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Change and challenge is in the wind as 2008 comes to an end. The same is true when examining this month's ReachMD XM 160 special series Focus on Global Medicine. We take a look at both the changes and the challenges impacting global medicine.

Have you ever thought about volunteering overseas, how do you get started? What are the risks? Is it worth it?

Welcome to the Clinician's Roundtable. I am Dr. Leslie Lundt, Director of Foothills Psychiatry in Boise, Idaho, 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 for having me on your show Leslie.

DR. LESLIE LUNDT:

Dr. Assefi, you've had such amazing international experience, tell us how you got started working overseas?

DR. NASSIM ASSEFI:

You know it started in 1991 when I graduated from Wellesley College and I wanted to have a real world experience in a developing country before starting medical school, so I applied for a bunch of fellowships and ended up getting a <_____> fellowship to study the impact of the Islamic revolution on women's health in Iran and that's how it started.

DR. LESLIE LUNDT:

So even before you went to medical school?

DR. NASSIM ASSEFI:

That's right.

DR. LESLIE LUNDT:

One of the things that you've been very willing to do which most physicians aren’t is to take time off and just go, how can you do that? How can you cut the leash that attaches us to our practices and our hospitals?

DR. NASSIM ASSEFI:

You know, I just make it up when I was a medical student and didn’t have any money, I would take out maximal loans and save up and pinch my pennies during the years so that I could have these international experiences and then I would be upfront after medical school and residency with my jobs telling them that global health work was an important part of who I am and I would negotiate that into the contract.

DR. LESLIE LUNDT:

Again from the beginning?

DR. NASSIM ASSEFI:

From the very beginning.

DR. LESLIE LUNDT:

So, tell us about your experiences in a run.

DR. NASSIM ASSEFI:

Well, when I first went to Iran, I like many secular Iranian American assumed that a revolution that was theocratic, conservative, fundamentalist Islamic would be really bad for health and women's health and rights in particular, but it turned out I was incredibly wrong and what happened was that with the Islamic revolution suddenly there was an equalization of resources between rural areas and urban areas, so the villages finally got electricity, running water, schools, and clinics. At the same time, there was a major push for literacy and women's education in particular. So now you see that women are the majority of university graduates in Iran. It's quite amazing, it's different from what we are used to hearing, and finally Iran really made healthcare a priority and delivered this healthcare through a community based universal primary care system and this has had tremendously positive results. Now the primary care is delivered at the first level by community health workers, who are kind of like midlevel physician assistant types and they cut down about 80% of visits to doctors and they provide all the basics that one might face in a developing country like diarrhea treatment, bronchitis, cleaning up the water, basic hygiene, family planning, prenatal care, that kind of thing, and through these measures Iran has a very strong primary care system and women's health system now.

DR. LESLIE LUNDT:

So again, much different than the sort of stereotype that most of us have about Iran and the rest of the Middle East.

DR. NASSIM ASSEFI:

That's right.

DR. LESLIE LUNDT:

Now, you've also worked in Cuba.

DR. NASSIM ASSEFI:

I have, and the Cuban example is actually very similar to the Iranian example. It turns out that their revolution was 20 years before that of Iran in 1959, and Fidel Castro made the rural areas a priority and through equalization of resources massive literacy campaign and their primary healthcare system was delivered through a doctor and a nurse team that live in the area where they serve and they served about 150 families, very very similar systems of health.

DR. LESLIE LUNDT:

Now, is there any way to translate these experiences that you've had in places as different as Iran and Cuba into the United States to help our healthcare system?

DR. NASSIM ASSEFI:

I think so. People say, well that works in developing countries, but we have a very different system in the US, we don’t have anything to learn from them, but in fact, I think we do. The first thing is that we must learn that governments have to prioritize health along with other community based drives. There is really no excuse for not having a universal healthcare system. I am sure most of your listeners know that we are the only industrialized country left that doesn’t have universal access to healthcare. So that's, 1. Is that the government has got to make it a priority. 2. Is that we have to equalize a lot of the disparities we have in this country. For example, an African American man in <_____> he lives 21 years less than an Asian American woman in California. We have tremendous racial base disparities as well as poverty based disparity, so we really need a system that gives equal access to all. We are also the only industrialized country without paid maternity leaves. We need to value our children and child care better and institute paid maternity leaves, and education plays a big role in health. Unfortunately, our Surgeon General post is quite political and even President Bush's appointee, Richard Carmona stepped away from the post saying that he was censored on issues like the ineffectiveness of abstinence-only education; however, he wasn’t allowed to talk about emergency contraception or even the effects of tobacco. So we need an educational system that talks about health in an honest and transparent way, and finally I think we have to prevent war if at all possible, not only is it incredibly destructive to the recipient country, but it's a huge opportunity cost for us, costing us this Iraq War up to 200 billion dollars a year, which could have easily funded the universal healthcare system, universal preschool; all the research we wanted and immunizations that we wanted. So I think those 4 points would really help us and both Iran and Cuba have demonstrated successful healthcare systems based on some of these issues.

DR. LESLIE LUNDT:

Now thinking back to my original questions about our listeners, who may be thinking about going overseas and volunteering in some healthcare capacity, in your experience, and you've done this so many times all over the world, what are the risks, what's the downside of doing this?

DR. NASSIM ASSEFI:

The downside of volunteering in developing world countries?

DR. LESLIE LUNDT:

Yes.

DR. NASSIM ASSEFI:

Well, the downside is that we are treating our own curiosity and need to serve about looking at the big picture issues, flying in someone delivering healthcare for two weeks, a month, or two months isn't really going to change the underlying health system and it can, in fact, weaken local health system. So if you are going to volunteer, I would recommend you do it with a long-standing program that will provide healthcare after you leave. So that's one major issue. The other is you might get sick, you might be traumatized by the depths of poverty and the impact of warfare, but I think overall the benefits are huge.

DR. LESLIE LUNDT:

So obviously you think it's worth it.

DR. NASSIM ASSEFI:

I do.

DR. LESLIE LUNDT:

Now, how do you deal with things like a family and mortgages and cars and all that sort of everyday life stuffs that seems problematic if you are going to leave the country and go work abroad?

DR. NASSIM ASSEFI:

Well, it depends how you do it. If you're doing a short-term volunteer stint of, you know, two weeks to three months, you basically have to continue with your payments domestically and arrange for child care or bring your kid with you because unless the atmosphere is very dangerous, I think traveling with children is wonderful and they are very valued the world over, but if you do decide to do healthcare work in a longer term way, you don’t need to necessarily suffer financially and there are organizations that you can work with that would help you pay your loans and put your stuff in storage and allow you to meet your financial needs while you are away. I always advise trying to live as materially simply as you can because we sometimes become the slave of our debt and our lifestyles and once you get out of that, it's so incredibly freeing, you can do the things that you want to do.

DR. LESLIE LUNDT:

Now, how your family dealt with you globetrotting?

DR. NASSIM ASSEFI:

They are used to it by now. My parents basically did stop talking to me when I moved to Afghanistan for two years; they were really worried. Everyday they were having problem sleeping and depressed and every notice of a suicide bomb would send a terror chill down their spine, but other than Afghanistan they are really quite supportive of all of my global health work, and until now I have been doing it as a single woman, but my husband to be in the next month will be coming with me.

DR. LESLIE LUNDT:

Now what about, I am interested in reentry after you do these incredible experiences overseas and you come back to the United States and work again in our system, what's that transition like for you?

DR. NASSIM ASSEFI:

You know, it gives you a big picture perspective. We spend so much time obsessing over whether one statin is more effective than the other statin and yet so much of health is not really dependent on medicines, but it is health behaviors, and if you get someone to stop smoking, treat their diabetes, get on any statin and live a lower stressed life, they are going to be able to live better from their coronary artery disease. We obsess a lot over very small things in this country.

DR. LESLIE LUNDT:

Do you find yourself ever impatient with the people of our country, who as patients don’t take responsibility even though they are provided with tremendous resources, but lack that personal responsibility that you mentioned is so crucial in regard to keeping their health well.

DR. NASSIM ASSEFI:

You know, I don’t find myself impatient with that. I tend to work with patients, who are poor or non-English speaking or are refugees and there are so many reasons why people don’t follow medical advice. I mean, for one, their lives might not be structured in a way that let's say, they can get exercise, may be they live in a dangerous part of town or may be there are no sidewalks or may be they are working all the time, and also I think it's the doctor's responsibility to help forge a trusting relationship with their patients such that the advise they give is trusted and acted upon in a way that makes sense for the patients, so I think this is really one of the biggest challenges of being a doctor is translating the medicalease into language that is going to make sense for that patient in the context of his or her lives.

DR. LESLIE LUNDT:

Makes great sense. I would like to thank you so much for being in our show today.

DR. NASSIM ASSEFI:

Thank you for having me, Leslie.

DR. LESLIE LUNDT:

We've been discussing global health experience with Dr. Nassim Assefi.

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 library. 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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