EXPERIENCE IN
AFGHANISTAN
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end. The same is true when examining this month's ReachMD XM160 special series
- Focus on Global Medicine. We take a look at both the changes and the
challenges impacting global medicine. You are listening to ReachMD, The
Channel for Medical Professionals.
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
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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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