War and Public Health

EXPERIENCE IN AFGHANISTAN

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What is the effect of war on public health. Welcome to The Clinician's Roundtable. I am Dr. Leslie Lundt, author of You Can Think Like a Psychiatrist, your host, and with me today is Dr. Nassim Assefi, a second generation Iranian American. She is an internist, specializing in women’s health and global medicine. Most recently she has been an academic in Seattle, a humanitarian aid worker and underground salsa dance teacher in Kabul, and an aspiring musician in Havana. She is the author of numerous scientific publications and Aria is her first novel.

DR. LESLIE LUNDT:

Welcome to ReachMD.

DR. NASSIM ASSEFI:

Thank you so much for having me on your show.

DR. LESLIE LUNDT:

Now, Dr. Assefi how did you end up in Afghanistan of all places.

DR. NASSIM ASSEFI:

You know it was a moment of idealism I had after September 11. I realized what a tremendous gulf there is between understanding of Islamic world and the West and if someone is an Iranian American who had come from an Islamic country had spent time working there in a health capacity and yet had all the privilege of an American medical education, I felt like this was an opportune moment to try to put all of my political activism and healthcare activism into action. So I was actually invited by the American Medical Women’s Association to go to Kabul in March of 2003, to check out what the impact of the Taliban had been on women’s reproductive health in Afghanistan. By that point, I had traveled to about 40 countries and had seen some war ravaged and impoverished countries and I didn’t expect to be shocked, but the situation in Afghanistan was worse than anything I had ever seen before. About 1 in 7 women died from pregnancy, 1 in 4 children did not live to age 5. There was more land mines there than anywhere else on earth and life expectancy was age 42 in a country that had very little HIV. So as a women’s health specialist and an educator, someone who came from the region, who could learn the language, who understood the culture and the religious background, someone who could be as comfortable speaking with the village women on her dirt floor to negotiating healthcare policy with the US Ambassador, I thought I have to go, and so I left my position at University of Washington at Harbor View Hospital and moved to Afghanistan for 2 years.

DR. LESLIE LUNDT:

What about your experience there? What can you share with us that is lasting this many years later.

DR. NASSIM ASSEFI:

You know the healthcare reconstruction effort in Afghanistan was more successful than any other country I had seen before. You had all of these international health advocates and actors coming together. So the US government was there funding my non-governmental organization Management Sciences for Health as well as the European Commission, the World Bank, the Asian Development Bank, and then the UN agencies like WHO and UNICEF, and we were all there acting in concert and bringing about health policy that made a lot of sense. The first thing that happened were massive national surveys to figure out why people were dying and what existing health facilities were there and who were the health providers and what are the resources of the country and they devised very logical, equitable health policy that paid attention to rural areas and paid attention to some of the gender issues and really sought to rebuild Afghan health provider capacity, but after two years of being there and seeing, you know, relatively rapid progress, when I first arrived in 2003, there was hardly any word of suicide bomb, may be there were 2 suicide bombs in the south bordering Pakistan, but by the time I left, there were hundreds of suicide bombs. Last year alone, there were nearly 140 suicide bombs and so I thought that security trumped healthcare in terms of the well being and the health of the people and that security was a prime concern, and so I can weigh from 2 years in a very functional public health program thinking I could have more impact, not as a doctor necessarily, but as someone, who spoke out about the situation and did my <_____> to prevent war and try to prevent all of this violence that was happening.

DR. LESLIE LUNDT:

You know as a psychiatrist I am particularly interested in hopelessness and how that may translate into suicidal ideation. What did you see there with regard to that?

DR. NASSIM ASSEFI:

In terms of hopelessness and suicidal ideation, I was amazed by how relatively low it was in Afghanistan despite the fact that this is one of the poorest countries on earth. People often don’t live past their fourth decade and even the majority of children have seen flying body parts, so there was a lot of depression, anxiety, and posttraumatic stress, but we didn’t see a lot of suicide. Part of it is cultural and religious. Where you did see suicide in Afghanistan, probably the most tragic clinical scenario for me was an epidemic among young women who are often in domestic violence situations, who had no rights and would set themselves on fire using kitchen oil and that was really horrible. I am not sure why, that I mean there were some cases of eating rat poison, but that seemed to be a particularly dramatic statement that not only am I going to take my life, but I am going to do it in this big and violent way to dishonor you and all the torture you have put me through kind of thing, but in the burn hospitals, there would be scores of women everyday dying. Now, that was quite tragic, but that’s not the general scenario there.

DR. LESLIE LUNDT:

So Nassim, it sounds like the things we see here in terms of cutting the wrist, that sort of behavior, you just didn’t see in Afghanistan.

DR. NASSIM ASSEFI:

No, much, much lower rates of suicide there.

DR. LESLIE LUNDT:

Touch us a bit about literacy.

DR. NASSIM ASSEFI:

You know, it turns out that the most powerful thing you can do for health status is actually sending girls to school and that seems like it wouldn't have necessarily be the case, but it turns out that even a girl educated up to fifth grade level is much more likely to marry later, has fewer children, do better birth spacing and girls and women are typically the healthcare decision makers for their families, so in these families where the women are educated, you see lower rates of infant mortality, lower rates of HIV, higher rates of immunization, and these women are more likely to send their children to school and also get jobs, so they break out of this cycle of poverty, which really helped with securing better health status.

DR. LESLIE LUNDT:

And did you see that happening while you were there?

DR. NASSIM ASSEFI:

I did, you know, in Afghanistan in rural areas when I first arrived, over 90% of women were illiterate and being a literate to me is almost like being blind and death. You are unable to get information outside of what is told in your house and you are often not able to find work and you certainly can't get all of these health programs that are being advertised through newspaper and billboard, etc. So the US government had a wonderful program that was based on sending girls and women through an accelerated literacy program and getting them to be healthcare providers, so that’s one very direct link of educating girls and women and getting them to a level of education where they can actually be health providers, but you do see that women and girls who have an education clearly have better health status.

DR. LESLIE LUNDT:

So, obviously human rights and health are intricately linked. Any other examples of this other than literacy?

DR. NASSIM ASSEFI:

Well, I think healthcare is actually a very small part, may be 20% of securing health status. So much of health status has to do with socioeconomic determinants, how poor you are, where you live, do you live in a remote village versus an urban area that has access to healthcare, how educated you are, what kind of family you come from, are you even allowed to get healthcare or do you have to ask permission of your husband. So I would say that socioeconomic, political, and human rights factors are actually more important than healthcare in securing health.

DR. LESLIE LUNDT:

So as physicians how can we help enable that?

DR. NASSIM ASSEFI:

Well, I think as physicians, it’s our responsibility to look at the big picture from a socioeconomic standpoint and fight for justice. I think almost all of the world’s problems today can be boiled down to this huge chiasm between the haves and have-nots so as we can fight for social justice on any front, I think it’s going to be incredibly effective.

DR. LESLIE LUNDT:

Any visions of going back to Afghanistan?

DR. NASSIM ASSEFI:

You know I am moving to Turkey next month and part of being in Turkey is being closer to the areas of the world where I would like to serve. One of the important things about being a physician, who does global health or any kind of service oriented work is that you have to pay attention to replenishing yourself and you have to be in a state of fullness and wholeness to be able to maximally give and living in Afghanistan is quite tough. I had Giardia more times than I care to recount and develop asthma from all the fecal dust in the air and there is the danger standpoint. So I do hope to go back to Afghanistan, but as things are currently, I won’t be going for long-term missions, just short term.

DR. LESLIE LUNDT:

So, what are you going to be doing in Turkey?

DR. NASSIM ASSEFI:

In Turkey I’ll be working on finishing my second novel entitled “Say I am You” which is about the unjust distribution of privilege and what people do with their good in life and that novel is set in Afghanistan, and I will be leaning Turkish with the goal of being a professor at one of the medical schools that teaches in English and also hoping to do some women’s health volunteering, may be in Eastern Turkey or among poorer populations in an around Istanbul.

DR. LESLIE LUNDT:

Thank you very much Nassim for being in our show today.

DR. NASSIM ASSEFI:

Thank you so much for having me.

DR. LESLIE LUNDT:

We have been discussing Dr. Nassim Assefi’s experience in Afghanistan and soon to be Turkey. I am Dr. Leslie Lundt. You’ve been listening to The Clinician's Roundtable on ReachMD, The Channel for Medical Professionals. We welcome your questions and comments. Please visit us at www.reachmd.com. Our new on-demand and podcast features will allow you to access our entire program libraries. Thank you for listening.

Thank you for listening to our special series, Focus on Global Medicine, as we celebrate this annual holiday season. Everyone at ReachMD wishes you and your family a happy holiday and a successful new year.

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