Pakistan, like most developing countries, is experiencing rapidly rising rates of cardiovascular disease, diabetes, obesity, and chronic obstructive pulmonary disease, and it has developed a draft national plan for countering chronic disease. It’s an impressive and elaborate plan, as I discovered when I discussed the plan last week with people from the health ministry in Islamabad. It will, however, be an uphill struggle to implement the plan and make a difference.

One problem is attitude. About half the deaths in Pakistan are still from infectious disease, and many people are understandably against shifting any resources away from controlling infectious disease. And resources are a problem. Pakistan is a poor country, and, as with most of the world, its finances are particularly shaky now. Annual spending on health for each person in Pakistan is about $4, enough perhaps for one packet of statins.

Donors are not keen on funding programmes to counter chronic disease as, again understandably, they want to concentrate on trying to achieve the Millennium Development Goals, which do not include anything on chronic disease.

It’s sensible to prioritise, and one of the challenges with countering chronic disease is that it needs a wide range of activities, many of which are in the territory of other government departments like finance, agriculture, and trade.

Before the meeting at the ministry I heard Shah Ebrahim from the London School of Hygiene and Tropical Medicine talk in Karachi about the best strategy for countering chronic disease. He advocated improving social determinants like poverty, concentrating on risk factors rather than diseases, and working to improve health systems, particularly primary care. When pushed on short term strategies he said increase taxes on cigarettes, ban smoking in public places, make unsaturated oil cheaper, and concentrate on treating hypertension.

Almost half of men in Pakistan smoke, and some cigarettes cost about 6 rupees for 10—about 3p. It may well have the cheapest cigarettes in the world, and cigarettes are smuggled out of Pakistan. Despite the cheapness of the cigarettes the government’s income from tobacco exceeds its total expenditure on health. Pakistan also grows a lot of tobacco and has a national body to promote tobacco sales. So government is very cautious on tobacco control, despite signing the Framework Convention on Tobacco Control. Smoking is banned in public places, but the law is flouted everywhere.

Then there is the problem of smokeless tobacco, which comes in some 134 different forms, all of them cheap. Half of men and more than a quarter of women use smokeless tobacco, and doctors regularly see people in their 30s with advanced oral cancer. There is also now a rage for shishas (bubble pipes from Turkey), which are used by 43% of males and 11% of females. Many parents who object to their children smoking cigarettes do not object to them using shishas because they don’t think that they are dangerous.

Then there are problems of implementing WHO advice on diet and physical activity. Most poor people consume far less fat than the WHO recommendation, but it doesn’t seem wise to encourage an increase. Salt restriction can be difficult because it’s an important source of iodine, and implementing advice on physical activity is impossible among the many women in Pakistan who are segregated.

Despite all these difficulties I flew back over the foothills of the Himalayas (did you know that Pakistan has five of the seven highest mountains in the world?) feeling confident that Pakistan, a country full of ingenious people, will find its own way to counter chronic disease.

Competing interest. Richard Smith is the director of the UnitedHealth Chronic Disease Initiative, which together with the US National Institute for Heart, Lung and Blood Disease funds centres around the world, including one at the Aga Khan University in Karachi.