How Shaukat Khanum built world-class cancer care from nothing

A London childhood and a mother who always meant to leave

The episode opens with Muzamil setting a careful frame. Shaukat Khanum carries a connection to Imran Khan and to a charged political history, and Muzamil asks listeners to leave the politics at the door and judge the institution on its merits — “a jewel in Pakistan’s crown,” he calls it, and a disservice to discuss any other way. What follows is two hours on how that institution was actually built and run, told by the doctor who has run its medicine since before it opened.

Dr Aasim Yusuf was born in London in 1962 and lived there until he was nearly fifteen. His mother was, in his words, an ardent Pakistani who never wanted to live in England; his father never wanted to come back. When Bhutto’s government ran an exam for overseas Pakistanis to join the civil service in the mid-seventies, she sat it, got in, and brought the family home. Yusuf is honest that England in those years was not the multicultural place it is now. Racism was, as he puts it, rampant — being called a “paki” on the way home from school was ordinary. He quotes a line he loved from Mohsin Hamid: prejudice is like a hair fallen across your eye that you keep flicking at because it bothers you but can never quite see.

He is careful not to romanticise the West, then or now. The England he left in the seventies was grey and economically bruised — three TV channels, coal miners on strike, candle-lit power cuts and a three-day working week. The point he keeps returning to is one Muzamil seizes on: developed countries were not always developed. They had their smog and their squalor and they fixed it. The trajectories diverged later, and Pakistan’s angle of climb simply widened more slowly.

King Edward, the Zia years, and a long road into medicine

Yusuf did not choose medicine so much as default into it. He wanted to be a fighter pilot; his mother engineered a visit to the selection centre only after confirming he was too young to join. She thought he should be a doctor, and in the late seventies, he says, you became a doctor or an engineer or you were considered a failure. He went to King Edward Medical College in Lahore on the condition that his mother get herself transferred to the city so he would not have to live in the hostel. She did.

He joined in 1980, into a class of 240 boys and 30 girls, the front two rows of the lecture theatre reserved for the women. The Zia years were, for him and his peers, the most stifling period of their lives — student unions banned, people beaten for talking to a girl, the climate seeping down through society far below the level of politics. The session that should have taken five years took six, padded out by the strikes and closures that followed Bhutto’s overthrow and execution. What saved the experience were the clinical years and the legendary clinical professors, and a small group of overseas-born students who, like him, had come back to Pakistan to study and became friends for life.

The mistake he still names: coming back without negotiating

After graduating in 1986 and a year of house jobs, Yusuf went to the UK in 1989 to train — general internal medicine, then gastroenterology, drawn to the specialty partly because it let him do procedures. Coming back to Pakistan was never in doubt. “My eyes were not aglow when I went to England,” he says. He could assimilate, he got every job he needed, but he never felt at home.

The way he came back, though, he calls one of the major mistakes of his life. His mother heard that Imran Khan was opening a hospital and suggested he apply. She drove out to a building site in the middle of nowhere and handed his CV to a girl working in marketing in a hut by the side. Months later Dr Nausherwan Burki — Imran’s cousin and the hospital’s chief medical advisor — called to say they did not really need a gastroenterologist but might have a part-time endoscopist role. Yusuf, used to fixed NHS pay scales and not knowing you were meant to negotiate, said he would take whatever everyone else got. He also said the line he warns recruits against to this day: that he was coming back to Pakistan anyway. “If you say to someone, well, I’m coming back to Pakistan anyway, that’s half the battle done.” He now runs recruitment, and he knows exactly how much leverage he gave away.

A hospital with no electricity, built from bare rooms

By the time he actually arrived in December 1994, the part-time job had become a full-time one. He joined four weeks before the hospital opened on 29 December. What he describes next is the part of the story that explains everything after it.

The hospital opened without electricity and ran without it for six months — a building designed for central air conditioning, with windows that did not open, stiflingly hot. Two enormous generators the Pakistan army lent the hospital kept the CT scanner and the radiation machines alive; lights and pedestal fans got what was left. Yusuf and a colleague went out and bought polo shirts because shirts and ties were unbearable. On his first day, the woman greeting new consultants took him to two bare rooms — no paint, no sockets, no false ceiling — and told him this was the endoscopy unit, and it was his to build. He decided where the sockets and monitors went.

When the first chemotherapy patients got sick and there were no inpatient beds yet, they furnished an unoccupied house on campus in about six hours and ran it as a ward; when one of those patients needed intensive care, they kitted out a room as an ICU and put someone on a ventilator. He once had to refer a patient for an ultrasound-guided biopsy he had never done before and never did again, because the endoscopes had not arrived and there was no other way to get the tissue diagnosis chemotherapy required. The hospital sat in wheat fields where Johar Town is now, and staff left in convoy at five in winter because people got robbed and mugged; one engineer was shot.

The lesson Yusuf draws is not nostalgia. Because physicians built the place from bare rooms rather than slotting into a working machine, clinical staff were given a preeminent place in the organisation. “It wasn’t just managers deciding these things.” That, he argues, is why the CEO has held the job for twenty-three years, why he himself has run the medicine since 2004, and why nothing feels insurmountable now — the people who survived the first years set the culture.

Quality as the line that cannot move

The thread that runs through the whole conversation is quality treated as non-negotiable. Yusuf’s standard is blunt: “If we can’t do something to our standards, we won’t do it.” Peshawar offers fewer services than Lahore, but the services it offers run to exactly the same standard.

His external proof is the Joint Commission, the body that accredits US hospitals against a book of 14 chapters, 285 standards and nearly 1,200 measurable elements. In 2018 the Lahore hospital became the third hospital in Pakistan, and the first charitable one, to win Joint Commission International accreditation. Peshawar followed in 2019. In 2021, mid-pandemic, when hospitals worldwide were declining reaccreditation because corners were being cut, Shaukat Khanum went through it anyway. In 2022 it submitted every site together under JCI’s new enterprise standard and became the first organisation in Pakistan and the second in the world to earn it. Only two other institutions in the country hold ordinary JCI accreditation, he notes — Aga Khan and Shifa.

Underneath the accreditation sits the cornerstone he is proudest of. Doctors and nurses are blinded to a patient’s financial status. Whether you pay or not, you get the same tests, the same drugs, the same food, the same room. The collection-centre network — close to 200 of them, plus home sampling in the big cities — exists to generate the revenue that lets the bulk of treatment be given free.

Why it turns most patients away

Muzamil raises the criticism the hospital hears most: that it picks and chooses its patients and refuses too many. Yusuf does not flinch from it. Pakistan diagnoses over 180,000 new cancer patients a year. About 45,000 reach Shaukat Khanum’s walk-in clinics in Lahore, Peshawar and Karachi. Of those, around 12,000 are accepted for treatment.

The choice, he argues, is stark and unavoidable. You can accept all 45,000, give them all paracetamol, and call it care — or you can treat a smaller number to a world-class standard. Acceptance is disease-specific: a given cancer has a threshold of age and stage, set by the likelihood of cure and by whether the hospital actually has the surgeons, drugs and machines to treat it. Because the money is zakat, he feels a duty to spend it where it can return someone to their family and their work. Patients who are refused are offered counselling by a psychologist and advice on where else to go, and they are told plainly that refusal is a limit of capacity, not a verdict on whether they can be cured. The honest answer to the demand problem is more hospitals: Peshawar nearly doubled capacity, Karachi will add as much again, and his estimate is that Pakistan needs roughly twenty tertiary cancer hospitals the size of Lahore’s to meet the real need.

The drain that is hardest to replace

The most sobering stretch of the conversation is about the people. Shaukat Khanum grew from 10 consultants to about 130 over thirty years. Since the start of 2023 it has lost 12.5% of them — 17 specialists, every one bound for a job abroad, none yet replaced. These are people it can take a decade or more to train, and the funnel that produces them is narrow: few go overseas, fewer train in the oncologic specialties the hospital needs, and fewer still want to come home when the economy is tanking and the rupee has cut their dollar-equivalent pay to a fraction of what it was. “Thank god for parents,” he says — family, more than anything, is what brings people back.

Nursing is worse. Pakistan is short, by his estimate, two million nurses — he is emphatic it is two million, not two hundred thousand. Shaukat Khanum hires qualified nurses, runs them through a year as trainees, funds postgraduate degrees in exchange for service, and still runs about a 20% attrition rate. He has made a kind of peace with the churn within Pakistan — a nurse who leaves for another hospital here still raises the standard of care somewhere. What hurts is the ones who go overseas, because they are irreplaceable. The hospital’s counter-move is its own postgraduate training: it takes the best of its trainees, sends them abroad for two years, and brings them back on a five-year commitment. That, he says, is the light at the end of the tunnel.

Regulation, brain drain, and a stubborn optimism

Yusuf helped draft the act that modernised medical regulation — moving registration online, letting people apply from a phone, and introducing a national licensing exam so that a graduate of any school, foreign or local, had to clear one standard before practising. He calls it a genuine improvement, and watched it rescinded almost as soon as Imran’s government fell, a reversal he attributes to the owners of private medical schools defending their interests rather than the public’s. He is careful about politics, but clear that he thinks the country lost something there, and lost it again when the Sehat Sahulat health card — which had begun pushing private hospitals to open even in rural areas because patients suddenly had money to pay — went on ice.

On the question everyone asks him — is cancer really rising, especially among the young — he refuses to overclaim. Pakistan has too little long-run data; Shaukat Khanum runs the country’s largest population-based registry, the Punjab Cancer Registry, and it is under twenty years old. What the data does show is that common cancers here present ten to fifteen years younger than in the West, breast cancer at a median of around 42 versus 52, driven by reproductive factors and cousin marriages, with oral and lung cancers climbing on pan, gutka and tobacco that arrived late and is only now cresting. Treatment, meanwhile, has changed beyond recognition — from the “slash and burn” of mutilating surgery and shotgun radiation to breathing-gated beams and targeted drugs, some individualised therapies running past a million dollars a patient. On AI, he is neither breathless nor dismissive: imaging and biopsy pattern-recognition are coming, the hospital is already running research projects on it, and he is wary of being “research colonised” by companies that want to download three decades of radiology in exchange for a free month — he wants technology transfer, engineers trained locally, the country left better off.

Muzamil closes by saying healthcare conversations usually bore him, and this was among his favourites in 380-odd episodes. He thanks Yusuf and everyone who has passed through the institution for their service to the country. Asked how he sees Pakistan in 2050, Yusuf is plain: he has always believed the country is on an upward trajectory, the angle varying but the direction holding. He has watched the hospital survive bleak periods — donations collapsing in 1997, Imran selling his last plot to pay salaries, recruitment freezing after 9/11 — and come through each one. Seventy-five years, he says, is nothing in the life of a nation. The next five to ten will be hard. The longer arc, he is certain, bends up.