Oum El Nour

We have been driving for over an hour. After battling our way through Beirut’s morning traffic, we slowly wind our way into the surrounding mountains. Hidden deep within (but yet managing to overlook the Mediterranean) is the Oum El Nour center. “No pictures of the building” I am quickly told when I pull out my digital camera. This, of course, is to protect patient privacy.

Although there are few recent studies in Lebanon, the WHO estimates a prevalence of approximately 0.2% for opiate abuse, 0.1% for cocaine abuse and 2.5% for alcohol abuse [1]. Oum El Nour (which means Mother of Light in Arabic) is one of a few inpatient rehabilitation facilities in the country.

We arrive with our AUB contact and are promptly introduced to one of the directors. As usual, we are stunned by how friendly and open everyone is towards a group of random American strangers. Average stays range from 15 to 18 months here and both men and women are offered care free of charge. The center is partly funded by the Lebanese Ministry of Health but also relies heavily on private benefactors.

The men’s center is home to 60 men, most of them polysubstance abusers including IV heroin. Patients are initially evaluated by a GP on admission and tested for HIV and hepatitis. If necessary, they are referred to outpatient psychiatrists in addition to seeing the therapists and counselors at the center. The use of methadone or buprenorphine is not legal in Lebanon and instead a strict abstinence policy is implemented.

“The difference in Lebanon,” the director explains, “is the presence of family as an integral part of the rehabilitation process.” The addict here is rarely homeless and usually lives within a busy household. “But what about the few who are homeless?” I ask, recalling the patients with substance abuse that I’ve treated over the last few years. To this I am met with largely blank stares and, after a somewhat prolonged pause, our friend from AUB answers, “it is very very rare. We may live within a tent, but we do so with our family”.

After detox and an initial isolation phase, relatives are brought in quickly and considerable time is spent with therapists working on family relations. The director believes this emphasis accounts for the extremely high rate of program completion (45%). Although long-term success rates are unknown, the AUB school of public health is busy collecting this data. In the meantime, patients are happy to receive another chance within the peaceful confines of Oum El Nour.

[1] http://www.emro.who.int/mnh/drugs_countryprofiles_leb.htm

Jordan!

We spent the weekend on a short trip to Petra, the site of an ancient Nabatean city a few hours south of Amman. We had originally hoped to drive to Jordan, making our way through Syria, but obtaining entry visas remains a challenge for US passport holders. We instead flew into Amman. Enjoy the photos. The last one is of the Roman Theater in Amman.

The Bedouin Health Project

Dumou', 16, is engaged to a distant cousin of hers. Fully veiled, she welcomes us with a shy smile into the small, decrepit apartment she shares with her father, his two wives, and their ten children. With all the mannerisms of a young teenager, she giggles when a sensitive subject is broached and glows when she realizes she is being addressed as an adult, before carefully volunteering her opinion on anything from women's health and pregnancy to domestic violence and early marriage.

Manal, in her 30s, has already taken her youngest daughter, born with a congenital retinopathy, to see several of the leading ophthalmologists in the region. Her son, who walks into the large and newly renovated family home sporting his newest jeans, is getting ready to go to college, which will give Manal more time to dedicate to the women's organization she helped found. Wearing sports gear, she effusively discusses the problems of access to healthcare as she describes the many medical conditions--high blood pressure, diabetes, heart failure--that her acquaintances suffer from, before reminding us that she has completed First Aid training and has been to visit many health professionals in different parts of the country. As we get ready to leave, she too, as Dumou' had done earlier, rushes to offer us food and drinks--although instead of Pepsi and chocolate wafers, she brings us tea and coffee in Chinaware along with home baked goods made with coconut.

These two women are Bedouins living in Lebanon. Both were selected by the Bedouin leaders as potential candidates to be Community Health Volunteers (CHV), as part of the Bedouin Health Project spearheaded by researchers at AUB's Faculty of Health Sciences in collaboration with the Ford Foundation and Oxford University. Between 50,000 and 75,000 Bedouins live in Lebanon, the majority of whom migrated from the Golan Heights after losing access to pastoral lands following the 1967 Six Day War. Today, most have settled in the fertile Beqa’a Valley. Those who are not Lebanese citizens have to buy private insurance or pay out-of-pocket for any healthcare expenditure they incur. The problem is not access to healthcare per se: Bedouins do seek medical care, particularly when dealing with pregnancy; however, they are overall reluctant to do so as their care is hindered by discriminatory practices on the part of providers and cultural norms that limit the women's comfort level while interacting with physicians. Surveys conducted by AUB additionally suggest that there is also an "overmedicalization" of health services with little or no focus on preventative care.

In an effort to minimize some of these barriers, the Bedouin Health Project is training CHVs to work as facilitators and mediators between the Bedouin women and the primary care centers in the Beqa'a region. Additionally, these women will receive training in children's and women's health in the hopes that they may serve as resources for the local communities when and where more specialized care is not available. The project is also involved in building local providers' cultural competency toward Bedouin attitudes and practices. While fraught with obstacles--most of the women selected by the tribe leaders are barely 18 and most of the providers, already overworked, are not particularly interested in training sessions on cultural awareness, the project has been enthusiastically received by the Bedouins, who see it as a first step toward their becoming more empowered in dictating their own healthcare

Tobacco control law press conference

Last week, AUB's Faculty of Health Sciences (FHS) held a press conference to announce its position statement regarding a proposed tobacco control draft law currently under discussion in the Lebanese Parliament.

Smoking remains a major public health problem in Lebanon, with a prevalence of close to 50% among the general population. A recent survey looking at students aged 12 to 16 in Beirut and Mount Lebanon found that 10.5% currently smoke cigarettes and 29.6% currently smoke narguileh (hookah). The latter, which is popular in the region as a recreational activity, has in fact been found to be just as harmful as (if not more harmful than) cigarette smoking. Despite having ratified the WHO Framework Convention on Tobacco Control in December 2005, Lebanon continues to have weak tobacco control policies, and the tobacco industry continues to hold a strong lobby: Many hospitals and schools are not smoke-free; tobacco advertising is rampant; and there are no restrictions on who can buy cigarettes, with a pack selling for less than a dollar. While discussions regarding the proposed law have generated some interest (a Facebook group named "Ban indoor smoking in public places in Lebanon" now boasts more than 15,000 members), overall the issue has not seen much light (and, in fact, an opposing Facebook group has sprung up: "NO to 'Ban indoor smoking in Lebanon'" with a little more than 100 members).

Widely attended by members of the public, the media, and the government, the press conference featured academicians from FHS and AUB's Faculty of Medicine, as well as government officials and representatives from NGOs. All of them strongly emphasized the need to adopt strong provisions in any tobacco control law. Their arguments focused not just on the health benefits but also on economic considerations including references to how stringent tobacco control laws would not harm tourism, the restaurant industry, or tobacco farmers. Many handouts--mostly in Arabic, but also in English and French--were distributed.

The position statement presented by FHS advocates the implementation of three main measures:
1) A total ban on tobacco smoking in indoor public areas;
2) A total ban on advertising tobacco products; and
3) The inclusion of large pictorial health warnings on tobacco products, covering at least 40% of two large surfaces of the pack with rotating messages every six months.

The current draft law proposes to have designated smoking and non-smoking zones in public areas, which studies have repeatedly shown to be ineffective in reducing the harm of second hand smoke. To demonstrate this, an experiment was conducted at the end of the conference in which the room was divided into a "smoking" and a "non-smoking" area: A machine located on the "smoking" side was used to smoke a number of cigarettes, and within eight minutes, the levels of ultrafine pollutant particles became equal on both sides of the room.

http://www.aub.edu.lb/news-images/103583-13

BGUH (part deux)

We spent another day at Beirut Government University Hospital, and had the opportunity to meet with the medical director and attend morning report.

Just as in the US, a significant percentage of Lebanese have private insurance, but the uninsured and the underinsured populations remain significant. The government insurance scheme does not cover outpatient care. There are discounted clinics (including at BGUH) where physician visits are more affordable, but patients are limited in their ability to pay for bloodwork or imaging tests. They are building new outpatient clinics at BGUH but the director told us that there is still no funding for ongoing patient care.

Many patients come to the ED for admission because they cant afford routine outpatient care. Furthermore, private hospitals severely limit their capacity to admit underinsured patients by limiting the available beds in the hospital. One of the hospitals we visited earlier reportedly has only 10 beds out of over 400 reserved for patients with the government insurance plan. Underinsured patients at private hospitals either wait for days in the ED for beds to become available or get transferred to the government hospitals.

BGUH is a modern tertiary-care hospital with an ICU, cardiac catheterization lab, PICU, etc. Its 400 beds are always at capacity, making it many times busier than the next largest government hospital. In spite of excellent facilities, the hospital is chronically underfunded, often without enough money for blood tests or radiologic studies, and loses 15-20 million USD annually. Government funds are often distributed based on political needs rather than medical needs with monies going to outlying regions of the country to show governmental support for those districts.

The morning report was mostly remarkable for how similar it was to our own. The case was an elderly man presenting with painless jaundice and weight loss who was being evaluated for likely pancreatic cancer. The discussion was identical to one we might have at Columbia including choosing appropriate blood tests and imaging modalities. Perhaps one difference was the greater emphasis on concepts of efficiency and cost-effectiveness. The patient had pre-renal azotemia and the initial debate was whether an abdominal ultrasound or a CT with contrast would be the preferred study based on safety, utility, and cost. Later we learned that the patient had undergone a non-contrast abdominal CT at an outside hospital a few months ago that was reportedly unremarkable. Now the thought was whether the additional time and expense of an MRI would be beneficial.

A nurse interrupted the presentation with a printed sheet of paper. This was the daily report of which tests had been approved by the government insurance for that day. Of the 15 items, perhaps one third to half had been rejected, including things as simple as a TSH assay. Cancer markers for a patient with a known mass were denied, as was a brain MRI for an individual with persistently altered mental status with negative workup including two unremarkable CSF examinations. The residents regularly spend hours speaking with the insurance companies to get these tests covered.

For our case, the team had decided on the MR scan, but we found out from the daily report that day that the request for his MRI abdomen was approved, but the MRCP was denied.

BGUH

Today we went to the Beirut Governmental University Hospital, or BGUH (also known as the Rafik Hariri University Hospital). Built in 2005, the hospital is large and modern and, in contrast to AUB medical center, cares primarily for the uninsured. The hospital is primarily affiliated with L’Université Libanaise but AUB residents also rotate here. Ola, an AUB intern, describes how they must rely heavily on their history and exam skills because lab tests and imaging are not necessarily available.

The medical team is composed of three students, one PharmD, one junior resident and one senior resident. The students, perhaps nervous by our presence, endearingly stumble through one-liners after which we walk-round. The entire team sees patients together: while the senior resident directs the encounter, medical students are expected to interview and carefully examine the patient. Family members are present and get to ask questions. Although I cannot understand the language, for the most part they appear humble and grateful for their relatives' care.

But despite the team’s clear dedication and efficiency, rounds occur amidst the disorganization and chaos of a perpetually underfunded hospital. Nosocomial infections are rampant and big-gun antibiotics (meropenem, tigecycline, polymyxin) are used aggressively. While affected patients are theoretically on contact isolation, gowns are uniformly unavailable. The PharmD on the team, however, does point out that now at least there are signs on the doors to indicate that patients are supposedly on isolation.

The team cares for a man with a gun-shot wound to the face and an elderly woman status post colectomy. When I voice surprise that these patients are not on surgical teams, one of the residents simply replies, “well, you know how surgeons are”. We also see a man who has been intubated on the floor for three days because ICU beds are unavailable. Chucks are used to restrain his wrists and his FiO2 is permanently at 100% because the vents are missing a valve necessary to decrease the oxygen.

Rounds illustrate the striking discrepancy between what patient care should ideally be and what doctors actually do given their limited resources. Although we grumble at Milstein when things don’t happen the way we wanted them to, it is sobering to see a hospital where every second of patient care is governed by this principle.

Bourj el-Barajneh & Shatila

We had a pretty sobering experience yesterday as we were invited to visit two of the predominantly Palestinian refugee camps in Beirut. We spent the day with members of Beit aftal Assumoud (BAS), a predominantly Palestinian NGO that provides social care and vocational training throughout the 15 refugee camps spread across the country.

The people we met were incredibly friendly, and seemed eager to share with us their stories, and it made it even tougher to realize that other than listening and observing, we had so little to offer.

The camps were formed in the late 1940s with the influx of Palestinian refugees into Lebanon and have been in existence since then. Through their history, they have been the sites of numerous massacres, and frequent violence. One of the teachers we met told us that her house has been destroyed seven times since the 1970s. Each of the two camps we visited was originally built for hundreds, but now houses over 15000 refugees in approximately one square kilometer. The buildings grow vertically with floors added in a hodge-podge of building every few years. Six story buildings are separated by alleys less than one arms length wide. There is no drinking water available, and the electrical system is a tangled web of open wires hanging over every street. There are no open spaces for kids to play or groups to gather.

The physical squalor of the camps is matched by the emotional and psychological struggles of the people we met. The refugees have few possibilities for advancement. They are not allowed to own property or start businesses outside of the camps. There are 70 professions in which they are not permitted to participate--nearly every educated profession is off-limits. We asked one of the social workers at BAS what happens to young people after finishing schooling, and he said that he couldn't really even discuss this because it makes him so upset.

We visited the BAS centers in each camp, both with small clinics on the ground floor and three pre-school classes on the upper floors. The organization spearheads vocational training and adolescent health education, which they found to be lacking at the UN clinics. In spite of their limited resources, the group has put together an impressive collection of pamphlets and literature, including a survey of teens' knowledge and attitudes towards family planning, reproductive health, emotional health, and self-confidence. One center had a recently opened adolescent reproductive health clinic that was staffed three days a week with a female gynecologist, urologist and psychologist, offering free routine medical care or even the opportunity to come just to ask questions. There was a tiny stock of medicines including oral contraceptives and antibiotics. Patients entered through an unmarked back door to remove the stigma of going to a sexual health clinic.

Social workers organized outreach programs into the communities for family guidance, cultural activities, and health education. Many of the teachers and social workers lived in the camps themselves and we heard repeatedly that their mission was, against all odds, to try and give hope to the young people.

Removed from their native lands, living without many rights, and labeled as terrorists by much of the world, the line between frustration and hostility seems delicate. As we were driving, we passed posters on the building walls put up by the families of two men who wished to remember their deaths and commemorate them as martyrs towards the Palestinian cause. One of the more shocking things we saw was a poster in one of the common rooms of the BAS schools that was apparently made by the students. It had a map of Gaza with bombs drawn in directed towards it from every direction. On each of the bombs was pasted on a logo of a US company cut out from newspapers.

As we left, the one of the organization's administrators said to us that no one is born a terrorist, but that out of the horrors of this place grows terrorism. It was amazing that out of all this could come an organization that is doing so much to combat the realities faced by the refugees.

The Hospital

We spent part of this week getting acquainted with the American University of Beirut Medical Center (AUBMC). It is a large, 420-bed teaching hospital and referral center. The department of internal medicine has approximately 12 residents per post-graduate year as well as two chief residents. At first glance, AUBMC is strikingly similar to Milstein (although distances do seem somewhat smaller and more manageable than at our home institution). English is the language of instruction and residents and faculty speak it fluently. The days, like ours, are divided between patient care and a busy conference schedule.

However, there are differences. The RN who greets us at the outpatient clinic wears a veil that matches her white nursing outfit. The medical students sport jeans beneath their short white coats. And, as seems to be the norm in Lebanon, female attire is extremely variable and ranges from tight leggings with knee-high boots, to demure hijabs paired with brightly colored nails as well as the more conservative burqas. (This last one is much less common, but still present in everyday life).

I am still trying to get a sense of the patient population at AUBMC. Dr. Shoucair, the director of outpatient services, explains that about a third of Lebanon has insurance via social security funds and that another 10-30% has private insurance. The remainder of the population falls under the care of the Ministry of Health, which only covers the cost of inpatient stays and medications for chronic diseases.

From what I gather, patients who come to the resident clinic are typically uninsured but have sufficient means to pay the 6-8 USD charged per visit. Patients, however, can run into trouble when it comes to paying for laboratory and other tests. If they cannot afford care here they typically go to government run hospitals, where costs are much lower although not entirely free. Next week we are hoping to head over to BGUH (Beirut Governmental University Hospital) with some of the residents rotating there.

Sidon and Tyre

Yesterday was a national holiday in Lebanon, the Feast of St. Maroun, the founder of the Maronite Church, the major sect of Christianity here. We took the opportunity to visit the southern cities of Sidon and Tyre, both thought to be inhabited since 4000BC, and both major Phoenician sea ports with their heydays around 900BC.

A surprisingly compact country, we reached Sidon half an hour after leaving Beirut, visiting the Sidon Sea Castle, which overlooked the Mediterranean and was built to protect the port town. The present city is a blend of the old and the new. The castle itself is an interesting mixture of cultures with the 13th century crusaders having built on top of the Romans who built on top of the Phoenicians. Just as one sees in modern Lebanon, there was a mosque and a Christian church built essentially side-by-side.

The strong interconnection between culture, politics, and religion and its ever-presence in daily life became even more apparent as we headed further south from Sidon to Tyre. A majority of the billboards posted along the highway were political in nature, either commemorating assassinated political leaders or supporting political positions. Even the current political structure reveals these complex interrelationships, with the constitution mandating the top three political posts of the nation must be held by a Maronite Christian, a Sunni Muslim, and a Shi'a Muslim respectively.

The south of Lebanon is a Hezbollah controlled region, and as we were close enough to the border to catch Israeli radio broadcasts, the increased security was evident. We passed half a dozen military checkpoints, all with armed guards, a many with military tanks, and a few with white UN vehicles patrolling alongside. While this surprised me as a foreigner, life at least appears to continue on as normal in these areas, with checkpoints seemingly providing as much irritation as stop lights, and restaurants and seaside resorts continuing to welcome visitors.

War Wounds

We arrived in Lebanon yesterday, with a plan to spend several weeks working on public health projects directed by the American University of Beirut. We had stopped in Paris on our way from New York, and had spent one cold, wet afternoon walking the city before proceeding to Lebanon. The chill of Paris still hadn't left us when we landed, so we wore winter jackets as we passed through immigration and even as we stepped outside of Rafic Hariri International Airport and faced, for the first time, Beirut. The airport sits beside the Mediterranean, and the driveway that greeted us was scattered with palms, cedars, and sunlight; we were happy to shed our jackets as we waited for a taxi in the warm air. Our taxi driver alternated between French, Arabic, and English, and the highway that took us into the center of the city was lined with billboards in all three languages. We are being hosted by the family of one of our group, and our hosts greeted us with a lunch of kibbeh and laban bi khyar. The sun had already begun setting when we finished eating, but we pressed out into the city to see more of where we will be working for the next month.

Past the gated campus of American University of Beirut, we descended to La Corniche, a ring road that runs along the Mediterranean. There families were finishing the picnics that had occupied their Sunday afternoons, and teenagers gathered beside blaring boomboxes. It was, on first impression, a tranquil evening in a city beside the sea -- a city that might have been any city except for the diversity of languages spoken beside us as we walked. But, on closer inspection, the grafiti scrawled on walls and the billboards overhead (many announcing a march to be held next week, on the anniversary of Rafic Hariri's assasination) suggested a different city -- a city recently ravaged by war and violence. As we wound our way downtown, we passed the St. George Hotel, where the firebomb that killed Hariri was detonated, and which now stands vacant. The Holiday Inn just a few blocks further along also stood vacant, its broadside pockmarked with shell blasts.

The monuments to Lebanon's violent past are not so much statues as billboards and buildings. The past is not far past. Nothing is safe yet. But the streets of Beirut are still lively. The restaurants that Sunday night were full. And we will find out as we work how the wounds of Lebanon's wars mark the people of Beirut as well as their buildings.

BK