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Global Health

Lebanon is a crossroad of East, West

Editor's note: Welcome to the Global Health page. The purpose of this feature is to raise awareness of global health issues with an academic spirit to help improve the quality of care provided to patients. E-mail

by Riad Ramadan
MD/PhD student, College of Graduate Studies
Located on the eastern side of the Mediterranean Sea, Lebanon is one of the world’s smallest countries with a total area of an eighth of that of South Carolina and with a population compar-able to that of the state (4 million).
This narrow coastal strip has witnessed during the centuries the rise and fall of many great ancient civilizations, hence serving as a significant crossroad between Orient and Occident. Today’s Lebanon is a country where a mosaic of religious and social backgrounds struggle to coexist amidst an ocean of regional conflicts and geopolitical turmoil. As a result of the lingering political instability and economic standstill, a sizeable Lebanese Diaspora has emerged during the past two centuries, with countries such as Brazil becoming home to as many as 10 million residents of Lebanese descent.
Despite its harsh political landscape, Lebanon still maintains remarkable educational standards, among the highest in the region.
In 2005, the United Nations assigned the country an education index of 0.845, based on its literacy rate and level of education from kindergarten to post-graduate studies (an index of 0.968 was given to the US). An interesting and surprising fact given the small population is the number of universities in Lebanon: a total of 41 nationally accredited schools, some having achieved American and French accreditations. As is true for the health care system, the Lebanese education sector is a stage of striking contrasts between the prosperous private system and the underprivileged public sector.  
Unfortunately, employment opportunities remain very limited in Lebanon and many graduates choose the option of pursuing careers abroad.

Health care in Lebanon: Huge potential unevenly distributed

by Ahmad Mashmoushi
MD/PhD student, College of Graduate Studies
With a care system coping with infectious and communicable diseases, along with a growing burden of chronic and degenerative disorders, Lebanon is experiencing an epidemiological transition, according to the World Health Organization.
Still, years of war and regional conflict have pushed Lebanese health care to evolve and advance a well-managed crisis network in light of an imbalance of practitioner-to-patient ratio. The crisis network has had a great impact on humanitarian relief for its civilian victims.
During its period of epidemiological transition, the strength of the Lebanese system is attributed to the huge potential of its health care human resources. Many educational institutions provide high quality medical training to a large number of health workers in different fields. However, this has led to an over-supply of medical doctors, many of whom seek careers in Europe and North America.
Since the early 1990s, the health system in Lebanon has developed and expanded in an unregulated and unplanned manner. As a result, the system’s performance is inefficient, as health outcomes do not correspond to the 12 percent of gross national product spent on health. This high level of public expenditure results from fragmented, inefficient resource allocation and service delivery, excessive investment in hospital capacity and high technology, and a lack of quality assurance and consumer protection.
The current health system is dominated by a flourishing business/high technology-oriented private sector that favors large cities and high-income patients. A surplus of doctors, especially specialists, and high-technology medical equipment co-exists with a shortage of nurses and other paramedical staff. The results are that primary health care is inadequately covered.
Currently, the Lebanese govern-ment is working on updating its health policy and implementing new measures to re-channel health services more uniformly among different regions. However, other issues such as corruption and true reconciliation should be addressed in order to create a good environment to improve the Lebanese health sector.

  • MUSC Annual International Bazaar: Taste the Nations, 11 a.m. to 1:30 p.m., Thursday, April 9 in the Horseshoe
  • International Family and Friends Picnic, 12:30 to 4 p.m., Sunday, May 10, Palmetto Islands County Park. Cost is $1, which is the entrance into the park

Clinician’s corner
A 23-year-old male medical student comes to your office complaining of fever and low back pain that started about two weeks ago. He describes a high-grade fever that has been cycling, rising then disappearing for several days. Lately, the fever episodes have been associated with drenching night sweats and nausea. The patient also reports a low back pain that has restricted his range of motion and is only moderately abated by non-steroidal anti-inflammatory drugs. His history is negative for chest pain, cough, vomiting, diarrhea or dysuria and patient is otherwise in good health. He also denies active sexual activity. He mentions however returning from a touristic trip to Lebanon a month ago. When further asked about food consumption there, he reports having ingested goat milk on one of his excursions. A negative TB skin test (PPD) was read a week ago.
On physical examination, the patient is alert yet nauseated. His body temperature is 103 °F, HR=95, RR=16 and BP=125/65 in both arms. His cardiac exam is significant for a harsh, grade 2/6, holosystolic murmur best heard at the apex and radiating to the left axilla. His musculoskeletal system exam reveals a limited range of motion of the spine upon flexion, extension and rotation. Tenderness is felt upon palpation at the sacroiliac joints bilaterally. He has no lymph node enlargement, hepatomegaly or splenomegaly. No significant skin discoloration. Genital exam is normal.
What is the most likely diagnosis? What is the most reliable diagnostic lab test?
A. Reiter’s disease       B. Extrapulmonary TB
C. Brucellosis               D. Ankylosing spondylitis

The correct answer is C: Brucellosis. Brucellosis (undulant fever) is a zoonotic, non-contagious disease caused by a Gram negative coccobacillus. Between 200 and 300 cases are reported annually in the United States, making it a rare entity, mostly occurring among travelers to endemic areas such as Africa and the Middle East. Transmission occurs mostly via ingestion (usually unpasteurized dairy products), inhalation and skin contact. The disease has a one-to-eight- week incubation period and manifests mostly with undulating fevers, malaise, myalgias and arthalgias.
Neurobrucellosis is an important condition that requires immediate attention, and which can range from confusion to meningitis and coma. Endocarditis with septic embolization is the most common cause of death from brucellosis. Orchitis and liver abscesses have also been reported. The quickest and most reliable test done to diagnose brucellosis is an antibody titer to the O-polysaccharide of 1:160 or higher. Treatment is usually a combination doxycycline/streptomycin for six weeks (rifampin has also been used in lieu of streptomycin but is usually less effective).


Friday, March 27, 2009

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