In 2015, Rana Abu Shakra Majali posted to her Facebook page that she had breast cancer. “I’m a very social person, and I couldn’t hold this back,” said Abu Shakra Majali, 43, who lives in Amman.
In Jordan, that sort of candor about cancer is unusual. Cancer is the second leading cause of death there, just after heart disease. Yet deep-rooted stigma means it often goes undiscussed. “They used to call it ‘the other disease’ or ‘that illness,’” said Walid Al Khalidi, CEO of Al Khalidi Hospital & Medical Center, over email from the Amman Hospital. “There is still a big element of fear.” The taboo is particularly severe with regard to breast cancer. Dr. Houriya Kazim, the first female surgeon in the UAE, couldn't get the “breast” in “breast surgeon” put on her medical license.
Because of her frank Facebook post, Abu Shakra Majali experienced an outpouring of support that many women in Jordan with breast cancer never get. And Abu Shakra Majali’s experience differed in another important way: she received state-of-the-art treatment, delivered by a new facility that draws from leading-edge U.S. treatment practices. Eighteen months later she is cancer free and back at work at the International School of Choueifat.
The cultural taboos about breast cancer create real risks for women’s health. Women frequently aren’t screened for breast cancer, don’t self-exam and are reluctant to discuss any abnormalities they may observe. Thus most breast cancers in Jordan are caught at stages III and IV, for which survival rates are low. It’s a situation that runs counter to trends in the West, where breast cancer rates are higher than those in the Arabian Gulf but are less deadly thanks to early detection. Not surprisingly, breast cancer poses an acute health problem for Jordan, accounting for 22 percent of all female cancers. It is the leading cause of cancer death among Jordanian women, according to a 2011 report from the King Hussein Cancer Foundation (KHCF). While 80 percent of breast cancers in the West occur in women over the age of 50, in the Middle East, North Africa and Indian subcontinent, the 80-percent line occurs more than a decade earlier. Three in ten cases are diagnosed in women in their forties, often when they are raising children, caring for families and hitting the prime of their careers.
The Al Khalidi Women's Health & Breast Center is trying to improve the prospects of women in the region who have breast cancer. Opened a little more than a year ago, the center was developed in collaboration with Lahey Hospital & Medical Center, a highly-regarded hospital in Burlington, Massachusetts, near Boston. The center is a part of the Al Khalidi Hospital & Medical Center (KHMC), in the heart of Amman’s medical district. As Al Khalidi explained via email, the medical center is a regional magnet facility that draws a steady stream of patients from Saudi Arabia, the UAE, Bahrain, Yemen, Libya and Iraq, creating a lot of hustle and bustle. But the Women’s Health & Breast facility is a discreet oasis, with its own entrance, valet parking and an airy décor of clean white tile. “As soon as you walk through the door, you get the impression that everything is immensely clean, very modern and well run,” recalls Rachel Butler, a British ex-patriot, 50, who was an early patient at the Center and successfully treated for breast cancer.
The welcoming aura is not just aesthetic but also strategic: The Center works hard to overcome deep-seated cultural reservations against too much medical poking and prodding of women’s bodies. “In Jordan, women’s healthcare is entirely elective based, and rarely do women choose to have annual check-ups,” says Dr. Wael Al-Husami, a native Jordanian and the Lahey director who runs Lahey’s International Division from an office in Massachusetts. “They go to doctors only when they have problems. If you have chest pain you see a cardiologist; abdominal pain, a gastroenterologist. Or you go straight to an emergency room.” Lack of funding for preventive health services also limits access. “Women’s healthcare is not the Ministry of Health’s first priority, and it can be viewed as luxurious,” he explained over the phone.
In contrast, the Al Khalidi Women's Health & Breast Center covers the entire spectrum of services women need to monitor and maintain their health over a lifetime, and it does so in a single location. From simple blood tests to bone density scans to leading-edge healthcare informatics solutions, the Center is, says CEO Al Khalidi, a “one-stop-shop for women’s health, diagnosis and treatment, with an emphasis on breast cancer, wellness and prevention.”
The partnership with the Massachusetts center gives patients in Jordan access to a broad range of care. Both facilities offer tomography — three-dimensional imaging — which is a rarity in the Middle East. Patients who have breast MRIs and other diagnostic testing at Al Khalidi Women's Health Center can receive a second opinion from Lahey physicians, typically overnight. “This is important and unique in Jordan because now patients can have their test results sent out to Lahey while they are here, and regional patients need only travel to Jordan, and not the U.S., and still get the same quality,” says Al Khalidi. Notably, the facility is one of the first woman-run centers in the Middle East, with a mostly female staff entirely managed by female physicians. “This is important to some of our patients,” Al Khalidi notes.
Jordan has 31 hospitals run by the country’s Ministry of Health, which include maternal hospitals and a dedicated cancer hospital. But the idea of providing routine pap smears and mammograms strike many people in the region as inappropriate, especially for unmarried women.
“Getting women in the region to get over the fear factor of knowing what they might have remains one of our biggest challenges,” says Al Khalidi. He shares an illustrative anecdote: “One woman stood at the door of the Center asking questions, and refusing to step in because she ‘doesn’t really want to know.’ After a lot of convincing, she walked in to do a check-up. When the results came back negative, both the doctor and the patient started crying.”
Such intimate care can be provided because the Center project is, for now, deliberately modest in scale: 20 staffers see approximately 40-50 patients a day. “If you start with a large project, you find challenges," says Lahey director Al-Husami. "We’re trying to avoid that. We know we cannot possibly cover the whole country. We’d actually welcome some more overseas competitors to help do that.”
Lahey’s model for international collaborations has been refined over the past 20 years through collaborative projects in Bermuda and Canada, with a particular focus on executive care. “We don’t manage the hospitals or staff them. Rather, we send specialists several times a year, and also offer administrative education,” says Al-Husami. He also returns to his native country several times a year to do outreach, most recently meeting with Amman’s mayor as well as staffers at the U.S. Embassy in Jordan.
Lahey Health CEO, Howard Grant, says that the company has become increasingly engaged in efforts to grow its system abroad “because patients deserve the best care possible, in their ideal location.” Building the Lahey brand in the Middle East is part of the incentive, too. “There are millions, if not billions, of dollars from the Middle East coming to the U.S. and Europe,” says Grant. Driving part of that business to Massachusetts is one of the primary motivators for the partnership between KHMC and Lahey. The key to a successful international relationship, he notes, is to fill a gap and complement versus compete with local offerings.
“We don’t want to compete, politically, or with local physicians. We want to help them, and provide what they need,” Lahey’s Al-Husami says. Al Khalidi Women's Health Center does not hire referring physicians, preferring instead to keep a staff of in-house resident and specialist doctors and to grant admitting privileges to attending physicians who work at local private clinics. So far, Jordanian women make up about 65 percent of patients, with the remaining 35 percent comprising regional and Gulf customers. Both groups pay either out-of-pocket or via insurance.
Patients Abu Shakra Majali and Rachel Butler, who is British and has been living and working in Jordan for the past 12 years, both cite the Lahey connection as one of their key drivers in choosing treatment for their breast cancers at the Women's Health Center. Each researched and then ruled out overseas options in favor of the convenience and comfort of not having to travel, coupled with the security provided by the Lahey association.
Abu Shakra Majali says she’s still bowled over by her entire breast cancer journey, not only by the sensitivity displayed by her doctors, but also by the swift and smooth speed at which her treatment progressed. “I received my diagnosis on June 28th. On July 4th, I had my first chemo session, which my medical oncologist, Dr. Sana Sukhon, told me would be the first of three. Even though I had the most aggressive kind of cancer, from my very first appointment she was nothing but positive.”
Abu Shakra Majali is similarly effusive about her surgeon, Dr. Layel Al Asir, who operated on her in November 2015. “She knew instinctively that I was against mastectomy and assured me that lumpectomy would be more than enough,” she says. “In surgery, she said it would take two hours, but she ended up spending six hours because she was so careful about removing the least amount of tissue necessary. Today you can barely tell the difference between my breasts.”
Abu Shakra Majali and Rachel Butler both say they are happy to be candid about their cancer experiences in hopes of lifting the proverbial veil off the disease in the Middle East, and to promote the idea of routine checkups for women. Their message of positivity can't come too soon. Official statistics are hard to come by, but CEO Al Khalidi estimates that only 20 percent of Jordanian women opt for preventive screening.
Changing cultural attitudes is still like “turning an aircraft carrier,” notes Dr. Rebecca Yang, an oncology surgeon and director of Lahey’s Breast Center in Massachusetts. She travels twice a year to Jordan to give lectures and work alongside local oncologists, radiologists, clinicians and leaders of the Jordanian Nursing Council. Yang says she’s convinced that patient experiences, like those of Majali and Butler, will become less exceptional over time. “By being proactive, patients can have a treatable cancer.”
Butler wholeheartedly agrees. “I would really like other people to see that cancer treatment, whilst a feat of endurance, isn’t all terrible,” she says. In fact, pulling up to the Center (a chockablock street where traffic and parking are notoriously nightmarish) to be greeted by name by the cheerful valet parking attendant, who extended her a polite smile and a debonair arm, made Butler feel like a VIP. “It was brilliant,” she says.
— Alessandra Bianchi
Alessandra Bianchi is a freelance writer based in Marblehead, Massachusetts.
Update: The article and photo caption originally misstated that Al Khalidi Women's Health & Breast Center was the first Women's Health Care Center in the Middle East. It was preceded by the Dubai-based Well Woman Clinic, operated by Dr. Houriya Kazim, which was opened in 2006.