Spring 2009 Vol. VII, No. 3
Diagnosing the System
The first of its kind in Lebanon and the region, AUBMC’s new Women’s Health Center puts women at the center of its care system.
Emphasis is placed on discretion and empowerment.
The statistics are shocking: research carried out by AUB and others in the region reveals that the incidence of breast cancer in the Arab world occurs ten years earlier than in the United States and Europe. Dr. Ghina Birjawi, a specialist in women’s imaging in the Department of Diagnostic Radiology at the AUBMC, has diagnosed one woman as young as 19 and many in their early twenties. She says that the majority of patients she sees with breast cancer are in their mid thirties to mid forties.
In addition, in 60 to 80 percent of diagnosed cases in the Arab world, the disease is highly advanced and may already have spread to other organs by the time treatment is started. In Lebanon, 15 percent of the cases are diagnosed as stage III or IV while two thirds of cases are stage II. A majority of cases in the region end in mastectomy, though in Lebanon the number has dropped to 50 percent. There is clearly a need for a campaign to increase awareness that will lead to earlier diagnosis and treatment and dispel many of the prevailing myths that surround this disease. The new AUBMC Women’s Health Center (WHC) will play a vital role in the Middle East by providing reliable information and superior care.
Originally conceived by an interdisciplinary team led by former FHS Dean Huda Zurayk, the Women’s Health Center has evolved over the years and is now under the tutelage of Dr. Adnan Mroueh, chair of Obstetrics and Gynecology. The Women’s Health Center, which is scheduled to open on the seventh floor of the Medical Center this summer, will be the first of its kind in Lebanon and will be a model for the country and the region.
The renovation work began last year after Mroueh “occupied” the space and transformed what were basically storage cages on the eighth floor to be his office. The proposed “one-stop shop” will offer state-of-the-art treatment and an energetic educational and awareness raising program in facilities designed to be different as well as effective. In keeping with the emphasis on discretion and empowerment, the waiting, changing, and consulting rooms are designed to shield patients and respect their privacy.
Luma Kronfol, director of special projects at the Faculty of Medicine and AUBMC, describes the physical planning stages for the WHC as akin to playing musical chairs. It began by moving ophthalmology to a new location and drawing up plans to integrate the different WHC clinics into the new space. Alongside its consulting and diagnostic rooms, the WHC will include an education room where women can consult audio and video resources, books, pamphlets, and other materials. There will also be facilities for exercise and pre-natal classes, as well as for instruction on nutrition and diet and even physical therapy treatment.
The WHC will offer general health screening with the emphasis on prevention, health education, and risk reduction in a range of clinical areas including reproductive health, musculo-skeletal health and osteoporosis, cardiovascular health, urinary infections; elderly health management, breast disease screening and management, and dermatological and cosmetic treatments. These health needs will be assessed with emphasis on the gender differences in organ systems including cardiovascular, urologic and
gastrointestinal, as well as the immune system and women’s psychology. The WHC will also promote healthy lifestyles by offering smoking cessation, weight management, exercise and fitness, and stress management services as well.
Dr. Faysal El Kak, MD and senior lecturer at FHS, believes the WHC will make AUBMC a regional trendsetter concerning women’s health. “There is going to be a lot of expectation around this center and it is very important that its vision is different from old medical models associated with disease and cure,” Kak says. “This means you are looking at a more comprehensive aspect of women’s health that requires the provision of a package of services that go well beyond treatment into prevention.”
In Kak’s view this means providing care not just for women who come to the center, but also for women who cannot—through outreach and education programs. For this reason, he sees the center as playing a major role in consciousness-raising through research, training, and education. He also stresses the need for community meetings, seminars, and even television spots on a range of women’s issues that are not only health related but also include topics such as violence, ethics, and psychosocial conditions. “This is the real expectation or the real role the center can play if it is to make a difference in the lives of the community and specifically of the women who live in the community,” Kak says.
An active proponent of outreach on women’s issues through his work with the Lebanese Family Planning Association and various NGOs, Kak insists that once the blueprint has been laid down for the Women’s Health Center, marketing will be crucial for its success. “You have this setting and then you have to go out and bring people [into the center]. You hold events, monthly events, like Mother’s Day, Aids Day, Breast Cancer Month. You create events around a theme: anti violence, birth spacing, maternity and paternity leave—there is so much one can do. This is why I think this center, being within AUBMC, is already in a place that gives it an edge in order to play an important role in the life of the woman but also to inform policy.” Professor of Clinical Medicine Dr. Ali Shamseddine, the head of the Hematology-Oncology division at AUBMC, points out that since 2000, the Ministry of Public Health, in collaboration with several institutions and NGO’s, has been promoting a program of screening and early detection each October. Shamseddine notes that, as a result of this annual campaign, the number of new cases is increasing and the incidence rate in Lebanon rose from 48/100,000 in 1998 to 71/100,000 in 2004, according to the data reported by the National Cancer Registry.
Healthy lifestyle promotion is integral to the services delivered.
The WHC will translate, disseminate, and publicize a wealth of patient education materials in Arabic to be used by NGOs advocating and implementing changes in health policies and programs. The center’s multidisciplinary research agenda will be crucial in its effort to inform policy on women’s health, including advocating for the inclusion of more women in clinical trials. Women’s health issues will be included in the undergraduate and graduate medical curricula. Students and residents will rotate through the WHC.
Kak believes that the center must carve a niche for itself as something very different—from the way it is designed, to the way it functions, to the way information is obtained and processed, and also, to how treatment is designed and administered and preventive medicine is practiced. “The woman herself has to be empowered. She has to tell me in what ways she would prefer me to deal with her,” he explains. “We have to make it an effective dialogue in order to really inform women and promote their health, so that the center fulfils its potential.”
Kronfol and the planning unit are striving to achieve these aims. From the way the waiting and consultation rooms are designed for maximum privacy to the way the center’s administration functions, “all components from medical consultancies, to testing facilities, to the support services (cashier, billing and insurance) will be integrated into the same space to make women feel protected, cared for, and valued. Once a woman enters the center she will realize that she is going to be well looked after. There is no more running from one floor to another, no more fragmentation; all her needs are here. This is a comprehensive woman-friendly space,” explains Kronfol.
This same philosophy inspires the new Mamdouha El-Sayed Bobst Breast Center, which is part of the AUBMC women’s health initiative. This diagnostic and women’s imaging center, funded by AUB alumnus and philanthropist Mamdouha Bobst, is situated in the basement within easy access from the Women’s Health Center. Planned in consultation with hospitals in the United States, the 350 square meter center is fully equipped to tackle all breast problems. Birjawi explains, “It will be a multi-disciplinary unit, so we will have the surgeon, the oncologist, and the radiologist in the same setting. We are planning on getting a breast-dedicated MRI and to have all the equipment necessary for biopsy whether under ultrasound guidance or under MRI or mammographic guidance.”
“We plan to have two sections: the main reception and waiting area with several dressing rooms, two ultrasound rooms with one or two mammography units, and a second room dedicated to biopsies or any other breast intervention. In addition there will be consulting rooms, offices, and a library for information on breast cancer.”
“In the long run, we will do the metastatic work for women like the ultrasound for the liver or intravaginal work in the same unit so the patient does not have to leave to go elsewhere. This is the whole purpose because women usually want privacy even if they are only coming for a single screening—mammogram—and the setting we are aiming for will be something peaceful, friendly, and private. Women are often tense when they come for these tests, so you don’t want to add to their stress.”
This new unit will be on a par with anything you can find outside Lebanon, the UK/US-trained Birjawi insists. “We anticipate many more patients, and women now expect to arrive, have their mammogram, and get their results on the spot. This will have to change in line with practice everywhere else in the world, where women are informed of their result later. However, for patients already diagnosed with a problem, everything they need will be handled on the spot, with everything in the same setting.”
Part of the Bobst donation is set aside for needy patients who could not otherwise afford to avail themselves of AUB’s facilities, and also for outreach programs. Several women have already benefited from this fund by coming to AUBMC for diagnosis or treatment. There will soon be a new joint program funded by the Bobst Center, in cooperation with a hospital in Tripoli. As soon as the logistics are worked out, the Bobst Breast Center hopes to launch an effective outreach program for the rest of Lebanon as well.
What Birjawi is now anxious to achieve is earlier recognition of breast cancer among Lebanese women. What the causes are and how to prevent breast cancer will take time to discover, but until that time, Birjawi would urge all women to adopt regular screening practice with their yearly mammogram. The new center will certainly help facilitate this program.
What’s best for my bones?
What is osteoporosis?
Osteoporosis is a disease in which bones become fragile and more likely to break. If not prevented or if left untreated, osteoporosis can progress painlessly until a bone breaks.
How common is it?
It affects one out of three women and one out of five men by old age.
If my back hurts or my bones or joints ache, is that a sign that I have osteoporosis?
Not necessarily. Joint aches are due to arthritis, whereas diffuse bony pains may be due to low vitamin D levels.
Why do some people get osteoporosis?
There is no single cause. Seventy to eighty percent of an individual’s bone mineral density is genetically determined. The rest is explained by lifestyle factors.
When should I get my bone density tested?
If you are a woman, at least 65 years old, have a vertebral deformity or fragility fracture, and/or have a medical condition known to cause bone loss, you should get tested.
My mother has osteoporosis, but I am premenopausal. Should I have a bone density test?
Healthy normal cycling premenopausal women should not have a bone density test.
What can I do to protect my children’s bones?
Encourage them to eat a healthy diet rich in calcium and vitamin D, to exercise, and to avoid smoking, excess alcohol, and consumption of carbonated beverages.
How much calcium should I take?
Calcium requirements vary during an individual’s lifetime, but there is greater need for calcium in childhood, adolescence, during pregnancy and lactation, and in later adult life. (See complete table on-line.)
What is a good calcium preparation?
In choosing a calcium supplement, look for labels that identify the product as “purified” or have the USP (United States Pharmacopeia) symbol. Avoid calcium from unrefined oyster shell, bone meal, or dolomite without the USP symbol as these historically have contained higher lead levels or other toxic metals.
When and how should I take calcium?
Calcium, whether as part of a healthy diet or in the form of supplements, is absorbed best by the body when it is taken several times a day. Calcium carbonate is absorbed best when taken with food. Calcium citrate can be taken any time.
Does coffee interfere with calcium absorption?
The amount of caffeine in a cup of coffee can reduce calcium absorption by a few milligrams, but that loss can be easily offset by adding a tablespoon or two of milk.
What kind of exercise is best for my bones?
Weight-bearing and resistance exercises are most effective in building and maintaining bone mass and density.
What builds bone back to normal?
Most drug therapies maintain or moderately increase bone mass by 3-8 percent. For additional information regarding medication check the Food and Drug Administration website: http://www.fda.gov/cder/guidance/1449fnl.pdf
—Dr. Ghada El-Hajj Fuleihan, MPH
Dr. El-Hajj Fuleihan (MD ’83) is professor of medicine
and director of the Calcium Metabolism and Osteoporosis Program
at the American University of Beirut Medical Center.