Correspondence
how much an effect of a treatment
For more on The Higher
Education Statistics Agency see
https://www.hesa.ac.uk/
news/01-02-2022/higher-
education-staff-statistics-uk-
202021-released
For more on the Race Equality
Charter see https://www.
advance-he.ac.uk/equality-
charters/updated-race-equality-
charter
For more on the Athena Swan
Charter see https://www.
advance-he.ac.uk/equality-
charters/athena-swan-charter
612
12 Etminan M, Brophy JM, Collins G,
is modified by another variable
(ie, effect-measure modification).
Modellers often add product terms in
the regression model such as logistic or
Cox, which correspond to multiplicative
interactions on the odds or rate scale.
However, additive interaction on
risks is more relevant for both clinical
decisions and public health and so
should be assessed as well.20 In either
case, studies will usually have little
power to establish even the direction
of an interaction and risk producing
misleading estimates if they screen for
interactions with statistical tests.
MAM is a statistical reviewer for The Lancet Group.
We declare no other competing interests. We thank
Sander Greenland and Jay Kaufman for their helpful
comments on an earlier draft of this
Correspondence.
Mohammad Ali Mansournia,
*Maryam Nazemipour
ma_nazemipour@yahoo.com
Department of Epidemiology and Biostatistics,
School of Public Health, Tehran University of
Medical Sciences, Tehran, Iran
1 Mansournia MA, Collins GS, Nielsen RO, et al.
A checklist for statistical assessment of medical
papers (the CHAMP statement): explanation and
elaboration. Br J Sports Med 2021; 55: 1009–17.
2 Mansournia MA, Collins GS, Nielsen RO, et al.
Checklist for statistical assessment of medical
papers: the CHAMP statement. Br J Sports Med
2021; 55: 1002–03.
3 Altman DG, Bland JM. Detecting skewness from
summary information. BMJ 1996; 313: 1200.
4 Altman DG, Royston P. The cost of
dichotomising continuous variables. BMJ
2006; 332: 1080.
5 Binney ZO, Mansournia MA. Methods matter:
(mostly) avoid categorising continuous
data—a practical guide. Br J Sports Med 2023;
published online Nov 28. https://doi.
org/10.1136/bjsports-2023-107599.
6 Greenland S, Mansournia MA, Joffe M. To curb
research misreporting, replace significance and
confidence by compatibility: a Preventive
Medicine Golden Jubilee article. Prev Med 2022;
164: 107127.
7 Mansournia MA, Nazemipour M, Etminan M.
p-value, compatibility, and s-value.
Glob Epidemiol 2022; 4: 100085.
8 Altman DG, Bland JM. Statistics notes: absence
of evidence is not evidence of absence. BMJ
1995; 311: 485.
9 Greenland S, Pearl J, Robins JM. Causal
diagrams for epidemiologic research.
Epidemiology 1999; 10: 37–48.
10 Lipsky AM, Greenland S. Causal directed acyclic
graphs. JAMA 2022; 327: 1083–84
11 Etminan M, Collins GS, Mansournia MA. Using
causal diagrams to improve the design and
interpretation of medical research. Chest 2020;
158: S21–28.
discussion of diversity and inclusion,
Nazemipour M, Mansournia MA. To adjust or
not to adjust: the role of different covariates in
cardiovascular observational studies.
Am Heart J 2021; 237: 62–67.
13 Kyriacou DN, Greenland P, Mansournia MA.
Using causal diagrams for biomedical research.
Ann Emerg Med 2023; 81: 606–13.
14 Altman DG, Bland JM. Missing data. BMJ 2007;
334: 424.
15 Mansournia MA, Altman DG. Inverse
probability weighting. BMJ 2016; 352: i189.
16 Greenland S, Mansournia MA, Altman DG.
Sparse data bias: a problem hiding in plain
sight. BMJ 2016; 352: i1981.
17 Mansournia MA, Geroldinger A, Greenland S,
Heinze G. Separation in logistic regression:
causes, consequences, and control.
Am J Epidemiol 2018; 187: 864–70.
18 Zou G. A modified Poisson regression
approach to prospective studies with binary
data. Am J Epidemiol 2004; 159: 702–06.
19 Greenland S. Model-based estimation of
relative risks and other epidemiologic
measures in studies of common outcomes and
in case-control studies. Am J Epidemiol 2004;
160: 301–05.
20 Knol MJ, VanderWeele TJ. Recommendations for
presenting analyses of effect modification and
interaction. Int J Epidemiol 2012; 41: 514–20.
Addressing racism in
academia
Several higher education institutions
have identified the Race Equality
Charter (REC) as a key strategy for
addressing racism. Similarly to the
Athena Swan Charter, which addresses
gender equity, the REC, launched in
2016, gives bronze and silver awards in
racial equality. The recent update of the
REC is therefore important. Overall,
the REC application process has been
substantially streamlined with greater
flexibility for applicant institutions to
focus on their own needs. However,
the 2021 review that triggered this
update also found that REC impacts
were least beneficial among Black
academics and absent among Black
professional staff.1 The review further
recommended a specific focus on anti-
Blackness, including the introduction
of a dedicated principle to address it.
These recommendations have not
been adopted.
Anti-Blackness is now widely
recognised as a specific form of
racism.2,3 However, despite decades of
Black people continue to be severely
under-represented in academia.
Data from the The Higher Education
Statistics Agency showed that less
than 1% of UK professors are Black
(a >4-fold deficit compared with the
general population), of whom only a
fraction are women. The failure of the
revised REC to promote more specific
targeting of anti-Blackness therefore
misses an important opportunity.
The emphasis on flexibility might
also weaken the effects of the REC. The
process-focused criteria for bronze
or silver awards do not indicate any
particular level of racial fairness.
Further comparison with the Athena
Swan Charter is valuable here. In the
months following a race review, which
recommended that the institution
considers “particularly the experiences
of Black women and other women
of colour”,4 The Liverpool School of
Tropical Medicine (LSTM) was granted
an Athena Swan silver award (a rank
held by <20% of universities). Yet at
the point of award, LSTM had never
promoted a Black female researcher
at any grade. A gender equality award
in the face of such failure to recognise,
nurture, and reward Black female
talent, in an institution that conducts
over two-thirds of its research in
Africa, casts a grim shadow over the
value of these charter marks, and
on the intersectionality that these
charters claim as a core principle.
Prof Seye Abimbola, Editor-in-Chief
of BMJ Global Health, has criticised
publications reporting research from
low-income and middle-income
countries in which authors from
those host countries are absent or
under-represented.5 He has described
such author lists as “crime scenes”,6
evidencing an intellectual violence
against the excluded.
The complete absence of Black female
progression at LSTM, an institute so
deeply steeped in work on Black people,
evidences a similar kind of exclusionary
violence. The Athena Swan silver kite
mark renders this violence invisible.
www.thelancet.com Vol 403 February 17, 2024

The fact that these charters are
sector-led also begs several questions—
eg, to what degree, however unin­
tentional, have underlying higher
education institutions’ cultures of
anti-Blackness hampered uptake of
the recommendations addressing this
problem? How does this sector-led
approach mitigate against lobbying or
exceptionalism (eg, LSTM consulted
with the REC host organisation about
its approach to small institutions)?
Answers to such questions are urgently
needed because, in the absence of
true change, these charter awards risk
worsening the distrust and alienation
felt by staff and students whose
institutions are being rewarded and
recognised for progress that they
themselves do not see.
I declare no competing interests.
Angela I Obasi
angela.obasi@lstmed.ac.uk
Liverpool School of Tropical Medicine, Liverpool
L3 5QA, UK (AIO); AXESS Sexual Health, Liverpool
University Hospitals NHS Foundation Trust,
Liverpool, UK (AIO)
1 Douglas Oloyede F, Christoffersen A, Cornish T.
Race equality charter review: final report.
March, 2021.
2 Kyobutungi C, Gitahi G, Wangari M-C, et al.
From vaccine to visa apartheid, how anti-
Blackness persists in global health.
PLoS Global Public Health 2023; 3: e0001663.
3 Bowden AK, Buie CR. Anti-Black racism in
academia and what you can do about it.
Nat Rev Mater 2021; 6: 760–61.
4 Arday J. Equity and inclusion at LSTM:
improving racial equity in global medicine—
an independent report. February, 2022. https://
www.lstmed.ac.uk/sites/default/files/LSTM%20
Race%20Equality%20Review%20-%20
Arday%20%28February%202022%29%20
FINAL.pdf (accessed Dec 22, 2023).
5 Obasi AIN, Abimbola S, Oriyo N, Morton B,
Vercueil A, Masekela R. Credit local authors
fairly on international research papers. Nature
2021; 598: 415.
6 @rumaraj123. Nov 2, 2022. https://twitter.
com/rumaraj123/status/
1587904886145966083?s=46&t=3awpbh1F
_Esx9LFR0nPWhQ (accessed Sept 15, 2023).
Economic crises and
cancer care in Pakistan—
timely action saves lives
Cancer treatment is often ignored
during economic crises; Sri Lankans
www.thelancet.com Vol 403 February 17, 2024
are still striving to stabilise their
health-care system.1 Currently, the
health systems in low-income and
middle-income countries are least
prepared to operate independently in
emergencies and combat global cancer
inequities. Alarmingly, in Pakistan,
political turmoil has contributed to a
catastrophic decline in the economy
and looming bankruptcy.2 Being the
world’s fifth most populous country
(with a population of >232 million
people), due to depleting reserves,
rising inflation, and calamitous
recent floods, the value of currency
in Pakistan has declined by 21·72%
this fiscal year.2 With a gross domestic
product of US$340·64 billion (per
capita $1471·1),3 Pakistan’s Human
Development Index has increased
from 154 in 2020–21 to 161 (score
0·544) in 2021–22.4
According to WHO estimates, every
year in Pakistan, 118 442 individuals
lose their lives to cancer and
173 937 new cancer cases are identified.5
By contrast, the Pakistani Government
has not planned for any substantial
measures to combat cancer incidence,
merely spending $38 per capita in 2020
on health care.6 Only 40 institutions
(government and private) across the
country declare themselves cancer
treatment centres, yet the demand
from patients considerably outweighs
the supply. The state-of-the-art Shaukat
Khanum Memorial Cancer Hospital and
Research Centre (SKMCH&RC), founded
by former Prime Minister Imran Khan, is
supported by national and international
fundraising efforts, and treats patients
from Pakistan, Afghanistan, and
Tajikistan, irrespective of their capacity
to pay for treatment.7
Cancer treatment challenges,
besides financial strain on people
with cancer, are far worse than we had
anticipated. Most anti-cancer drugs
are imported; following Government
import restrictions, a severe shortage
of medicines is anticipated. Due to the
depletion of foreign exchange and low
investment returns, pharmaceutical
companies have withdrawn their
Correspondence
business from Pakistan, while domestic
companies operate illegally in the black
market.8 Recruiting and continuing to
employ well trained doctors, nurses,
and other medical workers is a perennial
struggle in Pakistan. Worryingly, fewer
than 250 expert medical or radiation
oncologists are now practising
nationwide.7 According to the Ministry
of Health, Pakistan needs 2 million more
nurses.7 Paramedics in Pakistan are For more on the population of
emigrating to high-income nations.7,9 Pakistan see https://www.
worldometers.info/world-
The current Pakistan Government’s population/pakistan-
actions towards SKMCH&RC Chairman population/#:~:text=The%20
Imran Khan and probes into foreign current%20population%20of%20
Pakistan,the%20latest%20
funding10 might undermine the co­ United%20Nations%20data
operation of overseas donors.
The question is, what can be done
right now? First, it is necessary to take
concrete steps, such as reaching out to
international health-care organisations
and cancer care agencies to solicit
monetary donations, pharmaceuticals,
consumables, and equipment. Second,
austerity measures should be adopted
to ensure the judicious use of resources
and more reliance on empirical
treatment rather than laboratory
investigations. Third, the Government
should uplift import restrictions on
medical supplies and establish price
regulation of pharmaceuticals in
Pakistan. In conclusion, we would like
to reaffirm the famous adage—to save
one life is like saving all mankind—and
recommend the collaborative efforts
of international cancer organisations
and funding agencies for a worldwide
cancer care framework to deal with such
emergencies.
We declare no competing interests.
Usman Ayub Awan, Xingyi Guo,
Aamer Ali Khattak, Usman Hassan,
*Suliman Khan
suliman.khan18@mails.ucas.ac.cn
Medical Research Center, The Second Affiliated
Hospital of Zhengzhou University,
Zhengzhou 450014, China (UAA, SK); Department of
Medical Laboratory Technology, The University of
Haripur, Haripur, Pakistan (UAA, AAK, SK); Division of
Epidemiology, Department of Medicine, Vanderbilt
Epidemiology Center, Vanderbilt-Ingram Cancer
Center (XG, UAA) and Department of Biomedical
Informatics (XG), Vanderbilt University School of
Medicine, Nashville, TN, USA (XG); Department of
Pathology, Shaukat Khanum Memorial Cancer
613