Can one van improve a population’s health?

by JHI Staff on April 25, 2012

We don't talk about "bottom line" here at Johns Hopkins Medicine International as much as we do about "mission." In a nutshell, the mission is to improve health and health care around the world. One main way we do that is by creating global collaborations to help build and manage new and better hospitals, medical centers, clinics and other health care infrastructure. But we also sometimes take a step back and ask what else we can do. After all, what happens outside of hospitals can have a bigger influence on health than what goes on inside them.

The truth of that last statement was hit home to us in working with Tawam Hospital in Abu Dhabi in the United Arab Emirates (UAE). We manage Tawam, which is a public hospital overseen by SEHA, Abu Dhabi's government health care agency. Tawam has come to offer outstanding cancer care in recent years. But by 2008 it had become clear to everyone involved that for all Tawam could do to treat breast cancer patients at the hospital, many women were simply showing up far too late. Dr. Muhammad Chaudhry, a Johns Hopkins radiologist who now directs a Hopkins-affiliated imaging center on the hospital campus, told me he routinely sees women in their early 20s who have stage IV breast cancer—the later stages, where treatment is much more aggressive and the prognosis isn't as good.

That's relatively unusual in the U.S. and other highly industrialized countries, where breast cancer is more commonly caught in the early stages and is much more easily treatable. In fact, 90 percent of the new breast cancer cases at Tawam involve advanced stage cancer. Almost a third of female deaths in the UAE are due to breast cancer. About 45 percent of the women diagnosed with breast cancer in the UAE die from it. In contrast, in the U.S., women diagnosed with early stage breast cancer have around a 90 percent survival rate.

There may be genetic and lifestyle differences between the UAE and many industrialized countries that can partly account for this shocking gap in survival. But I think pretty much everyone agrees that by far the main reason is that women in the UAE weren't getting routine screening—breast self-exam, physician exams, and, especially important for middle-aged and older women, mammography or other imaging. Dr. Chaudhry told me that the profile of the disease in the UAE is pretty similar to what it was in the U.S. in the 1960s, before the U.S. instituted modern screening routines and techniques.

Clearly, one way we could have a huge impact on health in the UAE was to increase the rate of screening. But while Tawam and several other hospitals in cities in the UAE offer free breast cancer screenings, women weren't showing up for them. No wonder: it's a fairly big country, with vast rural areas that can be hundreds of miles from the nearest screening facility. To exacerbate the problem, there was a profound lack of information in the population about the importance of screening. And to make things even more challenging, there are strong cultural beliefs in the UAE that, for many women there, would make the idea of baring a breast to a doctor—especially a male one—extremely aversive.

To tackle all of these problems at once, in 2008 Tawam set up a mobile mammography van in order to directly bring to more rural areas both the word about the need for screening and the means for getting it done—and in a way that would be as culturally sensitive as possible. Accompanied by fanfare in the press and other publicity, and staffed entirely with female care-providers and technicians who were understanding of the reluctance women had about the procedure, the van saw some 200 women that year. Sometimes 20 women came into the van in a day, more than the number of daily screenings done at the time at Tawam itself. Last year, more than 2000 women were screened—sometimes more than 600 in a single month. There are plans to put together a small fleet of vans, in the hopes of reaching tens of thousands of women each year.

Is this modest program putting a huge dent in breast cancer in UAE? Maybe not, not yet. Of course, every life saved and difficult treatment avoided is a very good thing, and everyone at Tawam and here at Hopkins is proud of that. But, in long run, we believe the real impact will be in helping to bootstrap public awareness. Every article written about the program, every woman who tells family members, neighbors and friends, every other health care provider or system that is influenced to increase its own efforts, adds to the momentum. It's hard to say when we'll reach a tipping point in the effort that will see screening becoming almost as routine as it is in the U.S., but I have confidence it will happen eventually. Major health initiatives have to start somewhere, and in the UAE, at least, that van seems like a pretty good start. And a good reminder to us that health care is not always about hospitals.

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Comments

EC April 26, 2012 at 10:45 pm

Another great article! It's tough to break cultural beliefs but van is definitely a good start.

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