Vietnam) out-of-pocket expenditure has actually increased over time.
However, as Fig. 3 shows the health insurance coverage has had some degree of impact.

Figure 3: Change in out-of-pocket expenditure

Conversely, however, the amount of people experiencing catastrophic healthcare
expenses (more than 10% of total income) has not declined, except in Thailand andVietnam. This indicates that while coverage has increased, affordable access has not yet
been guaranteed.

28

In the case of Malaysia, medical impoverishment and catastrophic spending levels arequite low, which is a remarkable achievement.

Figure 4: Comparison of catastrophic spending in Malaysia and other countries

The proportion of population covered by health insurance systems has therefore improved,
but remains incomplete. The proportion of people covered should not therefore be
confused with universal health coverage (UHC) as these are two different concepts. Muchof the health insurance funding has been focused on hospitals rather than outpatient
services, one of the reasons for this being government funding constraints. While Japanand Australia each spend more than 10% of total GDP (2019) on health, LMICs such as
China, India, Indonesia and Thailand spend considerably less. This is why LMICs areconstrained in terms of the services they can offer.
Another issue that arises is inefficient use of resources. The high share of out-of-pocket
spending is an illustration of fragmented funding. Out-of-pocket expenditure is essentially
incurred by households, and it is not generally possible to negotiate with health service
providers on an individual level. Due to costs involved in healthcare services people are
not incentivized to visit hospitals or clinics for preventive care and screening. This is why inmany LMICs people only present at hospitals or clinics with advanced stage disease.
Hospitals and service providers are also disincentivized to provide preventive carebecause they can get more income from treatment of disease rather than preventive
measures.
Another issue is that doctors and healthcare sector workers tend to receive theireducation from the government education system and then gain employment in the private
sector, where wages are higher.

29

In Malaysia, roughly half of spending on health comes from the government, and 40% is
accounted for by out-of-pocket expenses.

Figure 5: Life expectancy and premature mortality in Malaysia

One area where Malaysia is not doing as well as might be expected is in its treatment of
non-communicable diseases (NCDs), with higher mortality than average. This points toopportunities for action in Malaysia in the future. Malaysia needs to invest more in primarycare, especially with regard to NCD prevention and chronic disease management, andinvest heavily in prevention. Malaysia also needs to get a handle on how to regulate its
private health insurance sector and other issues relating to out-of-pocket spending.

(4) Considering the equity dimension of healthcare coverage in Asia and measures
to improve affordable accessSome of the issues relating to affordable access may reflect the inability of some
population subgroups to access health insurance benefits (e.g. due to a lack of awarenessof eligibility). Another issue is the “missing middle” (often those who are close to poverty)
30who do not voluntarily pay premiums. Malaysia covers everybody in its health coveragesystem, including the near-poor.
One of the reasons that out-of-pocket expenditure has not disappeared entirely may
reflect a decision among the populace to seek care instead of going without care, due toincreasing disposable incomes and initiatives or systems instigated by the government. It
is therefore important to look at the use of services in each country and consider the
degree to which spending on healthcare services is discretionary by users, who areenjoying increasing incomes in recent years.
In terms of what can be done to improve affordable access to healthcare services, afocus on prevention is very important. Another issue is the need to invest in coverage ofprimary care, for example early identification and management of chronic conditions, andincentivization of private providers for screening.
Another and more technical issue, is to promote effective use of payment mechanisms topromote referral linkages across healthcare providers, and cost containment. Another key
challenge is to ease administrative processes for enrolment and also for awarenesscampaigns.
Malaysia is implementing a variety of initiatives to promote health and improve affordable
access. These include tobacco taxes and a proposal to ban the sale of tobacco products
to Malaysians born after 2007. The Malaysian government is also implementing anenhanced primary healthcare initiative to improve patient engagement and promote
continuity of care and management of chronic conditions.
Another area where Malaysia is making efforts is to improve coordination amonghospitals through the cluster hospitals program. It is also funding subsidized screening
services for the poor population (for conditions such as diabetes and hypertension, etc.).

Discussion
Sonoda: One of the core messages of today’s lecture is the importance of prevention
when it comes to the effectiveness of healthcare systems and the various factors that help
to achieve UHC. Professor. Mahal’s lecture is based on his economic approach, but thevarious issues raised also relate to politics and political policies. The strength and thedevelopment of private sector healthcare in Malaysia suggests that there is a historicaltendency towards small government, so what is the degree of political involvement inhealth in Malaysia and other countries?
31

Mahal: I deliberate skirted around political influences so that we could identify the core
issues. Ultimately all politics is about self-interest and the various choices are very often achoice for one group at the expense of another group. In the case of Malaysia, thegovernment has adopted a policy that focuses on private sector development inhealthcare. Any effort to regulate the private sector results in strong pushback within thegovernment of Malaysia. Malaysia is perhaps one of the most underregulated private
healthcare systems in the world. There have been at least eight healthcare sector reform
efforts in recent years and all have failed to be taken through to a successful conclusion
due to resistance from the private sector. The case of India is similar, in that the private
sector has developed broadly and rapidly to the detriment of the public sector in manystates. In one of the Indian states a former doctor came to political power, and he launcheda scheme in 2007 to provide generous coverage and in the next election he won by alandslide. This prompted other states to introduce similar schemes, but a major challenge
is underfunding. A major reason for the Chinese Community Party’s focus on healthinsurance is because severe disease can be economically destabilizing. The involvementof politics can therefore be facilitative, but it can also present obstacles.

Sonoda: There is a discrepancy between the scientific approach and the realities ofsocieties and cultures in each country. In medicine and healthcare each patient is uniqueand it is very difficult to provide a one-size-fits-all approach. Malaysia is a country that has
unique traits and it is important to combine a scientific approach with approaches that take
into account socio-cultural aspects.

Q: There is no health insurance system in Myanmar, so it has been very interesting to hear
about the various systems in Asia. With regard to the “missing middle” (near-poor), what is
the situation in low-income countries?

Mahal: I have worked with colleagues from Myanmar and around 2012 when the previous
regime was in power there was a township insurance plan that was introduced on a pilot
basis in about 10 townships. In terms of the notion of the “missing middle,” it has a very
particular connotation in the insurance world – it refers not to the rich (who can afford carefrom anywhere), nor to the very poor (who evidently require assistance), but the rest of the32population, who cannot be identified as poor, but neither are they rich. The primary issue
with this group is their lack of coverage, so that if they do become sick they are likely to fall
into the poor sector. As healthcare costs are not predictable there is a high risk ofcatastrophic out-of-pocket expenditure in the case of severe disease. In Malaysia there isnot so much of a problem of a missing middle, because the national health system does
offer coverage to the general population.

Q: In the case of China companies are supposed to pay for healthcare insurance, so whatis the case in Malaysia?

Mahal: I think you are talking about the Urban Employees Health Insurance Scheme,
which is a heavily subsidized scheme by the government, and the situation is very different
in rural areas in China, where people who work in the informal sector cannot be tracked.
91% of India’s workers are in the informal sector, and in Indonesia it is around 75%.

Q: There seem to be many challenges between the government sector and the private
sector. Are there any strategies to overcome out-of-pocket expenses?

Mahal: In the case of Korea there are high levels of out-of-pocket spending, but in thiscase it is mainly the rich population that is paying for care. In terms of out-of-pocket
spending for poor people the reality is that they are much more sensitive to out-of-pocket
spending, so such people who are living on the margins of poverty and who rely on
physical labor should be provided with full coverage. There are some very interesting
papers on this issue and long-term inter-generational poverty caused by out-of-pocket
spending.
In the case of Malaysia, the Ministry of Health is not receiving sufficient funding from the
Ministry of Finance and this is impacting prevention and screening programs. The
government is reluctant to regulate the private sector in Malaysia because it has a vested
interest in the system.

Kawahara: Thank you for a very profound talk today, and I hope that it will inform the rollout of the BEAUTY and Health Program.

33

Lecture No. 5
Understanding the psychological mindset of a cancer patient
Lee Kah Yee
Clinical Psychologist, National Cancer Society Malaysia (NCSM)(1) Introduction to the lecture
Dr. Kawahara introduced the lecturer, Ms. Lee Kah Yee, noting that the lecture would bevery useful for students who do not have a background in medical sciences, in order toorder to understand the nature of the disease of cancer. Cancer is a very complex disease
and has a strong psychological component. It is said that during the first two weeks after
being diagnosed with cancer, a patient may not be able to make decisions.
A great deal of knowledge has been accumulated through Ms. Lee’s work with patients,
which is available online and via her SNS sites. The lecture will also explore how Ms. Lee
is trying to expand understanding in society about cancer. This field is also key tounderstanding better the BEAUTY and Health Project.
Ms. Lee noted that she would be talking about the mental aspects of cancer and how
mental health can affect cancer and the well-being of patients.

(2) Cancer and mental health
In Malaysia many people tend to perceive mental health as a shortcoming, a personality
weakness or character flaw. Some people also tend to think that people can never recoverfrom mental health issues, or that it only affects certain people. These misconceptions
have been perpetuated over the years.
Mental health includes our emotional, psychological, and social well-being. It also helps
determine how we handle stress, relate to others, and make choices.
Just like physical health, mental health is important to all people in all age groups.

34

Figure 1: Overview of mental health definition

As shown in the figure above, mental health is complex and has a variety of causes.
A cancer diagnosis can have a significant negative impact on mental health, as shown in
the figure below.

Figure 2: Effect of a cancer diagnosis on a patient(3) Emotions and cancer
Cancer patients went through all this stage along in their cancer journey. From screening,
diagnosis, treatment, survivorship or end of life care, it all represent a heavy physical,
mental and social burden. Physical and mental well-being can be subdivided into avariety of symptoms as shown in the figure below.

35

Figure 3: Symptom domains relating to cancer

A diagnosis of cancer can make people feel overwhelmed, wondering if they are going tolive and also being affected by disruptions to their daily lives. People can also feeloverwhelmed when they hear medical terms that are difficult to understand. They may feel
helpless and lonely.
A cancer diagnosis can also cause anger, coming from feelings that are hard to show andbased around the question, “Why me?”Fear and worry are also manifestations of a cancer diagnosis, with people worrying aboutpain from cancer and its treatment, or how they will take care of their family and how they
will pay their bills.
People also feel vulnerable and helpless, questioning themselves and asking many “whatif” questions. This may lead to feelings of guilt, with people worrying about becoming aburden or envying others’ good health, or regretting their lifestyle choices.
Once people accept that they have cancer, they often feel a sense of hope. It doesn’tmean they have moved past the grief or loss. It does, however, mean that they haveaccepted it and have come to understand what it means in their life now.
It is important to note that not everyone will go through all of these emotions stage bystagey, Also they might not happen in order. Some people have described a “roller coaster
effect,” with lots of wild swings between these emotions.

36

(4) Adjustment to cancer
Studies show that the prevalence of mental disorders in cancer diagnosis shows thatcancer patients do not meet diagnostic criteria for any specific mental disorder. However,many people may experience a variety of difficult emotional responses. Distress can affect
the quality of life of patients with cancer and their families.
Distress is an emotional, mental, social or spiritual suffering. Distress can present with arange of feelings, from sadness to a loss of control and depression, anxiety, panic andisolation. It may also cause physical problems, such as nausea, having more pain thanusual, or sleeplessness. Patients with cancer have different levels of distress, as shown in
the figure below.

Figure 4: Levels of distress in cancer patients

Levels of distress range from normal adjustment through to diagnosable mental disorders.
Normal adjustment means that the patient learns to cope well with emotional distress andsolve problems related to cancer. In the psychological and social distress stage patients
have some trouble making changes in their life and may experience feelings ofdepression, panic or spiritual crisis. In the adjustment disorder stage, patients experiencea great deal of trouble making changes in their lives. Symptoms such as depression,anxiety or other emotional, social or behavioral problems may occur. Diagnosable mental
disorders stage includes clinical disorders that entail severe functional impairments that
affect a person’s ability to lead a normal life.

37

There are various signs of mental illness in cancer patients, including feeling anxious,
feeling depressed, emotional outbursts, sleep problems, weight or appetite changes,
becoming quiet or withdrawn, substance abuse, feeling guilty, or changes in behavior andfeelings.
In terms of when cancer patients need to seek help, signs could include the following, asdetailed in the figure below.

Figure 5: Signs that a cancer patient may need to seek help.

In terms of where to seek help, a patient can reach out to support groups, or consideringcounseling or psychotherapy, or consult a doctor.

(5) Psychological intervention
In psychological sessions sometimes Ms. Lee uses one-on-one therapy and counseling. In
these sessions it is possible for patients to focus on what they are most bothered about
and learn ways to cope with their cancer and changes in their life. Sessions also help
patients to deal with symptoms and figure out how to handle changes, such as end oftreatment and what to do if cancer recurs.
Other options are couple or family therapy, and also group therapy. Family therapy helps
family members to improve how they express their feelings and help resolve conflicts andhelp them come up with ideas about how to work together better.
Compassionate emotion-focused therapy (EFT) provides a comforting presence and38

practical support. It creates a safe and serene atmosphere for patients to express theiremotions and enable them feel at ease and allay fears about the disease. EFT also
attempts to expose patients to positive aspects of life, deviating their mind from agonizing
trauma and suffering. As a psychologist it is important to be a proactive listener and letpatients talk first.
Another form of therapy is cognitive behavioral therapy (CBT), which helps patients tolearn whether their coping methods are healthy and helpful. It is also to help cancer
patients to identify any negative automatic thoughts they are having and understand how it
affect their behaviors, emotions, and physical sensations.
Sessions also include meditation and mindfulness exercises, as well as self and gratitudereflection. The benefits of meditation and mindfulness exercises include, feeling grounded
and focused on the present moment, avoiding feelings of worry about future events,
reducing pain and enhancing the body’s immune systems, reducing feelings of depression,anxiety, anger and confusion, providing a sense of calm, peace and balance, increasingenergy and strength, and helping control thoughts.
Relaxation techniques are also important, including box breathing, deep breathing andprogressive muscle relaxation. The benefits of relaxation techniques include: lowering
overall tension and stress levels, helping patients relax when they feel anxious, preventing
and alleviating chemotherapy-induced nausea, improving sleep quality, decreasing bloodpressure, and helping calm patients’ minds.
Another important aspect during cancer treatment is self-care, including exercise,keeping a journal, eating nourishing foods, staying connected with family and friends,,
scheduling “me” time, and knowing that it’s normal to have bad days.

Discussion
Sonoda: Today’s talk was relatively broad and in the university context there are alsosituations in which you may come across people who are experiencing mental healthissues. It can be difficult for a third person to approach a person and suggest that theyseek help or therapy, particularly if the person in question doesn’t recognize that they havea problem. What sort of techniques would you recommend people to use when they aretrying to encourage cancer patients, they know to seek help?

Lee: There are a lot of cancer patients who are in denial about their disease. It is first39

necessary to listen actively to what the patient has to say. Family members may tend to
give advice rather than listen, but the first priority should be to listen to the patient’s own
feelings and experiences. It is important to listen what the patient is saying and try not togive suggestions immediately, but give them time to express themselves.

Sonoda: It seems that the people who want to recommend a patient to seek medical help
will need to have a great deal of patience, particularly if they should not try to provide
suggestions immediately.

Lee: When to seek help, and when to encourage patients to seek help can be difficult todetermine, but as was shown in the presentation (Figure 5 above) there are situations inwhich it is important to recognize the necessity of seeking help. In situations in which thepatient does not want to seek help, the first point of contact can be the patient’s family. By
providing information and suggestions to the family members can be a useful indirect wayof encouraging the patient to see a doctor.
It is also important to remember that there is nothing that can be done if the patient isadamant that they do not want treatment.

Sonoda: What would happen if the patient’s family approaches you to help the patient andadvise them to seek help.

Lee: It is important to establish a rapport with a patient before making any suggestions.

Q: You mentioned that cancer patients may not wish to seek help for mental distress, but
may be willing to visit hospital for physical symptoms. At what point do patients tend to
become more open to receiving help for mental health issues? Is there any connection
between the cancer staging (T1 to T4) and a patient’s mental health?

Lee: Through my work at NCSM, most patients are experiencing psychological and social
distress on the mental health continuum. Another interesting finding through my work isthat most people experiencing severe mental disorders tend to be family members, rather
than the patient themselves. In terms of a correlation between cancer staging and mental
health, conversely more patients with Stage 1 and 2 cancers tend to have mental
40

disorders, whereas those with T3 and T4 cancers tend to be more accepting of theirsituation.

Q: Is counseling for mental health covered by the national health service, or is it self-pay?

Lee: Mental health professionals’ fees in Malaysia are starting from around 250 ringgit persession but depends on the particular organization. CSM offers free sessions to patients,
which helps to alleviate the burden of cancer on patients and their families. Patients arereferred to NCSM via their primary medical provider.

Q: Given that Malaysia is a multi-cultural, multi-ethnic country, I would like to ask about if
you have any information about how different ethnicities react to a cancer diagnosis andwhether mental health issues are more frequently observed in certain ethnic groups.

Lee: The Malay population is less proactive in seeking help and lower-income Chinese
ethnic groups are also less likely to seek assistance, instead going to receive Chinese
traditional medicine. NCSM has found that most of the referrals and questions about
mental health are from higher income Chinese ethnic groups. Awareness of mental healthis tends to be low across the board among the Indian community, regardless of income.

Sonoda: What are the benefits of cross-disciplinary and cross-border collaborations, suchas those between Malaysia and Japan?

Lee: I do believe that the international collaborations are important for spreadingawareness about mental health literacy, not just for cancer, but for mental health overall. In
such collaborations it may also be useful to talk about differences between the situations in
respective countries and make collaborations more fruitful.

Kawahara: Perhaps the wisdom shared in this lecture will link through to the BEAUTY and
Health Project, which is also linked to mental health and general well-being.

41

Lecture No. 6
Understanding the perceptions of target audience to health education materials in
Malaysia
Mandy Thoo
Manager, Health Education, Literacy, Promotion and Policy, National Cancer Society
Malaysia (NCSM)(1) Introduction to the lecture
Dr. Kawahara noted that for the BEAUTY and Health Project in Malaysia the important
issue is what kind of learning and information about cancer can change people’s behavior.
It is important to understand how emotions and their impact can be effective in order toimplement the project. It is necessary to look deeply into people’s minds. She noted thattoday’s lecturer would by Mandy Thoo, who is the current Head of the Health Education,
Literacy, Promotion, and Policy (HELPP) department at National Cancer Society Malaysia(NCSM).
Dr. Kawahara noted that in the Q&A session of the lecture, Jane Aiko Yamano, Presidentof Yamano Gakuen would also be taking part in discussions.

(2) What is health communication and what is health education?
The Society for Health Communication defines health communication as the science andart of using communication to advance the health and well-being of people andpopulations. If you have given some form of health advice or message to someone in yourlife, you have done some form of health communication. Education is the larger umbrellathat is designed to improve health literacy. So you have communication and you use
communication to work on health education, in order to improve health literacy.
Health literacy is not just a person knowing what a health-related term means, but thatthey also can use the knowledge. So literacy does not include only the communication of
information, but also encourages or helps people build skills as well as confidence to use
what they know about health.
In terms of why health communication is important, participating students suggested that
it is an important method of imparting knowledge to people. Another reason healthcommunication is important is that in normal daily life there are few opportunities to know
about health, and therefore health communication in the community can play an42encouraging and enabling role in raising awareness. Health communication also helps tobridge knowledge gaps and reduce reliance on healthcare professionals.

Two health communication videos were shown, one concerning ways of reducing the riskof cancer, and another more commercially-oriented video promoting vaping instead ofsmoking.
Next, printed materials used in Malaysian awareness campaigns for cervical cancer andpreventing smoking were shared.

Students noted how these videos and printed materials are very different in theapproach they take, one being more clinical in nature and one being designed like a TVcommercial.
One issue that is faced is that the clinically-oriented videos/materials sometimes do not
get a good reaction from test audiences.
It can be quite difficult to develop materials without a clear picture of who the audience
will be. Due to budget and time constraints very often the materials developed are basedon a “one-size-fits-all” approach.
Despite everyone having different backgrounds, there are some universal aspects of ourlives that remain unchanging, and in the case of the BEAUTY and Health Program, thecommon factor is the motivating factor of beauty.
All health communicators are competing for resources that are finite and it is important tofind ways of grasping people’s attention and gaining their engagement. Attention spans are
getting shorter and shorter in today’s SNS, Facebook, YouTube, Instagram and TikTokoriented society. It is therefore important to remember when communicating information
about health that the materials being used are competing with many other materials/
videos, etc., that people may be more inclined to watch.

(3) Overview of the BEAUTY and Health Project
The BEAUTY Phase 1a study is titled “Do I like what I see?” and the aim is for a cancer
health education intervention program to: 1) explore and understand the content required
to develop a series of health education materials, 2) explore and understand the culturalrequirements of health education materials, 3) develop health education materials, and 4)
validate the materials.
43

Health communication has benefits for both patients and healthcare professionals. For
patients, there are the benefits of improved understanding of condition, improved
understanding of methods and means to manage medical condition, improved selfadvocacy, and increased motivation to comply with treatment. There are still strong
traditional beliefs in Malaysia that may distract patients from seeking care.
In terms of the benefits of health communication to healthcare professionals, these are:increase compliance of patient to treatment plan, improved patient outcomes, improved
cooperation as patients feel they are more involved, improved informed consent, andreduced use of resources and increased patient satisfaction.
Another key point to consider is who is providing/managing care in the community, andthis can include primary healthcare providers, community health workers, friends andfamily, and other members in the community. Students noted that very often in ruralcommunities it is families and friends that are key care providers/managers. In contrast to
the time spent with doctors, patients spend the vast majority of their time at home and in
the community, which means that it is friends, family and local community members who
have the largest role to play.
A key concern is what to do when there is a mismatch between what patients need toknow and what they actually know with regard to cancer. In the last five or six years there
was a paper on public health that listed six reasons why public health doesn’t worksometimes. The first reason is because it is assumed that all human beings are rational,
but this is not necessarily the case.
For example, in terms of the example of baby-led weaning, one of the successes in
expanding this practice was not the advice of healthcare professionals, but rather the
positive experience of mothers.
There are many health campaigns through multiple channels, so if all human beings are
assumed to be rational, how is it that non-communicable diseases are still rising? Ifcampaigns truly work there would be a much narrower gap of knowledge, attitude andpractice between health and society. It is important for health communicators to pay close
attention to their audience. Thought needs to be given to materials targeted to a particularaudience, and it is equally important to test materials prior to their rollout to assess uptake
and understanding among the general populace/patients. After receiving feedback after a
test-rollout it is then important to make the necessary adjustments.
In terms of the BEAUTY and Health Project, from literature reviews it is known that44

patients want information. Patients prefer printed materials for refresh and recall purposes,
and also prefer to have material first explained by health professionals. However, somepatients who possess a certain level of health literacy can find current materials too simple
in their approach to the extent that they appear condescending. These kinds of people
would prefer to receive materials through multiple media channels. It is necessary to
respond to these various learning needs.
A total of six theories have been referenced to build a theoretical framework for the
BEAUTY and Health Project. These are Ausubel’s Assimilation Theory, Cognitive Load
Theory, Atkinson and Shiffrin’s Information Processing Theory, Pintrich’s Metacognitive
Knowledge Theory, Vygotsky’s Zone of Proximal Development Theory, and Bruner, Worldand Ross’ Theories on the Concept of Scaffolding.
The above theories are then matched with theorized educational problems, including
difficulty in assimilating knowledge, large intrinsic cognitive load, knowledge decay, lack ofmetacognitive knowledge, learning tasks outside zone of proximal development, and lackof scaffolding (i.e. guidance/materials).
As efforts are made to understand the stage of understanding among people with regard
to cancer and factors influencing individuals’ learning it is important to consider whether
current cancer information materials are sufficient and whether the “one-size-fits-all”
approach is appropriate.
To do this effectively, under the BEAUTY and Health Project, focus group discussions
and cross-sectional surveys are being implemented.
In Phase 1 there are four arcs that require attention: 1) awareness and use of current
cancer health education materials, 2) cancer information needs and how they are fulfilled,
3) assessment of current cancer health education materials, and 4) preferences for cancer
health education materials.
The questions used in the focus group discussions concerning awareness of the types ofhealth education materials include the following: Have you seen materials? What do you
recall? How frequently do you see the materials?
With regard to cancer information needs, sample questions are: What information haveyou sought in the past few years? How did you seek the information? From where did you
get the information? What was the quality of the information?
With regard to assessment of current materials, sample questions are: Was there
anything you especially liked/disliked? Was there anything confusing? How useful was it?
45With regard to preferences for cancer health education materials, sample questions are:
What types of format do you prefer? What is your preferred channel? What is yourpreferred type of content? What is your preferred type of take home messages?
In the cross-sectional survey, people were asked to answer a variety of questions with“disagree” or “agree” responses. At the end of the survey the scores are totaled to
calculate an understandability score. These surveys are available in both printed andonline formats.
In terms of outreach to people, communication campaigns and advertising campaigns arevery different. Communication campaigns have a persuasive focus (seeking to encourage
behavioral change), whereas advertising campaigns have a perception focus (on aspecific product). Whereas communication campaigns aim to challenge specific desires orwants, advertising campaigns aim to satisfy desire and wants. A communication campaign
may involve personal cost or discomfort, whereas for an advertising campaign, the main
cost is choosing among brands. Communication campaigns can be sensitive, obtrusive
and emotional, whereas advertising may not involve emotional or affective attachment.
In terms of communication objectives, communication campaigns tend to be unclear, incontrast to which advertising campaigns are very clear.
A key sticking point for communication campaigns is that information may be perceived to
be unreliable. This is because groups may think that the information does not concern
them, or that they are already compliant with the required actions / lifestyle changes.
Advertising campaigns, on the other hand, while accessible and positively viewed, may notnecessarily have a massive effect in influencing behavior.
It is imperative to pay attention to how health education and communication are being
perceived by their audience. Communication is both a science and an art and a dual
perspective is important. On the part of science, it is important to analyze, design,
manage, and evaluate communication interventions, and for art side the key points are
creativity, judgment, experience, intuition and insights when communicating with others.

46

Discussion

Jane Aiko Yamano: As you mentioned, communication is both a science and an art. At
the Yamano Beauty College and Yamano College of Aesthetics we offer a wide range ofbeauty and welfare courses. Beauty is something that reaches out to people regardless ofgender, disability, or outlook. It is hoped that the BEAUTY and Health Project will help tomake people feel more confident, because when people are confident, they are more likely
to go out and do more. Communication is taken differently depending on country and age
group. In Japan, cancer is something that people feel they should hide, whereas in the
U.S. there are many communication groups where patients can come together and talkabout their experiences of cancer together.
It is therefore very important to understand your audience and identify the key message
that you are trying to get across.
Some doctors have a poor bedside manner, and it is hoped that reaching out to people
through beauty salons and barbershops will make it easier to talk about challenging
subjects. People also see their barber/beautician on a much more regular basis than theirdoctor. It is positive for society to be able to look good and feel good and thecommunication that takes place at salons can be very beneficial for cancer care.
To have “total beauty” there are five elements of “bido” (the “way of beauty”): hair (cutting,color, treatment, etc.), face (smiling), makeup (boosting self-image and shaping face),fashion (including national dress across all Asian countries), and mental and physicalhealth.
Our courses at all of our Yamano schools attempt to combine beauty with welfare,because beauty, looking good and feeling good has a tremendously positive impact on
well-being. In terms of mental and physical health it is important to feel able to talk about
your condition. It is also important to be able to talk about cancer because of thetremendous importance of prevention and early detection.
Although a person may not be 100% healthy physically, if they think positively and go out
and get their hair done, etc., it will help them to feel better. At the end of the day, it isimportant to smile and be happy.
It is to be hoped that the beauty industry can help to make a positive impact through thisproject and also gain insights that will be useful for the beauty industry.

47

Sonoda: It is very significant to combine mental and physical health factors with beauty.
When I was walking at the international division of the university we had a collaboration
with the University of Peking, and we created a program to learn cultural nuances throughthis collaboration. Several Japanese companies and industries were approached to inquire
about the efforts that were being made so that services and goods would be well-received
by Chinese consumers. This project also included Japanese beauty companies and theyemphasized the importance of communication and person-to-person interactions.

Thoo: Beauty is universal, as is health. In this project there is a great combination of bothscience and art that are well-positioned to be drivers for changing people’s behavior.
Beauty is hard to resist and has the real ability to give people confidence.

Q: With regard to the survey that is planned for the project, how will the impact of the
project’s message be evaluated?

Thoo: Whereas in an ad campaign you would be able to track effectiveness very quickly,
in a health communication campaign the response is not so quick. However, there is a“theory of half,” whereby half of the audience will remember the message, and then half
will be responsive, and half again will take action.

Q: Will BEAUTY Project beauticians in beauty salons need to have specialist medical
knowledge?

Yamano: I don’t think that specialist knowledge would be required, but they should be
prepared to give advice and encourage customers to either see a doctor or go for cancer
screening.

Q: What are the subjects that it would be best to raise in barbershops and beauty salons?
What kind of information would make people more responsive or positive about themessage? It is important to ensure that customers remain relaxed and are not put off by
the message.

Thoo: A communications campaign can be a bit confused about what it is trying to48

achieve. In the beauty salons, therefore, what do we expect the audience to do? Do wewant them to remember everything that the beauty salon staff tell them, or provide
sufficient information that they recall the conversation and then refer to the printed
materials to recall the content? It is important in this case to test the material that isplanned to be distributed. If customers are visiting a beauty salon it can be assumed thatthey have an interest in beauty or maintaining a certain level of presentation. It is therefore
important to train beauty salon staff to be sensitive to their customers and adjust their
responses accordingly.

Q: There is a tremendous volume of information on social media these days, but I thinkthat we need to produce much more health-related materials for distribution through social
media channels, because currently there are very few materials circulating on social media
about health. From a consumer perspective, where can you find more information about
health communication materials?
Also, with regard to interactions in beauty salons it is critically important to createconnections between the staff and their customers.

Thoo: In the case of NCSM there are materials available through our official channels.
However, there are vast quantities of health-related materials out there and the fact thatthey are not reaching you speaks volumes about their reach and efficacy. It also
demonstrates people’s interests and what they are searching for.
Health communication campaigns ultimately only result in the changing of behavior of asmall number of people. It is out of a desire to improve the proportion of people whose
behavior is changed that these beauty salon interventions are being planned.

Yamano: I think that visiting salons is a matter of gaining trust and improving
communication that is a very important way of helping society. Education is so importantbecause it is the unknown that people fear. When you gain the trust of a customer it will
hopefully make it possible to help that customer be healthy and encourage them tomaintain their health. I hope to hear more about the project in the future.

49

Lecture No. 7
40th Anniversary of the Look East Policy
Katsuhiko Takahashi
Ambassador of Japan to Malaysia(1) Introduction
Although I am not an expert on cancer, I agreed to take part in this seminar because I am
in a position to speak to a certain degree about Japan-Malaysia relations and the need forcontinued cooperation on various issues. Also, although the greater part of my diplomatic
career has related to the Middle East, I have also had an opportunity to work on issues
related to the Surviving Cancer in Asia seminar series, including Universal Health
Coverage (UHC) and human security. Particularly with human security, I was deeply
involved in negotiations that led to the adoption of the UN General Assembly Resolution on
Human Security in September 2012, and I worked closely with the late Mrs. Sadako Ogata
on this issue.
(2) Look East Policy and its achievements over the past 40 years
The Look East Policy (LEP) is a Malaysian policy with a long history. It was 1982 in Kuala
Lumpur at the Joint Annual Conference of Business Communities of Japan and Malaysia,
where Prime Minister Mahathir stated, “I have been exhorting Malaysians to emulate theJapanese, particularly in work ethic and ethical values, and we have come to realize thatthe basis of your rapid development is your sense of commitment and your continued
willingness to work.” The Prime Minister’s Office of Malaysia then described the LEP as
follows: “This policy means that the government of Malaysia will make a study of the best
examples and role models from Japan and Korea by adapting it to the conditions in
Malaysia.”
People tend to believe that the LEP relates to Japan-Malaysia relations, but it is important
to note that Korea was also included in its scope from the beginning.
What Dr. Mahathir envisioned originally seems to be bigger than the policy line of thegovernment, but Japan has been helping Malaysia to implement the LEP positively sincethen, because Malaysia was the only country at that time to create a Japan-specific policy.
So, what has been achieved so far?
As a result of the LEP, more than 26,000 Malaysians have received training or education.
From the beginning Japan helped to prepare curricula for Malaysian students before theirstudy in Japan, including preparatory courses in Japanese language, mathematics and50physics. Japan also tried to provide vocational training opportunities in Malaysia, including
the opening of vocational training institutes in Malaysia, such as Malaysia-Japan
International Institute of Technology (MJIIT).
The dispatch of students and trainees created a positive cycle of HR development andinvestment. Now more than 1,600 Japanese companies are operating in Malaysia, which
is a larger number than in other ASEAN countries. This fact itself is regarded as aremarkable achievement. Evaluation of the LEP needs to be done by the Malaysian side,
but Japan hopes that it has helped Malaysia to develop its economy to its current level.
Malaysia still needs to learn a lot from the outside world and HR development is needed tomove from low-skilled manual labor to high-end skilled industries. For example, 30 years
ago Japan helped Malaysia to set up their own automobile industry, with the help of
Daihatsu. Thirty years have passed, but certain components still need to be imported fromJapan, but cooperation continues.
Thanks to the LEP Japan is in a privileged position in Malaysia, therefore the best way isfor the two countries to continue to use this existing channel to provide mutual benefit.
Also, the need for working ethics and ethical values that Dr. Mahathir tried to learn fromJapan still exists and Japan is ready to extend a helping hand to Malaysia if needed.
On the other hand, the situation has changed domestically and internationally, and weshould not take for granted an existing friendly relationship between the two countries
based on the LEP. Rather, we should continue to enhance the LEP and take it to the nextstage. This is precisely the discussions that have been taking place between thegovernments of Japan and Malaysia in recent years.
As a result of a series of high-level meetings, Japan and Malaysia have agreed to takethe LEP further, and under new Prime Minister Anwar it is hoped the policy will continue.
(3) Look East and beyond – the future for LEP
There are two modifications that are needed for the LEP, the first is modifying the scope
and the second is modifying the relationship, and both modifications have two approaches.
First, with regard to modifying the scope of the LEP, the first approach is to expand thescope of manufacturing. LEP focused on manufacturing from the outset, and we cancontinue this focus, but with some modifications due to the advancement of technology inthe past 40 years. This kind of modification has been discussed for the last 10 years, sincethe 30-year anniversary, and Malaysia has elaborated the kind of cooperation it is seeking.
This includes areas such as digital, cybersecurity, 5G, aviation industry and renewableenergy. Japan and Malaysia have also agreed to discuss creating resilient supply chains in51

the wake of COVID-19. This kind of cooperation will continue to be the major pillar for the
LEP.
Another modification of the scope of the LEP is to expand the scope beyond
manufacturing. A new approach needs the involvement of other ministries in Malaysia.
One example for further cooperation is disaster risk reduction (DRR). Although Malaysia is
not susceptible to major disasters like Japan, awareness of risk, due to climate change
and other factors is increasing in Malaysia. Discussions are ongoing between Japan and
Malaysia on how to mitigate disasters, including more accurate weather forecasting, etc.
This is one area where there is potential for new cooperation under the LEP.
Another example where the LEP could be utilized is preparation for an aging society.
Aging is a relatively new issue for Malaysia, but by 2044 14% of Malaysia’s population will
be over 65. Japan’s population reached that level in 1994, meaning that there is anapproximately 50-year time lag between the two countries. Therefore, in order for Malaysia
to prepare for a future aging society, it would be useful to draw lessons from Japan. Agingis a multifaceted issue and includes lots of elements, including social security systems,
healthcare, care home management, and discussion on how to provide dignity in old age.
Japan has experienced challenges much earlier than other countries and new measurescontinue to be introduced as society ages. Japan is therefore in a position to show
Malaysia the successes and failures of aging-related policies. Malaysia also hopes tocooperate with Japan on the issue of aging. The Sultan of Selangor is keen to learn fromJapan on the issue of aging and it is one important area for collaboration.
Another potential area for cooperation under an expanded LEP would be healthcare,including cancer treatment. UHC has been promoted in the context of the Japan-ASEAN
framework and Japan concluded the ASEAN-Japan UHC Initiative with ASEAN countries
in 2017. In line with this initiative, Japan will develop HR and share knowledge forstrengthening health systems to realize UHC in ASEAN countries.
For Malaysia specifically, healthcare could be one new and promising area for the LEP.
Japan has already contributed to preparing medical infrastructure in Malaysia, andJapanese companies have started to invest in Malaysian medical services. During the
pandemic Japan also offered assistance to Malaysia, and there is a hope that more can bedone in the area of healthcare in the future. Japan and Malaysia already have several
initiatives ongoing in the medical field. The most outstanding initiative among these isJapan-Malaysia collaboration on clinical research, especially for cancer treatment. On the
Malaysian side, Clinical Research Malaysia (CRM) was established by the Ministry of
Health in 2012 and is playing a critical role.
52

Last month in Kuala Lumpur CRM and Japan’s National Center for Global Health andMedicine exchanged an MOU to collaborate in three areas: 1) Building clinical research
networks in the Asian region and worldwide, 2) supporting clinical research conduct andactivities, and 3) strengthening clinical research capacity in the Asian region.
Also, CRM and the National Cancer Center of Japan exchanged an MOU on the Atlas
Project in 2020, and last month engaged in an in-person meeting. The Atlas Project is the
Asian Clinical Trial Network for Cancers, established by the National Cancer Center ofJapan, and by exchanging an MOU Malaysia will benefit from early phase oncology drug
development, cancer genomic advancement, and drug access and development. ThisMOU spells out collaboration in the area of cancer research that includes infrastructuredevelopment, training opportunities in clinical research, participation in rare cancer clinical
trials, networking opportunities, as well as visits and attachments by research experts inboth countries.
This collaboration in clinical research will not only benefit Malaysia, but also Japan. Thisis a new type of LEP and it should be promoted in line with other modifications to thepolicy. These types of agreements that benefit both sides can also be new elements for the
LEP.
(3) Modifying the relationship under the LEP
It is with a view to benefiting both sides that the relationship under the LEP should be
modified. The traditional LEP used to pay attention to dispatching Malaysian nationals to
Japan to learn predominantly about manufacturing technology. In that sense the traditional
LEP was one-way from Japan to Malaysia, in a donor-recipient relationship.
However, it is now important to assess the LEP in a new light. Just before the pandemic
there were 400,000 Japanese tourists visiting Malaysia annually, while the number of
Malaysians visiting Japan was 500,000. Also the number of students studying in eachother’s country was more-or-less balanced, with 3,000 students each. This indicates howbalanced the relationship has now become.
As more Japanese visit Malaysia than before, now is a good time to learn from Malaysia.
Diversity and tolerance is a value that Malaysia is proud of and Japan would do well tolearn from Malaysia in this respect.
Another modification of the relationship is to enhance partnership. As Malaysia is situatedbetween the Pacific Ocean and Indian Ocean it has great potential to be a regional hub invarious fields, among others education and HR development. There is already the
Malaysia-Japan International Institute of Technology (MJIIT) in Malaysia and work is53

underway to establish a branch of Tsukuba University in Malaysia. These could become
two hubs to promote Japanese-style education in Malaysia and could contribute to the
future of Malaysia and the wider Southeast Asian region.
Clinical trials could also be a new partnership area for Malaysia and Japan and Malaysia
could become a clinical trial area in Southeast Asia.
Discussions are continuing between the two countries on how to make LEP mutually
beneficial.
(4) LEP, the new international situation, and human security
The Japan-Malaysia relationship is based on people-to-people relations through the LEP,
which is quite unique. The LEP has made the relationship extremely resilient. A question
now is how to best use this resilient relationship, particularly given the values that the twocountries share. This is one reason whey Japan is promoting the concept of a free andopen Indo-Pacific, because core values include the rule of law, free trade and safety ofnavigation.
Malaysia tries its best not to be involved in international conflict and avoid even making
comments on difficult security-related issues. This approach is similar to Japan’s approachin the 1980s, but after the Cold War ended Japan changed its approach to a moreproactive stance. This is when Japan started to discuss human security, as a concept that
contrasts to state security.
Human security is a notion that Malaysia can understand and demonstrate support for.
By accumulating happiness and resilience through human security it is possible to createstronger societies and nations.
That is not to say that human security should be an element of the LEP, but humansecurity represents a common approach of Japan and Malaysia, and human security canbe the common approach by which Japan and Malaysia work together.
The LEP is all about uniting, connecting and collaborating, and by enhancing the LEP thecommon values shared by the two countries can be exported to other parts of the world
and contribute to overturn anti-globalization sentiment as well as inclination towards
division and disconnection. As ambassador to Malaysia I will continue to do my best toenhance the Japan-Malaysia relationship based on the foundation of the LEP.
This is the 40th anniversary year of the LEP, and it also represents a new beginning for
the LEP. It is hoped that the policy can be further elaborated for the years ahead and thehealth sector is one very promising area in which the LEP can focus in the future.

54

Discussion
Q: Malaysia is starting to become an aging society, so in your view, what is the first thingthat you think Malaysia should do to prepare for the onset of an aging society?
Takahashi: A sense of urgency is currently lacking and there is a need to look at thepension system of Malaysia in the future. There are a lot of challenges ahead andgovernment funding is very much needed for social security, pensions and healthcare. The
tax system is also another area that will require attention in the future in order to prepare
for the coming of an aging society. A long-term perspective is critically important to prepare
and it is to be hoped that the new government will concentrate on this issue going forward.
Q: I have a question about the LEP and what are the different things that Malaysia canlearn from Japan and Korea, respectively?
Takahashi: In the case of Korea, Malaysia paid real attention to the pace ofindustrialization. Malaysia’s intention was to learn from both countries, which have different
backgrounds. The economic size of Japan and Korea was very different in the 1980s andthe number of students dispatched to Korea from Malaysia was smaller. However, Korea
now has some advantages in cultural and business aspects, and Malaysia is seeking tolearn about different things from the two countries.
Sonoda: I understand the importance of the concept of human security, and I would like tohear your evaluation of the importance of cancer prevention under the huge umbrella ofhuman security.
Takahashi: Human security is a very complicated notion and looks different from various
perspectives. Therefore, if you look at the UN resolution on human security, there aremaybe 12 paragraphs in total, half of which are dedicated to defining what is humansecurity, and half of which are dedicated to what is not human security. Cancer treatment
is one element of human security because health is one of the critical areas, together withpoverty eradication and education. If you can prepare basic infrastructure for awarenessand preparedness it can create a sense of security among the people.

55

Lecture No.8
Disparities in the Malaysian Cancer Care Landscape
Dr Saunthari Somasundaram
President of the National Cancer Society of Malaysia(1) Healthcare system in Malaysia
Similarly to Japan-Malaysia initiatives under the LEP, the National Cancer Society of
Malaysia (NCSM) and the Asia Cancer Forum (ACF) of Japan are working together toelevate human security in terms of prevention and early detection of cancer.
Today’s talk relates to disparities in the Malaysia cancer care landscape, including
specific disparities that hopefully under the new government can be worked on, with a view
to ameliorating or resolving them.
Malaysia’s formal healthcare system is divided into two distinctly separated sectors, thepublic sector, which is taxpayer funded, and the private sector, which is funded by private
insurance and out-of-pocket paying patients. One of the major issues in Malaysia is thatthe public and private sectors are not aligned. Because of that there are major disparities
in terms of the level of healthcare that is provided. The majority of Malaysians (over 65%)
use the public sector healthcare system. The pandemic has also boosted use of the publichealthcare system in Malaysia. There are over 1 million foreign workers in Malaysia, manyof whom also use the public healthcare system.
In terms of healthcare personnel, Malaysia currently has 71,041 medical doctors acrossthe public and private sectors, equivalent to one doctor for every 454 people, and 73
percent, or 51,912 doctors are working in the public health system. However, thehealthcare delivery system is not evenly distributed across states, due to rural disparities,
geographical challenges, socioeconomic factors and medical tourism among other factors.
Whereas the Klang Valley (Kuala Lumpur region) has 99.6 doctors per 100,000 population,
Sabah State has only 33.4 doctors per 100,000 population. This underscores thetremendous difference across the country.
In terms of institutions providing cancer care, the disparities are similar to the overall
healthcare picture, with most cancer-related care being concentrated on the west coast of
peninsular Malaysia. Cost-effectiveness pressures have pushed services to areas of highdensity populations. If patients have to travel far from their homes it tends to lead to latediagnosis, or intermittent treatment of disease. The question arises, therefore, as to why
hospitals and clinics are not more evenly spread and cancer care coverage is sparse to
non-existent in some areas. In East Malaysia there are issues of inaccessibility, but there56are large swathes of the two states that have very little healthcare delivery.
(2) Introduction and challenges to the Malaysian cancer landscape
In Malaysia, cancer control remains a complex, multi-dimensional issue. The cancer
control continuum concept has been in use since the 1970s and has been a good tool, but
it does not really show the complexities of cancer control and how they can be addressed.
The cancer control continuum helps to identify gaps and areas for collaboration.
A key challenge in Malaysia is the disconnect and non-continuity between the public andprivate healthcare sectors in terms of provisioning, with regard to diagnostics, treatment
and palliative services in cancer. The issue with the private healthcare sector is that there
is no monitoring and evaluation and so there is no data to demonstrate outcomes andquantify whether the extra financial outlay results in better outcomes. There needs to bebetter monitoring in this regard.
Prior to the global pandemic there was uncertainty relating to the health system amidst
economic turmoil and an incapacity to cope with rising disease burdens, long courses oftreatment and the continuous demand to provide access to newer, lifesaving therapeutics.
There is inequity in access to early detection and timely treatment for the lower
socioeconomic groups, with mounting financial concerns to patients and their families
looming large over the cancer landscape.
The turmoil in the health system in Malaysia results in delays in diagnosis and latepresentation within Malaysian patients, resulting in poorer outcomes and higher treatment
expenditures both at a micro and macro level. Large, crippling catastrophic debts areborne by patients and caregivers and there are long, indefinite periods of maintenancetherapy with life-saving yet highly expensive innovator drugs.
(3) Financial, economic and social impact of cancer in Malaysia
So, how does late diagnosis and financial impact affect the individual and the community?
As an example, the following slide shows the poor survival rates of breast cancer when
detected at a late stage.
As can be seen on the slide, in countries like Korea and Singapore, where screening
services are highly formalized and national based, the rate of early detection is muchhigher than in Malaysia, where screening is more informal and run by organizations such
as NCSM, making screening initiatives piecemeal.

57

Figure 1: Survival rates of breast cancer in Asian countries

The low number of stage 1 cases detected is not just reflective of the services that are inplace in Malaysia, it is also reflective of behavior. Without health-seeking behavior in place
it will not translate into people coming to use the services available. Health literacy istherefore a key challenge, both in the general populace and also among healthprofessionals.
Financial toxicity refers to problems a cancer patient has related to the cost of treatment.
Once diagnosed with cancer, patients often face and long and arduous journey to accesscare, begin and complete treatment, and adapt to survivorship. On top of financial
challenges, navigating the cancer care pathway from screening, diagnosis, treatment, andsupport care, are often fraught with logistical, informational, emotional and system barriers.
By having patient navigation protocols in place it is possible to support patients on theircancer journey. This is where the NCSM is rolling out patient navigation systems
throughout Malaysia in order to fill the gaps that exist, down from the hospital level to thecommunity level.
At the present time, one in two cancer survivors will face economic hardship within thefirst year of diagnosis. Cancer diagnosis also results in one in three Malaysian households
falling below the national poverty line.

58

Figure 2: Toll of cancer on households

Other out-of-pocket expenses that affect survivorship include hospital follow-ups, parking
fees, transport fees, childcare fees and lodging fees.
In terms of the economic impact of cancer, in 2017 DALY losses from cancer in Malaysia
was estimated to be around RM30.73 billion, or 2.2% of nominal GDP. The reason thisfigure is so high is that cancers are found in younger people in Malaysia.

Figure 3: Economic impact of cancer in Malaysia

59

A large proportion of cancer patients are also diagnosed during their most productive andeconomically active ages. This highly affects the economic productivity of a country.
Many employed individuals are unable to continue working due to prolonged workabsence, lack of workplace flexibility, and reduced productivity while going throughtreatment. Regardless of initial socioeconomic status, loss of income and unemployment
after a cancer diagnosis are major causes of financial hardship. The choices are often
stark: stay home and retain your job or get treated and lose at least several days’ worth ofwages or even become unemployed.
In terms of the social impact of cancer and the gaps between the public and private
sectors, self-paying patients seeking diagnosis in the private sector may experience delays
due to fee payment, insurance coverage, or the time-off needed for employer approval.
Out-of-pocket expenses are also far more expensive in the private sector, but are stillchosen due to the delays and long waiting times in the public sector. There needs to be
more collaboration and alignment between public and private healthcare systems topromote more seamless navigation for patients. Survivorship gaps also exist, with manyfacing long-term physical side effects, psychosocial distress, and financial hardship.
Cancer patients also experience losses in income and productivity, limits to daily activity,and costs in time and transportation needed to access regular medical care. Families facefinancial struggles and there are also barriers to governmental financial support, some ofwhich depend on the state/district in which patients live. There needs to be greater
consistency with regard to financial support across all states in Malaysia.

(4) Actions to ameliorate the impact of cancer
In terms of actions to reduce the impact of cancer, more people need to be screened anddiagnosed at an earlier stage of their cancer when treatment is most effective, and thechance of survival is at its highest. Some of the work done by NCSM is to encourage early
screening for early cancer detection.
In addition, timely, effective and innovative treatment should be made available when it
is needed to avoid the burden of undertreated cancer. Not all cancers can be detected
early, and the health system must not leave behind those diagnosed with advanced
cancer.
The financing and governance of cancer care also needs to be optimized to steer
towards better survival, reduced burden from cancer, and overall better health outcomes.
60

As mentioned by Ambassador Takahashi, health goes way beyond just looking at thewell-being of our bodies, it represents the security of the human being too, and therefore
all areas of the SDGs that impact health require attention.
One of the programs being implemented in Malaysia is the NCSM-ETIQA program forbreast cancer screening and detection. This program has helped to boost screening levels
nationally.
The Bringing Education And Understanding To You (BEAUTY) Program is aninternational collaborative project between Malaysia and Japan that addresses the system
gaps such as poor health education, literacy and awareness, and proposes a solution via
community empowerment at local barbers and beauty salons.
In conclusion, healthcare in Malaysia is divided into public and private sectors. There are
distribution, density and socioeconomic disparities that affect the cancer care landscape,and gaps exist with the cancer care continuum in Malaysia that causes devastating effects
financial, economically and socially. Health therefore needs a “whole-of-society” approachwith multisectoral collaborations.

Discussion
Q: I was interested to hear about the healthcare system in Malaysia and the lack ofalignment between the public and private sectors. Do people with sufficient money goabroad for treatment? Also, is the private healthcare sector run along business lines, rather
than for human security and human well-being?

Saunthari: The private healthcare sector in Malaysia started up in the 1980s and there
was a thought at the time that private healthcare would complement the public healthcare
sector. However, private healthcare wasn’t monitored and there was no oversight. The
private healthcare sector then became a business, particularly so with cancer. Cancer isthe fastest growing healthcare sector in private hospitals in Malaysia. The unfortunate partof this whole thing is that it causes a stigma with regard to public healthcare treatments,
where in many cases the public healthcare teams provide care that is certainly equal to thestandard of care in private hospitals. The private sector needs better monitoring andevaluation to see whether the provision of healthcare is to the standards that are
acceptable and within guidelines on cancer treatment. I am optimistic that the public andprivate sectors can work together, with the ETIQA program being one example. There are61

ways and means of working together and more should be done to identify them.

Sonoda: The disparity between the public and private sectors in Malaysia is somethingthat is seen in other countries too, but the message about the importance of early
screening and detection is one that is universal. This is something where there is room forcooperation between Japan and Malaysia.

Saunthari: It has been recognized by the Ministry of Health and the government that moreneeds to be done to respond to the increasing disease burden in an aging society. There ismuch that can be learned from Japan in this regard.

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Lecture No.9
Introduction to the BEATY and Health Project
Murallitharan M.
Managing Director, National Cancer Society Malaysia (NCSM)(1) Introduction to the lecture
Dr. Kawahara noted that during the lecture series students had been learning about UHC
for cancer in Malaysia. The final goal of the lecture series is for students to present theirrecommendations about the BEAUTY and Health Project. It was explained that Dr.
Murallitharan would present an overview to the BEAUTY Project in this lecture. The
following week a series of awareness-raising videos will be shared among students. These
videos will help students get a better understanding of the various initiatives being
advanced in Malaysia.
Dr. Murallitharan noted that during the previous weeks, aspects of the BEAUTY Project
had been discussed and he hoped to put into perspective some of the material relating to
the project.

(2) Malaysian cancer treatment journey: Prevention
In terms of the Malaysian cancer treatment journey, various people have spoken in thislecture series about the cancer treatment structures in Malaysia, the most fundamental ofwhich is the cancer care continuum. The continuum comprises various aspects. First,
through prevention the aim is to promote population health and well-being and prevent
disease and harm before it occurs. Prevention comprises various aspects, including
nutrition, exercise and not smoking, etc.
An issue that is faced is that very few governments around the world put money into
prevention, and because it does not have a curative aspects, ministries other than healthministries may be involved in prevention-related activities, including education ministries,
etc. This is the reason why prevention in health takes a social determinants of health-type
approach. Social determinants of health means that there are many factors that influence
health, but they may have little to do with health directly. For example, in Tokyo there is avery good public transport system, and individuals are de-incentivized from going into
Tokyo using their own vehicles. The unintended benefit of the broad use of the public
63transportation system in Tokyo is that people are forced to walk, either intentionally orunintentionally. This is an indirect mechanism to promote population health, by making
people do their 10,000 steps a day and be physically active. This type of intervention has
nothing to do with health, but it has a very indirect promotive benefit on the health of the
population.
In the case of Kuala Lumpur, although there is public transportation it is not adequate
enough to encourage people to use it comprehensively, which is why people still choose todrive their own vehicles (cars and motorcycles). The negative effect of people using theirown vehicles is that people do not feel the need to walk, as they are always using theirown vehicles. Public transportation is therefore a policy that can have preventive effects
for health.
Another area that has an impact on health while being unrelated to health is urban
planning. The built environment around individuals can optimize their ability to use thatenvironment for exercise and relaxation. Mental health plays a huge part in cancer, so thebuilt environment and relaxing spaces have a significant role to play in that area.
These examples illustrate that funding for prevention does not necessarily have to comefrom health ministries, as policies relating to transport and urban planning are sourced
from elsewhere.

(3) Malaysian cancer treatment journey: Screening
In terms of screening, the aim is to find diseases at an early stage when there may be abetter chance of curing the disease. Examples of cancer screening tests are themammogram, colonoscopy and the Pap test and HPV DNA test. In order to get a person
interested in screening it is necessary to encourage such behavior. In countries like
Malaysia where testing has to be paid for by users there has to be a desire to actually pay
for a test in the interests of health. This requires greater awareness about the importanceof screening being disseminated among the population.
Screening is something that needs to be done regularly throughout a person’s life, andthis makes it something that is even more challenging for people, particularly those whohave to pay for screening. It is important to encourage a mindset that is inclined to go forscreening. The “Health Belief” model is one way in which this can be realized.
In the “Health Belief” model there is a concept that there is always why people do what
they do. People are only going to take an action pertaining to health if the following criteria
64are met: perceived susceptibility, perceived severity, health motivation, perceived benefits
and perceived barriers.
In terms of perceived susceptibility, a person has to be made to understand that as ahuman being there is a risk of getting cancer. In order to create Health Belief, it isnecessary to inculcate an idea of perceived susceptibility, only then will people beinterested in taking health actions.

Figure 1: The Health Belief Model

The next criterion is perceived severity, namely that people understand that cancer willaffected them severely. If there is a possibility of being severely affected, this can prompt
people to take action in the form of screening. For example, COVID-19 is perceived as
being very dangerous, which is what prompts people to seek help (in the form ofvaccination) because they realize the elevated risks they face.
The third criterion is health motivation, which is related to a person’s individual motivation.
Individual motivation is influenced by the people around you and the more people are
motivated in terms of health, the more likely they are to take action. One of the mosteffective health motivating factors is when a loved one dies. A person can also be
motivated through modelling. Another way to increase extrinsic motivation is to operate a
program that incentivizes people to participate in screening.

65

The fourth and fifth criteria are perceived benefits and perceived barriers and it is equallyimportant for people to understand the potential benefits of changing behaviors andreceiving screening. In terms of perceived benefits, if a person believes that taking certain
actions will benefit their health, they will be incentivized to take action. Perceived barriersmeans an understanding of the constraining factors to health-improving actions. People
need to be able to perceive that the benefits will outweigh these potential barriers.
The BEAUTY and Health Project functions across all these five criteria.

(4) Malaysian cancer treatment journey: Diagnosis, treatment and survivorship
In terms of diagnosis, the aim is to find cancer at the earliest stages and often provides thebest change for a cure. Diagnostic procedures for cancer may include imaging, laboratory
tests, tumor biopsy, endoscopic examination, or genetic testing. For treatment, the goal ofcancer treatment is to achieve a cure for cancer, allowing the patient to live a normal life
span. Survivorship focuses on the health and well-being of a person with cancer from thetime of diagnosis until the end of life.

(5) BEAUTY and Health Project overview
Over the past weeks the lecture series has been discussing the BEAUTY and Health
Project. In essence the project comprises three phases: 1) the development of a structured
intervention comprising of health educational materials and content for the BEAUTY
program, as well as a training module for the barbershop and beauty salon “change
agents,” (2) development of an online, open access cancer screening and healthassessment resource registry for males and females, focusing on the main screen-able
cancers for males and females, and (3) seeking to encompass the actual deployment of
the intervention on the ground.
Through the BEAUTY and Health Project the aim is to intervene in barbershops andbeauty salons, which are places where people go for monthly haircuts. Barbers are being
trained to speak to customers about the importance of preventing cancer as well as
encouraging them to pick up and read prepared materials. The idea is that people will be
more disposed to going for screening if encouraged to do so by their barber / beautician,
who is someone who is close to them in their daily lives.
In phase 2, the project will seek to develop an online health assessment resource app,which will then be rolled out in phase 3 in order to test efficacy.
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The idea is to implement interventions on a monthly basis for six months and assess how
the barbershop / beauty salon interactions have impacted a person’s actions in seeking
cancer-related information or screening.
BEAUTY and Health Project is focused towards the prevention and screening aspects ofthe cancer treatment journey, as well as diagnosis to a certain extent.
Under the BEAUTY and Health Project it is assumed that individuals visiting barbershops
and beauty salons have no knowledge about cancer. It is also assumed that customers
have a long and trusting relationship with the barber / hair stylist, who has the power toexert influence on their customers. In this way the barber / hair stylist is becoming the
instrument of health motivation. Information provided via the app that is being developed
will include information on perceived susceptibility, perceived severity and provide healthmotivation, as detailed in the Health Belief Model. Efforts will also be made to overcome
perceived barriers. For example in rural areas there may be no hospital or clinic nearby,
but under the project it may be possible to arrange for transportation to the hospital or
clinic for screening, thus eliminating the perceived barriers. The overall aim is to drive
action among the individuals who visit the barbershops / beauty salons.
As described above, the BEAUTY and Health Project is also targeted towards changing
individuals’ behavior.

(6) Considering how to enhance the BEAUTY and Health Project
The BEAUTY and Health Project is a large-scale intervention project that seeks to raiseawareness about perceived susceptibility and perceived severity, as well as helping toameliorate perceived barriers.
Lecture series students are tasked with coming up with suggestions to enhance theproject. Questions to consider are how to improve understanding about perceived
susceptibility and perceived severity with regard to cancer.
Students are also asked to come up with proposals that can provide health motivation toindividuals. Are there any micro-interventions that could be implemented to help andencourage individuals to take appropriate actions?
It is hoped that students will provide very specific suggestions for enhancing the BEAUTY
and Health Project.

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Discussion
Dr. Kawahara noted that some students may be watching the lecture in an on-demand
format, so questions could be forwarded to Dr. Murallitharan after the lecture.

Q: I understand that there are some barriers to screening and diagnosis in Malaysia, but interms of accessibility, where do people normally get information about where they canreceive screening?

Murallitharan: Technically, Malaysians can visit their primary healthcare clinic, where they
can receive cursory tests, such as a breast examination. If something is found to be wrong
they will be referred to a public hospital. However, there are long waiting times in the publichealth system, even though the service is free. However, in reality, due to under resourcing
people go through the private healthcare system to receive scans. There is no standard
website or portal that tells people where they should go to receive screening/testing.
Instead, private hospitals advertise their services. There is no comprehensive mapping of
where you can go to receive screening. NCSM has developed a map of facilities around
Malaysia where screening services are provided. This map is available on a website that
also features various vouchers that provide a discount for cancer screening. Although thisservice does not cover all hospitals, it is an attempt to provide information on screening
availability.

Q: Are people who go to receive screening symptomatic or not?

Murallitharan: Almost 60% of all cancers in Malaysia are discovered in Stage 3 or Stage4, so this suggests that most people are going to screening presenting with symptoms.

Q: In this BEAUTY Project a smartphone app is going to be used to promote the project,
but will this not raise issues of IT literacy among older people?

Murallitharan: One in three adults have low health literacy and a cancer literacy
questionnaire is also being implemented currently. Health promotion materials are going to
be distributed through multiple channels. The first channel is mainstream media, andadvertisements are going to be placed on commuter trains, as well as buses and subway
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systems. Messaging concentrates on getting people to become more interested in theirperceived susceptibility, as well as appreciating perceived benefits.
Also, through mainstream newspapers there are plans to carry health promotion
materials.
In addition, outreach via television and radio is being planned, which will include
information about the BEAUTY and Health Project.
In order to promote uptake of the app, efforts will be made to encourage children to
download the app for their parents, who may have lower IT literacy.
In another development a major advertising agency has agreed to promote the BEAUTY
Project on its electronic billboards.

Q: How will the barbershops and beauty salons be selected? Will rural areas be selected?
Also, how will barbershops be persuaded to put up posters about cancer, which can beperceived as a very negative topic?

Murallitharan: The aim is to give the barbershop / beauty salon workers motivation to
become “change agents.” They will be provided with training to interact with customers
and raise awareness about cancer. They are being asked to play a role in helping anational effort to improve cancer screening. They are also being provided with a small
incentive to promote registration of their customers on the app. In addition to these efforts,
barbershop / beauty salon owners and staff will be provided with cancer screening for free.
The barbershop / beauty salon venues will also serve as a base for screening activities in
the future.
With regard to encouraging participation, it is inevitable that some people will not beinterested, but efforts need to be made to enhance people’s responsiveness andacceptance of the project.
In the pilot testing phase both urban and rural areas are being targeted, and in urban
areas the key targets are the urban poor.

Q: With regard to the question from another participant about barbershops / beauty salons
not wanting to talk about cancer, in a recent set of interviews with various potential
cooperating barbershops / beauty salons there were some shops that were very positive
about cooperating, particularly those in high-end urban areas. In contrast, some other69

stores were reluctant to engage with their customers about the topic of cancer, because
they are worried that customers would be put off by this potentially difficult topic. This
reluctance is seen more predominantly in less affluent areas.

Murallitharan: The challenge will be to engage with various communities. In many cases
beauty salons are run by ethnic-Chinese people, with customers coming from all ethnic
backgrounds. Some upper-middle income groups that are religiously conservative may be
averse to talking about cancer, but efforts need to be made to work with the various
outliers.

Q: When deploying the project to specific religious, ethnic or age groups there may besome people who are resistant to changing their ideas, even when encouraged to do so.
What can be done to persuade these people?

Murallitharan: We need to recognize that there will never be a 100% success rate inreaching out to people, so the app will concentrate firstly on the 50-60% of the population
who are most responsive. The important thing is to first roll out the app and the project inorder to assess its effectiveness and take-up. The materials have already been created forthe project in four different languages and using four difficult cultural contexts.

Dr. Kawahara thanked all participants for their input and active engagement with the class.

70Lecture No.10

Believe in the power of BEAUTY (Bringing Education and Understanding To You): A
community-based intervention program aimed at improving cancer-specific healthknowledge, literacy and risk-reduction practices

Norie KAWAHARA
Project Associate Professor, Institute for Advanced Studies on Asia (IASA),The University of Tokyo
Representative Director, Asia Cancer Forum(1) Introduction to the BEAUTY and Health Project
In her lecture Dr. Kawahara explained the details of the recently launched BEAUTY(Bringing Education and Understanding To You) and Health project and the history ofsimilar projects and the rationale behind their implementation in the diverse region of Asia.
The BEAUTY and Health Project in Malaysia is being supported by Astellas Pharma Inc.,
under its Access to Health initiative.
This project is a cancer control activity program that includes cancer awareness in thecommunity through barbers and beauticians, building a cancer prevention registry anddeveloping a cancer education database, etc. It is planned to be implemented in Malaysia
for three years in collaboration with the National Cancer Society of Malaysia, the Asia
Cancer Forum and Astellas Pharma Inc.
Before explaining the details of the current BEAUTY and Health Project, Dr. Kawahara
began with an introduction to the Asia Cancer Forum, one of the implementing bodies ofthe project, and also provided details of the case of community-driven awareness-raisingprograms implemented previously in rural China.

(2) Introduction to the Asia Cancer Forum
The Asia Cancer Forum (ACF) was established in 2004 as the Asian Cancer Information
Network. It changed its name to its current form in 2008 and since then has continued to
implement various activities.
The overarching vision of the ACF is “Surviving Cancer in Asia” and to realize this vision
its stated mission is as follows:
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“The Universal Declaration of Human Rights states that everyone has theright to share in scientific advancement and its benefits equally. Based onthat spirit enshrined in the Declaration, with the aim of overcoming thecommon challenge of cancer that is faced by humanity as a whole, andlinking it to human life in the Asian region, we have attempted to bring
together several types of “intelligence,” which we have subsumed as the“3Cs”: Collective Intelligence, Contextual Intelligence, and ContinuousIntelligence.”
The ACF aims to engage in the following actions: 1) implementation of cancer care thatleaves no-one behind, 2) Livelihood-based research and multilayered perspectives
through the use of information technology, 3) Surviving with cancer, the ancient connectionof the land, and a recycling-oriented symbiotic infrastructure, and 4) the formulation ofinternational proposals that transcend public-private and interdisciplinary frameworks,
centered on the shared challenge of cancer.
Since its inception the ACF has focused its efforts on the health agenda in Asia,
particularly in the context of realizing universal health coverage (UHC) for cancer care in
Asia. Together with regional and international institutions, ACF has sought to encourage
and invigorate collaborations, both between researchers and among academia, industry
and government.
While recognizing that cultural diversity in Asia may be an obstacle to overcoming cancer,
this cultural diversity in itself is also a tremendously powerful force. The ACF considers it to
be important to carefully bring together the various societies in Asia and seek to address
the various different views and perceptions regarding cancer in the region.

(3) Healthcare education project in Harbin City, Heilongjiang Province as theforerunner for the BEAUTY and Health Project
The origins of the BEAUTY and Health Project date back to healthcare educational
projects implemented in Harbin, China, the first of which was launched in 2005. A Japan
International Cooperation Agency (JICA)-funded project to engage in grassroots
assistance was implemented from 2014 to 2017. This project, summarized below,
suggested the necessity of implementing similar research in other countries in Asia.
Heilongjiang Province is a predominantly rural area that is subject to extremes oftemperature and lags behind other regions of China in terms of economic development. As
72such there are major health disparities between Heilongjiang and other provinces. Initialresearch was based on a desire to find out about what people in this rural region of China
think about cancer.
This research was informed by comments made by the scholar Christopher Cheng in2009 that:“Culture affects both the risk factors for cancers and the meaning of thedisease by influencing the behavior responding emotionally, cognitively
and socially to this disease….Culture will determine approaches toprevention, early detection, treatment choices, and management of side
effects such as pain, appropriate psychosocial support, rehabilitation
efforts, survivorship issues, hospice use and effective end of life care.”
The JICA project targeted elementary and junior high school students and their parents.
The children were first targeted by using a DVD-based educational video, and theirparents or guardians were subsequently questioned about the child-to-parent feedback on
the classroom lesson, as well as about lifestyle, awareness, and prevention. The
questionnaire consisted of 24 pertinent questions, including two personal informationquestions (age group and sex). Answers were collected from 287 respondents andsubsequently analyzed. The questions were first analyzed in relation to respondents’ age
group and sex. Then the answers were inspected using correlation analysis (Spearman’sRho) to see whether there were any patterns in respondents’ attitudes. For questions withstrong correlation, Chi-squared analysis was then implemented.
One interesting finding in China was that older generations had a tendency to believe thatlifestyle practices or changes can help prevent cancer. As cancer education has been
uncommon for all generations in China, the tendency is not a result of school education
but should be considered to be a result of life experience, especially empirical rules
resulting from daily observations regarding lifestyle and cancer diagnosis. This question
certainly requires follow-up surveys in other countries to see whether it is a distinctly
Chinese trait, Asian trait, or some sort of basic human behavior.
In terms of gender, the only visible difference was seen in terms of lifestyle priority.
Female respondents had noticeable priorities in securing enough physical rest and anutrition-balanced diet, whereas male respondents prioritized cutting down on smoking
and drinking. Possible reasons may be attributed to differences between genders insmoking and drinking, daily work schedule, and family-chore responsibilities. This trend
73should be similar for other countries, but percentages would vary highly due to national
differences in work-life balance and gender roles.
Another gender-related difference was observed in respondents’ attitudes towards making
decisions in terms of cancer treatment. Far more female respondents wished to discussmatters with family members than male respondents. This may also be a transnational,
basic gender-influenced trait, although the degree of family dependency would vary greatly
by culture and ethnicity.
The project in Heilongjiang Province provided a valuable opportunity to implement patientengagement activities in the community. The shift from traditional models of healthcaredelivery to community-focused models is imperative for the realization of UHC. Anotherimperative is the development of low-cost systems that will enable and encourage people
to manage their own health.

(4) Project outcomes point to future research themes
The project in China highlighted the fact that Asia is a region with unique difficulties forproviding uniform measures for cancer control and treatment, due to significant disparities
in medical and healthcare standards and regional cultural diversity. Furthermore, it is notenough to merely identify the many socio-cultural impacts upon prevention, screening,
diagnosis, disclosure, therapeutic decisions, and palliation of cancer; it is also important todiscern the socio-cultural influences by factors such as nationality, ethnicity, race, religion,
beliefs, ethics systems, and geography. The project concluded that in the future it would be
important to seek to: 1) Identify differences and commonalities in the perception of cancer,2) Assess individual and shared needs, and 3) Use the results as a barometer for cultural
attitudes and social systems relating to cancer.

(5) Lessons from the project in China
During the project in China, there were a few areas where project implementation did not
go according to the initial plan. One of these was the initial attempts to raise awarenesswith local public experts, which were of only limited success.
It was this limited success with using local experts that prompted the project team to turnto local beauty salons to take on an awareness-raising role. The rationale behind thismove was that beauty salons are places where local people visit on a regular basis, andhairdressers and beauticians have interpersonal skills with their clientele.
74

The beauticians were asked to form a group centered on the local women’s association.
The project team distributed information on both beauty and medical check-ups, and also
provided a beauty course using products from a well-known Japanese cosmetics brand.
The prospect of receiving beauty advice and testing products provided an incentive to
people to attend the course, with the local beauticians taking a central facilitating role.
The use of beauty salons as an entry point to the local community led to the creation ofvarious networks, and also enabled the project team to reach out to young mothers about
the value of good health, the importance of prevention and the availability of cancer
screening programs.
One of the major challenges faced was the widespread image of cancer as a “death
sentence,” that of a fatal disease from which people cannot recover. It was therefore
important to share information about survivorship and emphasize the critical importance ofearly diagnosis. Such stories were provided by people from within the community or
network, who had their own survivor stories to share.
The use of beauty salons in rural China showed that such local touchpoints are avaluable means of reaching out to residents and encouraging them to receive screening
and check-ups. The project found that the rate of behavior change was high only whenpeople were able to communicate with relatable people in their own communities and get a
concrete picture of the message. Although perhaps a cliché it is true that to move people itis necessary to reach out to their hearts as much as their minds.
In the activities in the rural villages of northern China there was a strong sense of how
positive reinforcement and optimism have the power to change people’s lifestyles andhabits for the better. Social implementation activities using the power of “beauty” also havethe potential to support sustainability. What is important is to provide value to people at thebest possible timing, with the best possible contents, and best-suited communication
methods. To understand the pain points in people’s individual situations and the selfrealization they want to achieve, it is important to have frequent and regular contact withthe people you are seeking to help.
From that perspective, barber shops and beauty salons are undoubtedly one of the bestpositioned places of interaction for maintaining such regular and frequent contact in thecommunity.

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(6) Launching the BEAUTY and Health project in Malaysia
It is these experiences in China that gave momentum to implementing a similar project in
Malaysia. In multi-ethnic Malaysia, more than 60% of cancer patients are diagnosed at anadvanced cancer stage (stage 3 or 4). Many of these patients have little or no access totreatment or knowledge about prevention. As a result, the level of health-related educationand health literacy is inadequate. Many cancer patients also have financial problems thatmake it difficult for them to continue regular treatment.
The BEAUTY and Health Project will support cancer control efforts through a program by
the National Cancer Society of Malaysia (NCSM) and the Asian Cancer Forum (ACF), withthe support of Astellas Pharma, Inc. The program aims to build a database for cancer
education, which patients can use to obtain advice on cancer screening specific to men
and women. Patients who register on the 'Malaysian Cancer Prevention Registry Portal'
can also use the site to assess and manage their own health risks. In addition, community
engagement sessions for cancer disease awareness will be held in local barber shops andbeauty salons frequented by local residents.

Fig. 1 Image of how communication methods will be implemented
for a community-based digitally driven intervention

Advances in digital technology have made it possible to access not only people's attributedata, but also data about their thoughts and behavior, which offers the potential to get aclearer picture about individuals. Interest in and precision of patient segmentation is76

already increasing. Not only will this be critical to resolving health inequalities, it will also
be important for eliminating waste and targeting resources in order to improve outcomes.
As marketing methods have demonstrated for years, segmenting groups of people isconsistently shown to be superior to a one-size-fits-all approach. It is this this one-size-fitsall approach that particularly fails those who have most to benefit. Individualized
communication is recognized to be an essential method to help to change behavior.
Therefore an app-based approach using salons and barber shops in the community is
expected to be an effective means of deployment.
As shown in the figure below, people’s attitudes to cancer screening can be anticipated tofall into one of five phases:

Fig. 2 Phases of understanding and engagement with screening and checkups

For the purposes of the HEALTH and Beauty Project, the plan is to focus initially on people
who are in the “contemplation” phase, who are aware of cancer and the importance ofcancer risk reduction, but have not yet felt motivated or incentivized to receive screening
for cancer. It is for these people that an app-based digital-led intervention is to be
implemented for screen-able male and female cancers.
After the initial deployment to people in the “contemplation” phase, it is hoped that the
project can be expanded to encourage collaboration among various stakeholders in the 12
areas detailed in Figure 3, through the promotion of the use of the app and the utilizationof data collected.

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Fig. 3 Twelve areas for collaboration among stakeholders

It is anticipated that the digitally-driven interventions that are scheduled to be implemented
through the BEAUTY and Health Project will help to catalyze social transformation, andcreate social and economic value from a medical starting point. One of the rationales
behind the project is that in the future tackling cancer will require a significant shift in theway we all live and work, and can only be achieved through an “all-society” approach,systematically combing the power and reach of all sectors.
The Partnering Initiative (TPI), the Union for International Cancer Control (UICC) and
Bupa have worked together to co-create a partnering guidebook, Better Together,
designed particularly for non-profit organizations seeking to partner with companies
against NCDs. The guidebook sets out how to bridge the divide between societal sectors,
and to engage with business and create effective partnerships to address the causes of
NCDs. The Asia Cancer Forum is currently working on a Japanese translation of thispublication, which it is hoped will help to share insights and best practices from various
countries.
In terms of sustainability, it is hoped that the BEAUTY and Health Project will help todevelop replicable and sustainable community-based, digitally-led interventions, leading to
the creation of a new ecosystem that supports UHC (Figure 4).
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Fig. 4 Anticipated stages of development of digitally-led interventions(7) Specifics of project implementation
In terms of the specifics of project implementation and some of the end targets that areenvisaged, one goal is to boost cancer screening rates in Malaysia for common cancers,which currently stands at around 20%. As shown in Figure 5 below, cancer screening
behavior of the Malaysian population generally falls into one of four quadrants. The aim of
UHC is to cover people in all four quadrants. However, due to limited resources, it isimportant to develop a master plan to achieve the target and prioritize action plans in eachquadrant.
Although people in Group A have ready access to cancer screening, even in this group it
is important to ensure that attrition rates do not increase. People who fall into Group B
have the greatest potential for boosting the screening rate in Malaysia, as they are in a
receptive environment.
However, the currently reality is that Groups C and D combined account for 80% of the
Malaysian population, so other support mechanisms are also needed, including the
project’s aim of implementing digital interventions through beauty salons.

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Fig. 5 Marketing communication design based on the “behavior change model”

In designing an intervention support program therefore, individualized design tailored tothe target is required. It is important to construct an intervention support program with highreproducibility by segmenting the targets at each stage of behavioral change using
external variables and testing hypotheses on the decision-making process and the processof behavior change (Fig. 6)

Fig. 6 Integrated model of behavior80

In preparation for the project the development materials are classified into three literacy
levels based on the outcomes of a government health literacy survey. These literacy levels
are defined as “limited,” “sufficient,” and “excellent.” The NCSM has also developed
teaching and awareness materials that match these three levels of literacy in a total of four
languages (Malay, Chinese, Tamil, English). It will be therefore important to explore the“level of interest” (interested/uninterested) within each group, in addition to their level ofliteracy. By conducting analysis of 24 attribute types and understanding their conditions
and needs, it may be possible to formulate an intervention concept that is individualized
and optimized according to each phase and create a single, all-encompassing mechanism.

(8) Digital specifics – What will the app do and how will it be implemented?
The app to be utilized for the project is called BEAUTY. It is anticipated that the app will be
installed using beauty salons and barber shops as touchpoints. In addition to attributeinformation, information on other items such as awareness, knowledge, behavior, locationand values will also be collected by the BEAUTY app as registered information.
The information registered on the BEAUTY app means that health levels can bemonitored using the dashboard My Page on BEAUTY. The level of a subject’s interest cantherefore be predicted from the personal information acquired, and a personalized
program is developed accordingly within the app.
App functions can be built up in stages, giving consideration to the segments that need
to be implemented.
The Japan project team is currently discussing the possibility of adding a points system
to the app, as well as implementing a program that promotes circulation from urban to rural
areas. It is very important to aim to realize a sustainable mechanism that will continue torevolve around the relationship with providers of content provision support. Collaboration
with corporate health management practices will also be encouraged. In the initial
In the initial stages the aim is to use as narrow and precise a focus as possible, out of adesire to ensure adherence and continued use of the app and its features. Coupons andother incentives could be provided to enhance uptake of the app.
The app will aim to respond to and appeal to various types of people by providing
personalized content for everyone from rationalist health enthusiasts, to people who seek
to maintain good health for the sake of their children, etc. (Fig. 7)

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Fig. 7 Anticipated target app user types

In terms of the services the app will provide and what and shoe problems it may be able tosolve, the aim is to develop and deliver a holistic intervention support program fromawareness-raising to behavioral support, tailored to behavioral change, to delivercommunity-based, digitally-driven interventions to improve cancer-specific healthknowledge, literacy and risk reduction practices. The figure below shows a detailed imageof the type of problems the app could solve, with anticipated benefits and output ideas.

Fig. 8 App services, problems responded to and potential outcomes82

Once in operation the app will need to be consistently updated and improved. Accordingly,
it will be necessary to formulate hypotheses and implement testing to quantify andstandardize each process to increase the effectiveness of community-based, digitallydriven interventions. The figure below illustrates the indicators and variables that areplanned to be used to assess and improve the app functions.

Fig. 9 Flow of community-based, digitally-led interventions

The final aspect of implementation will be to address the task of creating a sustainablesystem. The project team is in discussions with the NCSM to implement ecosystems andupscale activities to realize a self-sustaining ecosystem. As with all international joint
projects, two-way conversations and searches for answers are of critical importance.
Mutual trust and good intentions are essential in order to overcome any cultural or habitualdifferences.

(9) Next steps and outlook for BEAUTY
For a beautiful future and social implementation of cancer care that leaves no one behind,an urgent challenge is to engage in branding of the BEAUTY (Bringing Education andUnderstanding To You) concept and related mechanisms and functions as a digitally-led
narrative-based intervention.

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Beauty is both personal and universal, and the BEAUTY and Health Project has theability to win the hearts and minds of people and change their behavior for the better.
However, the key point of this project going forward is to realize the fusion of digital andhuman interactions.
This project will acquire information about people that originates in the relationships thatpeople have with their hairdressers/barbers in their daily lives as touchpoints. Although
digitally driven this is fundamentally a human-centered approach.
When approached about their hopes for the project, hairdressers in Malaysia responded
positively, noting that although the topic of cancer may be difficult to bring up in the context
of a beauty salon or barber shop, it is the hairdressers and barbers themselves who canadjust how they approach individuals to find the best time to broach subjects and in sodoing personalize advice and information for each and every individual.
The project team will continue its efforts to reach out to more than one million Malaysians
by promoting cancer prevention and early detection through health education and literacy.
Efforts and outcomes will continue to be monitored, analyzed and adjusted, and the Asia
Cancer Forum and National Cancer Society Malaysia will report on progress regularly.

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