Role Model

by JHI Staff on June 12, 2012

About a week ago, I read of a ceremony in Abu Dhabi that was held to recognize a group of extraordinary women for their achievements and contributions to various public and private enterprises across the UAE. Among the many other prominent recipients of the Emirates Women Award was Taif Sabah Al Sarraj, Ph.D., L.D., chief of clinical support services at Tawam Hospital in Al Ain, one of our international partners.

We are proud that our affiliates around the world and their staff members win a large number of awards and recognitions every year. But Dr. Al Sarraj’s award is especially significant.

Let me explain. In the United States, over the past four decades, we have come to take for granted that women can reach positions of great responsibility as high-achieving organizational leaders. But in some countries and regions, few women aspire to high achievement in the workplace, or they are impeded by deep-rooted cultural norms. But Dr. Al Sarraj has broken through boundaries and stereotypes.

A mother of three, she manages a staff of 500 at one of the busiest hospitals in her country. As she noted in a recent newspaper interview, combining two roles is not a small task.

“It requires years of hard work, and women are not like men. We multitask. It’s not just the business we look into, but also raising a family that is equally important to us … This is the first time I applied to the EWA. It feels wonderful because this means a lot to me as a woman. Men have one role — that is to achieve in business. But women juggle so many roles,” she added. Al Sarraj said that as compared to a few years ago, Emirati women have come very far. “We can still do with more women in the medical profession. Most of them shy away from this field due to the strenuous work timings.” (From Khaleej Times)

In many countries, health care has long been a pioneer in providing excellent employment opportunities for women, along with a full measure of the respect and status that comes with a valued career. What is truly wonderful is to watch that global range expand, with more and more women bringing their expertise to our field as nurses, physicians, administrators, and leaders of health care institutions.

I’d like to use one example here. In most countries, skilled nurses are always in demand, and, for various historical or cultural reasons, most nurses are women. But in some regions, nursing carries a lower status than it does here in the United States. At Hopkins, our nurses are a valued and integral part of the clinical-care team. They closely advise in treatment plans, and can move up the ladder of experience and responsibility into positions of senior leadership.

But that’s still not true everywhere, and this can create a sticky situation for us at Johns Hopkins Medicine in our international collaborative work. At Hopkins, we cherish diversity and understand the business value of bringing together people of varying backgrounds and perspectives. But when we’re operating in other countries, we are determined to respect cultural differences rather than pass judgment on them.

Our partners are our esteemed colleagues. We’re all committed to improving health care delivery through collaboration. But that doesn’t mean we can’t make a difference. We can nudge, where appropriate, and we can try to lead by example. What’s more, when patient care and outcomes are at stake, we don’t compromise. That gives us a different reason to ask for change, one that our partners don’t mind hearing.

One of the changes we often seek is to elevate the status of nurses within the hospital’s culture. Our affiliates invariably have responded positively to that mandate. The result is the significant empowerment of nurses — and of many other women in the region who aspire to health care careers. Many of these nurses become senior leaders in their hospitals, and are widely respected and admired in those roles.

And that goes for health care professionals like Dr. Al Sarraj, and our administrators, too. It is neither our role nor our mandate to attempt to change cultures that differ from ours. However, it is one of our core principles to improve the delivery of health care in our own nation and throughout the world. To do this, you need great people. As much as possible, we provide opportunities for women to gain the skills and mentoring necessary to step into these roles, and to go as high up the career ladder as they would like to go.

The result is improved health care and teams of dedicated people getting the job done better than it was being done before. Today, in countries where one rarely sees women in positions of influence, we can point to many successful women at our affiliates. And as our affiliates become more involved in providing or supporting education and training programs for nurses, physicians and others—as many of our partners do—we’re seeing even more women entering the health care field, destined and determined to reach impressive heights.

As other women in the communities around these hospitals see these women achieve positions of responsibility, they too can end up feeling empowered and inspired to pursue career achievement.

I won’t claim that we are the only agents of change in these regions. But by helping to present positive role models, maybe we’re making a small contribution to the process.

So congratulations, Dr. Al Sarraj! Johns Hopkins Medicine is proud to have you as a colleague.

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Collaborative workspaceI happened to see this recent New York Times article about offices arranged as open workspaces. A main point of the article is that these sorts of workplace layouts tend to be noisier and distracting, leaving some companies struggling to find ways to give employees a little peace and quiet.

One of the reasons the article caught my interest is that we’ve recently moved into new offices here in Baltimore, and, unlike our previous space, this one features an open layout. We do have a number of meeting rooms of all sizes that anyone can commandeer for planned meetings, so as to avoid needlessly disturbing others. But other than those meeting rooms, everyone, including me, is working right out there in the open in low-slung cubicles—no high-walled, sound-trapping dividers here. What’s more, the layout is such that in order to get to anything in the office—the coffee machine, copiers, bathrooms, elevators—you have to walk past any number of colleagues. Everybody sees everybody else 20 times a day.

At first it was almost uncomfortably quiet, with people speaking in hushed voices, or avoiding speaking at all, out of fear of bothering others. But as we got used to it, it’s gotten moderately noisy. We all experience more interruptions, too—it’s never long before someone pokes his or her head up to ask a question of someone 15 feet away. And you always get grabbed by one of those dozens of people you walk past on the way to the coffee machine. We all do our share of grabbing others, too, even though we know they’re probably focusing on something they need to get done. And when two people start up a conversation across cubicles—in spite of the availability of the meeting rooms, most conversations are still spontaneous and out in the open—others will typically turn away from their work for a minute to join in. All in all, the environment here is starting to remind me of a Panera Bread restaurant near my home, which always seems jammed with laptop warriors noisily comparing notes with their fellow coffee drinkers and snackers.

And that, of course, is exactly what I hoped would happen. Open spaces, at least for us, aren’t about a way to cram more people in at lower cost. (We’re all pretty comfortably arranged, actually—though at the rate we’re growing, who knows how long that will last.) It’s about facilitating and even prompting collaboration.

Everyone says they want collaborative environments. But when they actually get placed in one, they sometimes discover to their dismay that there are some real costs to collaboration. In the case of open-space offices, one of those costs is that it can get noisy and distracting. There are times you just want bear down on something you’ve got to get done, and these sorts of offices aren’t always ideal for that. Some people may find it’s taking longer to get some important tasks done.

But I think, on balance, that it’s a small price to pay for the benefit that increased collaboration brings. The most creative ideas, the solutions to the biggest challenges, the thinking that really moves needles, are rarely the product of individual efforts. It comes from many people putting their heads together. People with complimentary skill sets and varying work styles and unique ways of looking at the world. People who may often find their collaborative partners frustrating, but who stick with it and find innovative ways to get to common ground.

Part of the reason that I’m a big believer in the advantages of collaboration, in spite of the potential drawbacks, is that Johns Hopkins Medicine has long prided itself on its deeply collaborative culture. I myself have always leaned heavily on my colleagues here to help me solve problems. I know from plenty of first-hand experience that good ideas and decisions don’t generally spring out of my lone ruminations, or those of any other one person.

But there’s another, possibly more important reason I put collaboration over efficiency and focus. Namely, I constantly see the value of collaboration playing out in the very core of our work in partnering on health care infrastructure projects in other countries. When we started doing this well over a decade ago, we thought Hopkins would be jumping in to other countries to tell them how to build great health care facilities. Some of those efforts didn’t go well. As we frequently find ourselves saying, what works well in Baltimore doesn’t necessarily work somewhere else in the world. We discovered that building great health care facilities requires intense, give-and-take collaboration with local partners.

To try to achieve that level of collaboration, we don’t just hole up in Baltimore and then occasionally parachute in to check on progress. We do a lot of traveling, and many of us spend consecutive weeks, months and even years abroad. And our overseas partners send any number of their people to Baltimore frequently, and sometimes for very long stays.

Is that the most efficient way to do things? Probably not. Does all that travel make it harder to focus on getting certain things done? Sometimes. Is it a “distracting” and “noisy” way to work? Sure. But the innovative, effective, durable and most of all collaborative solutions that come out of pushing ourselves and our partners to share environments are simply invaluable. We plan on sticking with our noisy way of working. We think it’s one key to our—and our partners'— successes.

I'd say more about it, but I’m in Istanbul right now, and have to run to a meeting with our partners.

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I have an article just out in the June issue of the Harvard Business Review. (Non-subscribers have to register to read the whole thing, but registering is free.) The article is about some of the challenges we at Johns Hopkins Medicine have faced in partnering in developing markets. As I put it in the article:

Having worked for 15 years on projects ranging from clinics to hospitals to major medical education and research centers in more than a dozen countries, including Chile, Lebanon, Panama, Singapore, and Turkey, we’ve seen several efforts run off the rails, or nearly do so, for many reasons. We’ve emerged from these early missteps and challenges with a highly flexible model for collaboration that has led to significant successes and enabled us to grow our business at a rate far beyond that of the any other U.S. academic health care center.

Among the questions I deal with, at least briefly, in the piece: How do you help these hospitals acquire expertise normally acquired in the U.S. from a network of academic institutions? How do you establish the culture needed to nurture and maintain that expertise and put it to best use? How do you adapt the expertise to meet the unique limitations, strengths, traditions and needs of a region? How do you pull enough top U.S. professionals out of their intense career routines for the months or even years required to carry out a big project? How do you forge buy-in to these massive, ambitious projects from groups ranging from governments to the World Bank to investment banks?

These are the challenges we take on every day here, and let me hasten to add that, as I emphasize in the article, I can’t think of a more worthwhile thing to do. We here all consider ourselves privileged to work with our partners, and each and every one of our affiliate facilities around the world is a great achievement for everyone involved, and we couldn’t be prouder to be associated with them. The fact that it’s often tricky to get from those initial conversations with a potential partner all the way to a world-class clinic or hospital or even full-fledged medical campus in a region that hasn't previously seen the likes of it doesn’t take away from that achievement; it adds to it.

One point I wish I had been able to elaborate on in the article a bit—space is always tight in a magazine of the Harvard Business Review’s caliber—is that our partnerships aren’t just about everything we at Hopkins can do for our partners. These are true collaborations, and what we bring to the party is just one component of what goes into making these facilities work. We don’t just contribute to these partnerships; we learn a lot from them, too. That's something I’ll be writing about in a future post.

Speaking of collaboration, one thing that really struck me about the process of writing for the Review is how intensely collaborative the process is. I wouldn’t pretend that I’m a capable enough writer and thinker to expect to be able to just sit down and spit out an article that meets the standards of a publication like that. Still, I was surprised—as apparently most who write for the Review are—at how much work the editors put into these articles, and how much they ask for from the writers as an article goes through many drafts. As someone who runs a fairly substantial organization, I’m all too aware that my thinking is not often subjected to the sort of hard-nosed, highly critical examination that really makes you question your premises and step outside your comfort zone. I certainly invite people here to run me through the ringer that way, and sincerely wish it would happen more often. But realistically, how many people are going to do that to their bosses?

The Review editors had no such qualms, to their credit. They’re advocating for their readers, not protecting my feelings and interests. I don’t mean they were nasty—far from it. But they’re demanding and very smart. As a result, the version of the article that ultimately ran is much harder-edged and unflinching than what I originally turned in. I have to admit to feeling a little queasy about the article pointing out some of the difficulties and shortcomings we’ve encountered in such sharp terms—referring, for example, to these sorts of problems as “nightmares.” But the editors had every right to push me that way. The fact that we normally prefer to emphasize our partners’ strengths and contributions doesn’t necessarily make for as useful an article, from the point of view of a reader who wants to know how to avoid and deal with the challenges her organization might face someday in working with overseas partners.

So, my thanks to the editors for pushing me. And my deep assurances that, as I say in the article, none of these challenges takes away from the fact that we work with terrific partners on truly impressive projects that end up having large, positive, enduring impacts. The “nightmares,” in contrast, are relatively few and fleeting, as nightmares tend to be.

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A Belated Leap to a New Medium

by JHI Staff on May 22, 2012

I'm about to start tweeting. (You can follow me @JHISteve.) It's hard to claim that my finally joining into a major phenomenon that has been in full swing for several years, and that has become one of the most important communication channels in contemporary life, is big news. In fact, I don't think anyone these days needs to explain why they're on Twitter. But what may be worth my briefly commenting on is why I've put it off so long.

I'm of course proud of being a global representative of a 135-year-old brand, one of the most respected in all of medicine and health care, and one with a mission that everyone here is passionate about. (For the record, the official version of the Johns Hopkins Medicine mission is to "improve the health of the community and the world by setting the standard of excellence in medical education, research and clinical care.") It has long seemed to me that the practice of frequently tossing out short, off-the-cuff messages that can instantly end up on the smartphones and computer screens of anyone anywhere is not entirely friendly to my fear of doing anything that might in the slightest tarnish Hopkins' image, or interfere in any way with its mission.

But I've come around to the point of view that this is one of those cases where staying quiet can be more damaging than risking saying the wrong thing. Not being of the generation brought up on this stuff, it's taken me a while to fully realize that people look to trusted names to keep them posted on what's going on and to make clear their viewpoints and directions, and to do it on a day-to-day basis. In a way, to neglect to do so is in itself sending a message--that we don't care what you think, or that we don't want to be transparent, or we just don't have anything interesting going on. None of that could be further from the truth.

So I'll be tweeting. And looking forward to any and all feedback, suggestions and viewpoints.

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Plan B from Istanbul

by JHI Staff on May 21, 2012

Anadolu Medical Center in Istanbul, TurkeyAll countries have their unique qualities, and any one place might seem wonderful to some and a great deal less so to others. But it's my guess that most people who have had a chance to spend some time in Turkey would agree with me when I say that it really is a special place. Take Istanbul, perhaps the only city in the world that neatly straddles two continents. And not only geographically—Istanbul's personality is clearly forged from both its European and Asian ties. That mix comes out in everything from the food to the politics to the language to the personalities of people you meet. (Turkey was long considered a candidate for admission to the European Union, but wasn't admitted—and now can appreciate the fact that its economy is relatively booming, unshadowed by the deep problems of the EU.)

Johns Hopkins Medicine has strong ties to Istanbul through its affiliate there, Anadolu Medical Center. Anadolu, too, is unique, even by Istanbul's standards. Most health care in Turkey comes through the government, though there is an increasing presence of private sector hospitals and clinics. But Anadolu, funded by a large foundation, is relatively special in being a non-government, not-for-profit institution, in some ways resembling a U.S. academic medical center. The academic part is a work in progress, but the hospital offers much the same sort of leading-edge facilities and expertise you'd find at many U.S. medical centers. That includes two linear accelerators for nuclear medicine, robotic surgery equipment and cutting-edge imaging capabilities, with the professional staff to match. All of that has helped Anadolu establish a top-notch reputation in areas including oncology and cardiac surgery; in addition, it will soon have an organ-transplant program.

There has never really been anything like it anywhere in the region. As a result, Anadolu attracts patients from Eastern Europe, Russia and the Middle East. Many of them are affluent, and can afford the costs of travel and of non-government-subsidized health care. Other, less-affluent patients have made considerable sacrifices to receive a higher level of care and a better chance of good outcomes for themselves and their loved ones.

Some might say these traveler-patients are part of the "medical tourism" movement. If you've been reading my blog, you know how I feel about that term. I don't like it because it blurs the distinction between two very different groups of patients: Those who shop internationally for a "good deal" in medical treatment, and who may even apply the savings to actual tourism; and those who travel because they want or need access to higher quality or more immediate care, or services that may not be available at all in their own regions. Though most of the hype you read about medical tourism applies to the former group, I think that group is actually a much smaller one than it's made out to be—but more on that in another post.

The point I want to make here is one that was driven home to me recently in a conversation with Bob Kiely, the head of Anadolu Medical Center, who came to the job last year after a long and much-celebrated career in U.S. hospitals. Bob's not a physician, but he told me that he goes on rounds there every single day, just to visit with patients and families and see what's going on in the very front lines. Each day, he makes a point of stopping by the pediatric ward and visiting some of several dozen Iraqi children who are there at any given time, having been brought to Turkey for complex treatments they couldn't have gotten back home—typically cardiac surgery, sometimes performed at Anadolu on infants as young as six weeks old.

You might think that a group of sick children makes for a heartbreaking scene, but Bob says it's actually a lot of big smiles around there. The smiles are from mothers who are finally seeing their children on the road to recovery, staff who are happy to be making a difference and kids who are, well, just being kids. For Bob—and for me, too—it's a great reminder about why we do what we do, wherever it is in the world we're doing it.

Call these kids medical tourists, if you want. As far as I'm concerned, they're patients who need and deserve good care. Ideally, these patients could get that care down the block or across the city. But this is the best option they have right now, given that the people of Iraq are working to rebuild their country. While that work progresses, the staff of the Anadolu Medical Center are doing an amazing job caring for these patients and their families. I'm so proud that Hopkins and its affiliates can help provide a Plan B.

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Recently, two of Johns Hopkins Medicine's international affiliate hospitals were named to HealthExecNews' list of "The 25 Most Beautiful Hospitals in the World." One is Hospital Punta Pacífica, in Panama City, and the other is Clemenceau Medical Center in Beirut.

I found myself having several different reactions to the news in the space of about 15 seconds. My first reaction, of course, was: Great! It's always nice to be recognized, and have a little extra positive attention called to some of the facilities that we're so very proud of. Whenever I see a health care-related "best of" list, I can't help scanning for our name, and feeling a little thrill when I spot it, or a bit disappointed when I don't, and this was no exception.

My second reaction was: Wait a minute, these are hospitals. Do we really want to be known for the pretty faces we help put on many of them? Don't we want to emphasize quality of care, outcomes, patient satisfaction?

And then, finally, I was able to reconcile those two initial reactions. First of all, on a more careful reading of the article, it's clear that it takes pains to point out that the question of the physical appearance of a health care facility isn't divorced from questions of health. As the article puts it:

The elements in today’s best designs have been proven to improve patient care...In developing this list of The 25 Most Beautiful Hospitals in the World, we considered interior and exterior features and their health-promoting qualities.

That is, it's not just about being prettier—it’s about having facilities whose designs can contribute to patient well-being. Thus the article notes that Punta Pacífica's rooms have been "specially designed to promote and enhance rapid recovery." And that Clemenceau provides patients with in-room Internet access, and that

the interior design also allows [clinical staff] to use innovative medical equipment like completely film-less digital imaging centers and real-time video conferencing equipment to connect with other physicians and specialists inside or outside of [the medical center].

Obviously, though the headline and the list name refer to "beauty," the list seems to really be about the sort of comfort, convenience, and access to better care that well-designed facilities can provide.

We're big believers here that there's a lot more to the patient experience than simply what tests and treatments the patient gets. Healing also has a lot to do with attitude, mood and emotion. And while patient outcome is surely a critical metric of the hospital experience, helping a patient to feel comfortable and well-taken-of along the way really does matter. Many patients, after all, are admitted into hospitals with what turn out to be relatively minor ailments—a bad case of gas whose symptoms required ruling out a cardiac event, or a sudden loss of vision that was merely a quickly passing migraine. If the patient is stuck in a cheerless, unfriendly hospital environment that inflicts all sorts of inconveniences on him or her for a few days, then that will turn out be a more unpleasant aspect of the whole event than the actual physical problem. If the medical problem is a more serious one, the last thing the patient—or the patient's family—needs is the additional tribulation of a harsh environment.

That's why Johns Hopkins puts a lot of care and resources into making its hospitals here, in and around Baltimore, places that can provide a boost to the mood of patients who may be coping with a stressful time. Our newly opened clinical facilities are loaded with artwork, and with spaces for relaxation, play and pleasant distraction. The all-private rooms are more like hotel rooms than hospital rooms, though they and all the facilities are absolutely start-of-the-art from a medical point of view. And we feel the same way about our international affiliates, supporting them in every way we can to provide the best possible patient experience—first and foremost medically, of course, but also in terms of the overall environment.

So sure, why shouldn't I be proud of seeing some of our affiliate facilities make that "most beautiful" list? What could be better than having a patient feel that his or her experience at a hospital had an aspect of beauty to it? Patients deserve all the help they can get.

Anyway, it's not as if we don't get recognition for the other side. We're proud around here that our main hospital has been named the best hospital in the U.S. by U.S. News & World Report year after year. Our affiliates around the world win all sorts of regional health care awards as well.

So don't hate us because we're pretty. We seem to be doing a fine job at taking care of patients in every way that it's measured.

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Health Care’s Foreign Invitation

by JHI Staff on May 7, 2012

An interesting article entitled "Health Care’s Foreign Invasion" by Dr. Kate Tulenko ran at Salon recently. (It's adapted from her new book.) A brief excerpt:

Approximately 15 percent of all health care workers and 25 percent of all physicians in the United States were born and educated elsewhere. This means that 1.5 million health care jobs are “insourced,” occupied by foreign-born, foreign-trained workers brought into the United States on special visas earmarked for health care jobs. This number is 50 percent greater than the total number of jobs in the U.S. auto-manufacturing industry.

Tulenko sees this situation as deplorable, and in exploring its causes largely focuses on the demand side of the situation. In essence, she argues that American society blocks most would-be home-grown health care workers from the industry by making training too competitive and costly; that the health care industry takes advantage of the fact that foreign health care workers accept lower wages and worse working conditions; and that, in failing to restrict their immigration, Congress and the president are falling down on the job.

But let's look at the supply side here—that is, the question of where these foreign-trained workers are coming from, and why they'd want to come here. They're coming from less-developed countries where decent jobs are hard to find, and good jobs are nearly impossible to find. Getting trained for health care jobs—typically nursing—is one way out. But those better-paying nursing jobs aren't in their own countries, they're here and in other more-affluent nations. Why? Well, yes, part of the reason is that there's a shortage of health care workers here. But perhaps a more important reason is that there is a lack of good health care infrastructure in their own countries. They don't by and large come here only because they admire our way of life, they come here because we have lots of good hospitals and other care facilities in which they can effectively use their skills, and their countries don't. Tulenko points out some of these disparities herself:

The WHO Global Health Workforce Alliance estimates that there are a billion people alive today who will never see a health worker in their lives. In Ethiopia, one in 10 Ethiopian children will die before his or her fifth birthday—yet there are more Ethiopian physicians in the Chicago area than in all of Ethiopia, which, with 80 million people, is the second most populous country in Africa. As their most skilled nurses emigrate to work in U.S. nursing homes, middle-income countries such as Jamaica and Trinidad have nurse-vacancy rates of 60 percent or higher.

We could enact protectionist legislation to bar health care workers who come to the U.S., as the article seems to vaguely recommend. But here's another suggestion: Why don't we work with these countries to help them build the sorts of health care infrastructure that would provide good jobs, eliminating the main reasons for their looking to other countries for employment? We've seen that happen again and again in the countries in which Johns Hopkins has worked with local entities on health care capacity-building projects—including in Trinidad and Tobago, one of the countries Tulenko singles out. The emergence of quality medical facilities even spurs people to return to their home countries. When we helped build a leading-edge medical facility in Beirut, Lebanese health care workers who had moved to other countries came streaming back in to take jobs there.

And, though it may seem counterintuitive, helping other countries build better health-care-related educational institutions, whether it's schools of nursing, medicine or pharmacy, would also be a double win. Right now people in these countries who want good health care training often have to go to other countries to get it—and once they leave and are trained elsewhere, they're much less likely to end up in their home country than if they had been trained at home in the first place. We expect to see exactly that happen as a result of the campus we're helping to build in Malaysia.

And here's the kicker: When developing countries build better hospitals, they often find that the local oversupply of health care workers suddenly becomes a shortage of well-trained and experienced doctors, nurses, administrators, pharmacists and others. And guess what country they often turn to in order to import that talent? That's right, the U.S. For years, we at Johns Hopkins have been finding terrific jobs overseas for U.S. health care workers in the hospitals we work with in other countries. Wouldn't it be nice if instead of having to import health care workers, we became an exporter?

I'm all for training more health care workers in the U.S. for our own needs, as Tulenko urges. But I'd also emphasize looking at how to help those elsewhere in the world in ways that pay off for us, too.

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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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Clarifying medical tourism

by JHI Staff on April 23, 2012

Here’s an article of mine recently published in The Chicago Tribune. It takes on the hype about “medical tourism”—a subject we keep hearing all kinds of claims and comments about, but that is really an imprecise, murky idea. It’s also a phenomenon I would argue isn’t nearly as big a deal as many make it out to be, at least in terms of what most people think of as medical tourism. Well, don’t get me started on that now, I intend to write a post about that a bit further down the road.

In any case—and as I elaborate on in the Tribune article—I sometimes fear the hype about medical tourism will be confused with, or even worse taint, the sort of thing we do at Johns Hopkins Medicine International. We’re not about zipping people around the planet to find a better deal in an elective procedure. We believe everyone deserves local access to the best possible care. Sure, when that care isn’t available locally, it makes sense to bring the patient to where it is, which is why many patients from around the U.S. and world come to our Baltimore campus. But what we most stand for is helping different countries build the health care systems they need so that fewer patients have to travel. But as I say, more on “medical tourism” later.

For now, check out my piece featured in The Chicago Tribune.

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From Baltimore to Beijing – welcome to my blog!

by JHI Staff on April 5, 2012

So I'm finally getting around to starting a blog, and here's my first post. As much as I'd like to mark this momentous occasion with an astoundingly informative insight into the world of global health care, I probably should just use this post to introduce myself, and say something about what the blog is likely to be about. Though I have a feeling that this blog, probably like most, might in some ways end up being about different things than originally intended.

I'm the CEO of Johns Hopkins Medicine International (JHI), a group attached to Johns Hopkins Medicine that collaborates with partners in other countries on health-care projects. (You can read about JHI here, and learn more about me and my background here.) I won't be the only person posting to this blog, thanks to the fact that I'm lucky enough to be surrounded by colleagues here and at affiliates who are amazingly insightful on a routine basis. So I think one of the best things I can do with this blog is occasionally step aside and let one of those folks have a say.

Not that there aren't plenty of things I'd like to talk about. I'm obviously biased, but I happen to think that the effort to improve health care on an international basis is one of the most exciting things going on in the world today. It's a huge and enormously challenging undertaking, and getting more so all the time. Working with partners in other countries to build hospitals and other health-care infrastructure brings up all kinds of interesting questions about culture, tradition, the goals of health care, the role of academic research, the best means for training and supporting doctors, nurses and other providers, the quality and safety of patient care, the relevance of U.S. health-care models, best practices, preventive medicine, paying for health care, outreach efforts, the role of government, the nature of collaboration, how social change affects health care, and much, much more.

To make it even more interesting, the answers to these questions vary tremendously country to country, and even within countries region to region, city to city and neighborhood to neighborhood. Sometimes it feels like we at JHI and our partners overseas are reinventing some basic aspects of health care with every project. That can be a good thing, of course, given that pretty much everyone agrees health care is far from perfect here in the U.S. or in any country, and is crying out for innovation at all levels. But constant reinvention can also be demanding and even frustrating. We have basic approaches and systems that can serve as starting points, of course, but we don't have the perfect, universal formula for creating health-care infrastructure, and we're pretty sure there's no such thing.

I suppose that's enough for now.  The momentous insights are to come. (Well, at least mildly interesting insights, I hope. Maybe my colleagues will be able to deliver on something closer to momentous.) And I might as well warn you that as obsessed as I am with global health care, I'm likely to stray off topic once in a while, just because I can. Hey, it's a blog, not a medical journal.

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