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Cultural barriers, fears keep some women from medical care

Jeannette Dakhallah, left, 51, learns breast self examination using an artificial breast as Hiam Hamade, 55, center, and Diana Awada, 56, watch. (Patricia Beck/Detroit Free Press/MCT)
Jeannette Dakhallah, left, 51, learns breast self examination using an artificial breast as Hiam Hamade, 55, center, and Diana Awada, 56, watch. (Patricia Beck/Detroit Free Press/MCT)Read more

By Cassandra Spratling

Detroit Free Press


DETROIT — Fear and modesty kept Diana Awada of Dearborn, Mich., from getting a mammogram.

Four times she made an appointment, and four times she cancel ed. Getting your breasts checked for signs of cancer wasn't something many women in Awada's Arab-American community felt comfortable doing.

The day Awada did show up for the test, the machine wasn't working. "Good," she thought, as she rushed away.

But just outside the Dearborn health clinic, Awada, 56, bumped into Hiam Hamade, the woman who had convinced her to schedule the X-ray screening in the first place.

Hamade persuaded Awada to going back inside for a cup of coffee. The pair chatted until the mammogram machine was up and running again.

It's a good thing they did.

Awada's mammogram revealed a cancerous lump. After surgery to remove the lump and two years of chemotherapy at the Karmanos Cancer Institute in Detroit, Awada's cancer is in remission.

"Hiam saved my life," Awada says. "And who was the first person I saw when I opened my eyes after the surgery? Hiam. Right beside me."

Hiam Hamade (HEE-AHAM HA-ma-de ), 55, is a public health nurse who travels mosque-to-mosque, door-to-door and friend-to-friend throughout metro Detroit's Arab-American community, preaching the importance of breast cancer screenings and teaching women how to do self-exams.

Hamade, a native of Lebanon, does it because early detection is the surest way to survive the disease. She knows that cultural beliefs cause some Arab-American women to shy away from both breast and cervical cancer screenings. Low-income and uninsured Arab-American women are even less likely to get screened.

"Cultural inhibitions, combined with language barriers and financial concerns, have been major roadblocks to Arab-American women when it comes to seeking health care that can save lives," says Dr. Adnan Hammad, senior director of the Community Health & Research Center at ACCESS in Dearborn, located at the clinic where Hamade works.

Only 42 .9 percent of Arab-American women age 40 to 49 reported having a mammogram in the previous two years compared with roughly 74 percent of all Michigan women, according to a 2008 report from the Department of Family Medicine and Public Health Sciences at Wayne State University.

Another statewide survey of 1,000 Arab-American women by the Michigan Department of Community Health revealed that 45 percent had never had a Pap smear and that 31 percent age 40 and over had never had a mammogram screening.

Hamade, who has been a nurse since 1975, aims to improve those numbers.

She runs the Breast Cancer Outreach Project that operates out of the health clinic at ACCESS, the Arab Community Center for Economic and Social Services. It's one of six metro Detroit projects receiving a grant from the Susan G. Komen Race for the Cure. In Detroit, the annual fund-raising walk/run will be Saturday at Comerica Park.

Hamade takes her message wherever she goes, armed with knowledge, compassion, cultural sensitivity and a warm and ready smile that helps put women at ease.

"She's a sweet, gentle soul who really believes in what she does," says Laura Zubeck, a nurse and director of volunteer administration at the Karmanos Cancer Institute. "She works tirelessly, going into homes, bringing people into the clinic at ACCESS and to Karmanos.

"She not only talks to the women, she talks to the men in families to convince them to bring the women or let them come to the clinic. Everybody who knows her loves her."

Hamade's fight against breast cancer went from professional to personal when Hamade got a mammogram in 2004 that revealed cancer. She did the test that December day simply because a winter storm had left the clinic empty.

Like many of her clients, she initially chose to keep her cancer a secret. She had surgery to remove the cancer during Christmas break and was back to work in early January.

"I didn't want anyone to look at me like I was weak," Hamade says. "Well, I was stupid."

Hamade's experience helped her see just how pervasive stereotypes about cancer can be, especially in the Arab-American community.

"In our community, it's something people don't talk about. They keep it a secret. They don't even like to use the word 'cancer,'" Hamade says. "It's like this shame; especially men don't want anyone to know if their wife or daughter has it. And don't even mention a Pap smear."

Hamade has always made her own way despite growing up in a world where women historically have done what the men in their lives — fathers and then husbands — want them to do.

She studied nursing against her father's wishes; he wanted her to become a teacher.

"He thought of nursing as being a servant," says Hamade, who moved to the United States in 1984.

But the fact that her father, the late Kassem Kazan, encouraged her to get any kind of an education was progressive, says Hamade, who is divorced with four children. "Many people asked him, 'Why are you paying this much money for her education; she's a girl?'"

Some of those same cultural norms conspire to make many Arab-American women resist vital health screenings.

Modesty about the human body is held in high regard among religiously observant Muslims and non-Muslims alike, says Hammad.

In addition, cancer is rarely discussed among Arabs, who call it al-marad al-khabith, "that terrible disease," instead of its actual name, Hammad says.

These feeling are rooted in historical misunderstanding about cancer, he says. Some Arabs viewed chronic diseases of any kind as shameful, and believed that they occurred because the victim did something wrong; they also believed that the ailment would afflict other family members.

"They saw it as God's will and thought, 'I will be cured if it's God's will.' You didn't even say the name because you didn't want to be cursed with it," he says.

In 1996, Hammad tapped Hamade to start ACCESS's breast cancer project.

"She is bilingual, bicultural, compassionate and passionate about health care," Hammad says.

Hamade's initial goal was to get 100 Arab-American women educated about breast cancer. Since then, the program has grown to include a staff of seven home health educators. Along with Hamade, they made 2,200 home visits last year. Hamade, who visits with information and gift bags, says home visits are the most successful way to get Arab women into the clinic or hospitals for testing and follow-up treatment.

"You first have to gain their trust with constant education," she says.

At the ACCESS center, women enter through a private door. All seven members of the medical team (doctor, nurses and nurse practitioners) are women who either speak Arabic or have someone on hand who speaks the language. The program also offers free transportation to and from the clinic.

"When I first started, 1 or 2 percent of the women kept their appointments. Now, only 1 or 2 percent are no-shows.

"I'm just very, very happy and pleased to have a position that serves and educates my community," Hamade says. "I believe in the community, and I believe in cancer prevention."



Early detection of breast cancer is a key to surviving the disease. Later diagnoses lead to larger tumors, more advanced cancers and lower chances of survival.

The Karmanos Cancer Institute and the Susan G. Komen Race for the Cure continue to recommend annual mammograms for most women beginning at age 40. They disagree with a 2009 federal task force report that recommends annual breast cancer screenings for most women beginning at age 50.

Low-income women have lower screening rates, are 41 percent more likely to be diagnosed with late-stage breast cancer, and three times more likely to die from breast cancer, according to the independent, nonprofit Institute of Medicine.

Uninsured women are more likely to receive a late-stage breast cancer diagnosis and are 30 percent to 50 percent more likely to die from the disease than women with insurance.

Most breast cancers and breast cancer deaths occur in women age 50 and older.

Although rare, younger women can also get breast cancer. Just 5 percent of all breast cancers occur in women under age 40.

About 85 percent of all women diagnosed with breast cancer do not have a family history of the disease.

Source: Susan G. Komen for the Cure