.

Reflections on the NIKI 2007 Educational Trip to Iran, What is Lacking? What Can We Do?
June 20, 2007

The NIKI group traveled to Iran from May 28 to June 14, 2007. The educational trips included medical universities in Mashhad, Tehran, Shiraz, and Tabriz. The group gave lectures, grand rounds, arranged workshops, round table discussions, hands-on procedures, surgical operations, group discussions, genetic laboratory set up, visits to scientific genetics labs, stem cell research and biopharmaceutical research labs. Some group members discussed starting collaborative projects with their Iranian colleagues and others accepted student mentoring and advisory roles.

We had a strong transplant group including Dr. Hossein Shokuamiri of Louisiana State University, Dr. Mark Laftavi from State University of NY in Buffalo and Dr. Hamid Shidban of University of California, heads of transplant sections and experts in liver, pancreas, small bowel and renal transplantation respectively. In addition Dr. Esmail Al-Abdullah, a world-renowned expert in islet cell transplant from the City of Hope Medical Center in California accompanied the group.

Medical genetics was well represented by Dr. Nasser Parsa, a senior genetic scientist from the NIH and Dr. Alireza Haghighi from Oxford University. Dr. Saeid Kamali taught pain management and nerve blocks. Dr. Morteza Khalaj taught chronic wound care and gave multiple lectures on how to heal intractable, infected, ischemic wounds. Dr. Nasser Ghasemi continued pressing the Hospice idea for the 3rd year in a row and Drs. Maleki, Zali and Khalili, the Deans of medical universities of Mashhad, Shahid Beheshti and Tabriz respectively agreed to start working committees to look into setting up Hospice in their region this yea. Dr. Hormoz Azar’s operating techniques, especially on Mitral valve repair was well attended and well received. Attendance at Dr. Adel Aziz courses on Advance Trauma Life Support (ATLS) was unprecedented.

Presence of Dr. Ismail Mahdavi, Professor of Psychology at the U Mass, Boston was a real bonus. Unbeknownst to me, he is a real celebrity and the most known face in Iran. He had hosted a TV show named One Thousand Untravelled Roads, dealing with family matters and real divorce cases that lasted four years and 270 episodes. He gave several TV and radio interviews and boosted NIKI status in Iran.

Dr. Navid Madani from the Harvard school of public health and an expert in HIV virus, who traveled to Iran 3 weeks earlier, visited several medical schools to lecture about HIV and to continue collaborative research with several universities, in addition to starting new projects.

Dr. Masumeh Namavar traveled to Iran twice this past year to teach stress related coping mechanisms, early detection of depression, and suicide prevention in school children.

We had the pleasure of having in our group two non-medical individuals, Professor John Allen of England who specializes in science parks and Peter Lu of Harvard University Physics department who discovered the connection between medieval Islamic mosaic designs and quasi-crystals. Peter’s paper in the Science magazine was the subject of much discussion late last year. 

Group members mostly agreed that Iranian physicians and medical universities have come a long way in both practical and basic science research during the last several years that we have been visiting Iran.  In addition medical school officials are putting major emphasis on basic science research and publishing articles in peer reviewed foreign journals. International eyes are being focused on Iran recent claims on HIV/AIDs treatment, stem cell research curing hereto forth incurable diseases like spinal cord injury, liver failure, etc.

Since the purpose of the NIKI group is focusing on the needs of the Iranian health care and medical schools curriculum, I thought the followings are issues that need further attention. These were brought up and discussed by me in every meeting with the medical university professors, deans, administrators, TV and newspaper interviews:

1-Addiction to narcotics and illicit drugs is relatively common especially amongst the younger age group in Iran.  According to some sources more than 2 million individuals are affected. There is an urgent need to include courses in medical schools and provide nationwide workshops for family practitioners to learn how uniformly and effectively prevent, detect, and treat addictions. Addiction must be looked at as a disease rather than a crime by all government agencies. Clean needle and syringes, plus methadone clinics should become available and easily accessible. Addiction can potentially destroys families of addicts and effective intervention may require social service as well as temporary financial help if the program is to succeed.

2-Tobacco smoking prevention in young and cessation must be an urgent public health issue. Public places should be non-smoking areas. Smoking cessation advice and counseling should be easily available. Cigarettes should be highly taxed to the extent that its use becomes prohibitive.

3-HIV/AIDS is increasing in prevalence amongst addicted individuals via contaminated needle sharing. Increasingly younger age groups are practicing unsafe sex. Serious attempts must be made in educating medical students and medical community about prevention, detection and treatment of this dreaded disease. Safe sex education should begin at the secondary school level if HIV transmission via unsafe and uneducated sex is to be prevented. Other measures should be implemented urgently to prevent unsafe sexual activities.

It is suggested that the Health Education Ministry establish a higher office that its only responsibility is to address addiction, HIV/AIDs and Tuberculosis.

4-Pain management needs further attention both in medical schools and in medical communities. Patients suffering from acute post operative pain or chronic pain must not be denied adequate pain relief, whilst thru education abuses are prevented.
Patient controlled narcotic administration during early post op period, and in those suffering from pain due to chronic debilitating illnesses or terminal cancer must become standard care rather than an exception.

5-Nutritional issues and training specific to Total Parenteral Nutrition (TPN), must gain popularity in poorly nourished hospitalized patients to help them heal and able to be discharged faster.

6-BLS and ACLS needs to be taught to all graduating medical students, practitioners, and those involved in emergency medicine and conscious sedation. Establishing emergency room residency programs is overdue.

7-Hospice care of terminally ill patients in the last six-months of their life, and palliative care of incurable patients should be taught to medical students and health care professionals and thru establishing nonexistent geriatric residency programs.

8-Chronic wound is the cause of long hospitalizations and frequent limb amputation especially in diabetics and those with poor circulation. Training in chronic wound care and clinics specializing in treating such patients are a cost effective necessity in every big city and medical center.

9-Enforcing traffic laws will reduce motor vehicle fatalities. The desired organs of brain dead victims of MVA should be used more often for cadaver organ transplantations. Iran needs more than one transplant center that is presently located in Shiraz. Our group under supervision of professor Shokuamiri has been willing to train physicians and nurses to start transplant centers in Mashhad, Tabriz, Isfahan and Tehran. Iran has many qualified physicians, surgeons and medical centers, and there is no reason why a patient from Khorasan or Azarbayjan should not be treated in their own region.

Transplanting a kidney that is bought from the poor must be abandoned in its present form and replaced by cadaver or living related kidneys.

Dr. Shidban suggested that in order to increase and make cadaver organ transplant more popular in Iran, that brain dead organ donors be given the status equivalent to a martyr since each saves lives of several terminally sick patients by giving 2 kidneys, 2 lungs, a heart, a pancreas and one to two liver in addition to other tissues.

10-HTN, Type II DM, obesity and inactivity is increasingly contributing to cardiovascular sicknesses like CAD and CVA. The number of coronary bypass (CABG) surgery is skyrocketing. There is a major need for increasing public education about prevention, detection and treatment of these metabolic conditions. 

11-Prevention, early detection and treatment of breast cancer, colon cancer, cervical cancer, as well as stomach and esophageal cancer in the endemic areas needs to be taken seriously by physicians and health insurance agencies.

12-Another area of deficiency is in record keeping. I spoke with many excellent surgeons who have done hundreds of highly specialized surgical procedures but did not know about their infection rate, length of hospital stay, morbidity and mortality rates. Hospitals are not routinely checked for their shortcomings by independent organization like JCAHO in US. Physician’s work in the hospitals are not measured by looking into pharmacy records for mistakes, and quality indicators like tissue committee, transfusion committee, infectious committee, morbidity and mortality committee, ethics committee, patient care assessment committee, quality assurance and quality improvement committees. Education, sanction and follow up mechanisms are not well defined in case of a problem physician or rogue hospital.

13-There is no board of registration in medicine, run by the state and federal government and independent of medical societies like in US. The equivalent of board of registration in medicine is “Nezam Pezeshki”, consisting of one or more local physicians elected by their peer, capable of creating potential for abuse and public dissatisfaction. A truly independent public/government/physicians combined organization will make physicians truly accountable for their mistakes and will restore public trust.

14-On the part of physician’s quality, cost effectiveness, conflict of interest issues, relation to pharmaceutical industries, medical equipment importers, private hospitals ownership, self referrals etc, there needs to be systematic and measurable quality indicators. Physicians and hospitals quality indicators scores must be published yearly online, by newspapers and other media events with the understanding that these scores are changeable and quality can/may improve. Physicians and hospitals must be given an opportunity to improve themselves and gain public trust. Health Insurance companies, medical malpractice records, hospital records, patient satisfaction surveys etc., can be a major source of information for quality measures. Physicians and hospital tiering can help bring down the cost of health care, reduce co pays by patients who choose to see a tier 1 physician or go to a tier 1 hospital, as compared to tier 2 or 3 doctors/hospitals.

These pivotal changes are urgently needed to improve the country’s health care system and bring it up to par with western institutions. It requires commitments, manpower, considerable budget, and some new legislation to give it teeth when necessary and makes applicable penalties enforceable. Furthermore, None of these can be effectively accomplished without comprehensive, nationwide, all- inclusive computerized medical records.