- The data says that more than half of the country's population is made up of women, but women's healthcare has grown increasingly politicized.

Today's guest is on the front lines of care, offering healthcare from a mobile clinic that meets patients where they are, literally.

She's Dr.

Mary Fariba Afsari this week on "Story in the Public Square."

(upbeat music) (upbeat music continues) (upbeat music continues) Hello and welcome to "Story in the Public Square," where storytelling meets public affairs.

I'm Jim Ludes from the Pell Center at Salve Regina University.

- And I'm G. Wayne Miller, also with Salve's Pell Center.

- And our guest this week is a doctor and board certified OB-GYN.

Dr.

Mary Fariba Afsari is also the author of a remarkable new book, "Labor: One Woman's Work."

She's joining us today from Portland, Oregon.

Mary, thank you so much for being with us.

- Thank you for having me.

- You know, I mentioned to you that this book was, I thought, incredibly moving and powerful and evocative.

Why did you write it in the first place?

- I started writing this book about 10 years into my career.

And I was an OB-GYN, busy practice, but also a writer at heart, and I decided to get back into my writing.

I had learned that my grandmother in Iran in the 1950s had died when she was only 26 years old.

And this was a story that was very little spoken about in my family.

All we knew is that my mother had lost her mother at the age of 26 years old.

Her mother was 26.

My mother was only four.

And she was pregnant.

And at this point, being an OB-GYN, and nobody really having any answers as to what might have killed her, it was her fifth pregnancy in six years, I decided that, as an expert in the topic of obstetrics, I might be the one that could figure out that mystery of her death.

And so it led me to start asking some questions, and then it led me to start writing a story that is somehow a recreation of maybe the last year of her life, what might've led her to make some decisions that ultimately tragically ended up with her dying, and in doing that, I also saw the parallels in the work that I do as an OB-GYN, and so I started writing my own stories, stories with patients, and weaving those two together, and that's what turned into this book.

- So Mary, the book I found absolutely gripping.

It was a fast read.

It was an emotional read.

And I wondered as I was reading it, was there somebody that you were writing it for?

Who was the audience that you had in mind as you wrote?

- It was a super interesting process, because I started writing about my grandmother.

And at that point, I really felt like she had somehow entered my life.

Like she was with me.

I would have interactions where I would kind of feel her presence, especially during some really challenging situations that I was facing in my career, with burnout, with seeing many, many patients with complicated situations.

So I think I started out really writing it for myself, trying to reconcile the decision that I had made to become a doctor, trying to understand what it is to be an OB-GYN, and then as time went on, I really recognized how my grandmother served as a moral conscience for our times, and that her story, which is a story of what happens when women don't have agency, when women don't have a choice, how they may make decisions that can end tragically, and then generationally, we are left with this hole in our matriarchal lineage.

And so I would say I wrote the book for my family, I wrote the book for my siblings and for my children to maybe have some sort of a story that links us back to our ancestors in Iran over decades, what they may have endured, and then I started writing it for my colleagues and my patients and the generations that are coming after me, for my daughter and her friends, for my son and his friends, and what they are now facing with the restrictions and the policies that are making it very, very difficult for a lot of people to obtain equitable reproductive healthcare.

- So Mary, there's a theme that flows throughout the entire book, and I'm gonna quote from the book, and that is, quote, "When women don't have a choice, bad things happen."

We're living in a post-Roe world.

Is this just about abortion rights, or are you hinting at something bigger with that statement?

- Yeah, it's absolutely not just about abortion rights.

When I talk about the work that I do, abortion may or may not come into play in a clinic, in a practice.

Individual physicians and individual people make decisions about what they're going to do as far as their pregnancy care goes.

But this goes way beyond that.

I talk about bodily autonomy quite a bit in the book.

I also refer back to Iran and the Woman, Life, Freedom movement that erupted in 2022, sort of simultaneously with what was happening in our country in a post-Roe-Dobbs world.

And I see the infringement on choice, on bodily autonomy, on an ability for a person to choose what to do and what not to do with their own bodies as a very dangerous, slippery slope.

And I think when we start to control one aspect, it opens doors to control all the aspects.

And so that's what I'm talking about when I talk about choice.

It's not choice related to just one issue.

It is who we are as individuals, and it is a basic human right to be able to make choices about how we function within our own bodies.

- So Mary, that Supreme Court decision, what has it meant for you and your work and others in the field and for women's health in general?

If you can just elaborate a little bit more on this very monumental decision.

- We're four years in to this decision, unfortunately.

This summer, we're able to recognize that it's four years since the Dobbs decision was made.

And so we have enough data now to look back over the last four years to understand whether or not that decision has been beneficial for people in this country, and what we are seeing is that we are not seeing a decrease in abortions, which seem to be the impetus, supposedly, for that decision.

We don't see a decrease.

Abortions have actually increased.

And we don't see a decrease in maternal death or maternal morbidity.

And we're not seeing an improvement in perinatal outcomes.

It's not like babies and mothers are healthier as a result of this decision.

The problem that we're facing is that when you make policies that police how doctors are able to care for their patients, you are now nitpicking one situation over another situation.

And every individual patient who presents to a clinic or a hospital is usually a complex, multifaceted organism, and the decisions around pregnancy are rarely simple.

There's rarely just one aspect to what that person is facing.

I tell the stories in my book, I think, in pretty granular detail.

I think the reason why readers feel affected by the stories is because I'm trying to take you along with me to listen to the conversations, to be in the room when patients present.

And it's not just around pregnancy care.

It's around their overall life care.

And that's where reproductive healthcare is really misunderstood.

We start taking care of teenagers from a young age when they start getting their menstrual cycles, and there are a whole host of conditions that come along with that, all the way through menopause and beyond.

And when you start to limit what doctors are able to do and you close down facilities and doctors leave states, what you're doing is leaving entire gaps of the population without anywhere to go for any of their care.

And we are seeing the repercussions of that all over the country, including in Oregon, where the laws for us are still protective, but women are struggling to find the care that they need in a timely manner.

- Yeah, I struggle with this reality as a man with tremendous privilege in this space, because I don't feel like my healthcare has been politicized the way women's healthcare has been politicized, the way the healthcare for the transgender community has been politicized.

And I wonder, working in that field, do you feel it on a daily basis?

- I appreciate you saying that.

Lately, as I've been talking about this book, I've been saying, you know, "No one's walking into a urology office."

- No.

- And looking to see, you know, what's happening in that visit, and saying, "Well, you can do this and you can do this and you can talk about this, but actually, this is out of bounds."

That's never been done.

It's not happening in any of my other, you know, specialty collegial offices.

It's really just in our space.

It's one of the reasons I dedicated this book to OB-GYNs, you know, in addition to my grandmothers.

And yes, everybody is facing this as they walk into our clinic.

I know we'll get to this, but I started a mobile clinic.

We're in our fourth year.

I started this mobile clinic pre-Dobbs decision, basically seeing what was happening around the country, recognizing that these access rights were going to be systematically reduced and stripped away.

And so what's happening is that people are now having to travel very long distances in order to receive... And I am talking about basic gynecologic care.

I am not talking about anything that's special.

I'm talking about women who are menopausal, younger women who have infertility.

Maybe they have metabolic syndrome that is impacting their, you know, ability to get pregnant or have regular cycles, severe pain with endometriosis.

So, a gynecologist is addressing a whole host of these issues.

We're also surgeons, and we have the option to take patients for surgeries all the way up through hysterectomies.

Now, what we're seeing is that people are being forced out of their communities, doctors are leaving, and so women are having to make decisions about where to get their care.

And if you look left and you look right and there's nobody available for two to three hours, you're now traveling four hours or six hours.

And then what happens to the clinics and the hospitals in our situation?

How are we able to meet those needs?

So, it is a ripple effect that is for sure affecting everybody.

- You mentioned the mobile clinic, started in an RV.

It's now called FemForward.

Talk about the creation of that.

There are some humorous moments when you buy this van and outfit it with medical equipment and then go into the community, but give us that story and what it does today.

I mean, it meets an incredible need.

- Yeah, I had this idea that if I could take myself anywhere, and we could just pop open and see patients, that we could improve one of the issues that we're facing, which we call maternity care deserts, reproductive care deserts.

So, it is very hard to sustain a brick and mortar in an area where you might have a rural population, and so that's why there's not a lot of specialty care in those communities.

But what if we could take ourselves into those communities once a week or once a month and see patients the way that we see patients in the middle of any kind of major city?

So that was the impetus for the clinic.

Now, I've never actually been inside of an RV.

I'm a tent camper.

I didn't really know what that looked like.

I thought maybe, you know, I could get a van like the Amazon trucks that are driving around everywhere.

I realized those are a little bit small and they're not very cozy.

And so I did walk into Camping World, and I walked into this 31 foot RV, and I really had this feeling of like, "This is it."

We have two separate spaces, you know, a front room where patients can come and sit on a couch and get checked in.

There are counter spaces, there's a sink, there's a functioning bathroom.

And then there's a back room that we can privatize with a curtain and turn that into an exam room.

There's plenty of cabinets.

And so that is what we did.

I purchased an RV not really knowing what we were getting into.

I didn't know for sure where we were gonna be parking, I didn't know for sure how we were gonna get patients, but I'm gonna say this.

When you have an idea to start something that's maybe a little bit outside of the box, it's really good to start where you know people and where people know you.

So, I started the clinic in Portland, Oregon, where I had a good reputation.

I had patients who I knew would trust me.

I had providers who I knew would refer to me.

And that's where we began.

And we started with two patients.

We parked in a church parking lot the first couple of weeks.

We had a few people trickle in.

And we are four years now into FemForward Health.

We have over 2,000 patients on our roster.

These are regular patients like somebody that would go see a doctor in their brick and mortar practice.

They're a part of our patient community.

We do multiple visits for most of these patients, because people come in with problems and we follow up.

We have set locations where we see people so they know where they're coming.

Every Monday, we're in this community.

Every Thursday, we're here.

Every Friday, we're there.

And we have the ability to drive two hours, and we parked on a pier on the Oregon coast, we parked on a pier on the Oregon coast, and we saw women all day long who have very limited access to gynecologic care.

And we did their well visits, we placed IUDs, literally on a pier, where there were tourists walking around and there were bubble blowers, and we were able to provide the same quality standard of care that we are able to provide anywhere.

It is a joyful experiment, and I think it's proving a model of specialty care and reproductive healthcare that I would love to see spread across the country.

- One of the great strengths of this book is your writing style.

You blend humor, information, inspiration, sorrow where needed, it seamlessly works together.

But I want to hit on the humor thing just for a second here.

Tell us about, first, buying that van, and then, like, trying to get it gassed.

I mean, you drove it, but it was not an easy start, not an easy launch, we should say.

Tell us about that.

I laughed out loud at that part of the book.

- Yeah, there's a line in the book where I call my mom and I tell her that I'm going to be running this mobile clinic, and I've bought an RV, and my mom asks me, "Who's going to drive the RV?"

And I said, "Well, I'm gonna drive the RV."

And she says, "You know how to drive an RV?"

And I said, "Listen, I became a doctor.

I do robotic surgery.

I think I can figure this out," right?

And I had a lot of optimism.

I did figure it out.

There were definite bumps and bruises.

I'm driving the same RV today, and so you can see the evidence of the crunch marks from turning into the gas station the first time.

I was a little bit squealing behind the steering wheel as I tried to make this turn.

I had people all along the way that could see me behind the wheel and who helped me out, who guided my driving abilities, and so I've become a quite skilled parker and a lot of things that I didn't think I would ever learn how to do.

So, you know, the generator breaks, and I have to be out there troubleshooting it.

Air conditioning issues, dumping the sewage.

I mean, these are things when you start something, you don't anticipate.

But truly, there was nobody else to do it in the beginning, and so it has been me and my very small staff, and we have figured it out together.

We've laughed a lot as well along the way.

I think that's the only way to do it.

- What have you heard from from your patients about... So, you know, getting healthcare in a mobile clinic in the back of what I'm sure is a tricked out RV, what are you hearing from your patients about that experience?

- When I didn't have the RV and I would just talk about it, I had a lot of feedback from friends and family members who were a little skeptical that anybody would want to come into an RV and have the type of vulnerable exam experiences that we perform as gynecologists.

It involves getting completely undressed and being put on a table, and we're doing invasive exams, including procedures that we do back there.

We have diagnosed cancer through biopsies.

We're placing IUDs.

I have an ultrasound.

So, there is a lot happening in the back that even walking into a regular, you know, exam room might make somebody nervous to undergo.

So I'm gonna tell you this.

My patients have proven all of those naysayers wrong.

They have shown up with an open mind.

And when I ask my new patients how they found us, what inspired them to come to our clinic, because interestingly, in this area, our patients do have a choice.

So there may be rural communities where there's nowhere else to go, but we have a large segment of our patient population that actually could go somewhere else.

We have a highly professional, actually well-insured patient population in addition to the rural communities that we serve.

So when I ask those patients what inspired them to come, the greatest news is that they learned about our clinic, they read about our mission, they looked at our photos, they read our reviews, and they decided that they wanted to become a part of this new way of providing healthcare that feels like something bigger than themselves.

And maybe that's what the Dobbs decision has inspired for folks, is an aspiration to be a part of the change, and that's what this clinic is doing on a very small scale.

We're one little clinic that's offering something different.

We do trauma informed care, so when people walk in, if they don't feel comfortable and they don't need an exam or want an exam that day, if they're opting out of getting undressed, we respect that decision.

But most people choose to come back.

And it's been an incredible community building experiment for me.

It's brought the joy back in medicine for me.

It's been the antidote to burnout.

And so that is where we are today, and we are growing.

- Yeah, you mentioned that you hope that this would become a model for women's healthcare across the country.

What has to happen for that to actually take place?

- Several things.

An idyllic model of healthcare, which is what I think we have, which means I see one patient at a time.

People are used to now, post-COVID, waiting in their cars, receiving a text, and then they come in one at a time for an appointment.

This is very different than the old model that I used to practice in, which worked very well as well.

Not to criticize it.

It was my private practice for a decade.

But you have a waiting room full of patients, and you have two to three exam rooms, and you pretty much just hop from room to room, and you try to maximize how many patients you see in a day, because when it comes to reimbursements and being able to keep a clinic going, and to have enough profit to cover your overhead and your staff and pay your doctors, that is the way that healthcare is run today.

Now, we are running what I consider this idealized model, where I choose how many patients I get to see in a day and I choose how long to spend with them.

There's a reason our patients keep coming back and why we've grown through word of mouth, and it's because our patients feel heard, they feel seen, they don't feel rushed, they feel the intimacy of this small space where they get to interact with their doctor.

We use secure messaging with our patients, and so they're able to actually, on their phones, text us for appointment requests or questions or prescription refills.

It's very sort of seamlessly integrated into people's lives, which is how I would like to see healthcare performed.

But the current way that medical care is reimbursed, women's healthcare is reimbursed at an even lower rate than other healthcare, and so it is a difficult model to sustain if you are working simply within the traditional medical care system.

And so I think that reproductive healthcare requires subsidies.

It requires funding.

It requires a commitment from the government and foundations and grants to really keep it going.

- So, Mary, part of your story is an immigrant experience.

Your family left Iran on the eve of the Iranian Revolution, came to America.

How did that affect you and your family and even your name?

- Yes, I was born in Chicago, and when I was about 18 months old, my parents made the decision to return back to Iran.

They were in the United States for my father to complete his medical training.

Back then in the '70s, there was a wonderful scientific professional relationship between the United States and Iran, and so visiting professors from Johns Hopkins tapped my father to actually finish his internal medicine training in the United States.

So, I was born here, and then they made the decision to return, which had always been the plan.

But like thousands of Iranians, when there was the rumbling of a revolution, of regime change, and the recognition that life in Iran was probably going to change in a very dramatic way, and that it would be a very different place to raise children, my parents returned back to the United States, and I grew up in California.

But when you're a kid of immigrants, especially at a time when the country that your family is from is on the evening news every single night, because we went from the hostage crisis to the Iran-Iraq War to, as we know now, you know, 40 years of witnessing the people of Iran and the freedom that they are fighting for, you know, sort of in opposition to the regime that has been in control, it's not easy to witness that from afar.

I recognize the privilege that I have been given, the ability to grow up and become whoever I wanted to be.

That was the goal of my parents for me.

But I always keep in the back of my mind where we're from.

We still have family there.

And there is a parallel in the way that I live my life sort of in contrast to my cousins and my aunts and uncles who are over there, who are similarly just trying to live their lives in a way that we all dream about.

- You know, Mary, we've got literally about 45 seconds left here, but is there a link between the struggle for freedom and women's rights in Iran, and those same struggles here for women in the United States?

- It's a mirror, isn't it?

I don't think that we ever anticipated that physicians in this country would be criminalized or women in this country would be getting arrested for making simple choices around life-saving care.

And the fact that we are seeing that happen here and we recognize that it happens in other countries, including in Iran, I think is a dire warning for us, unfortunately.

- Dr.

Mary Fariba Afsari, the book is "Labor: One Woman's Work."

It is remarkable.

Now, that is all the time we have this week, but if you want to know more about "Story in the Public Square," you can find us on social media or visit selve.edu/pellcenter, where you can always catch up on previous episodes.

For G. Wayne Miller, I'm Jim Ludes, asking you to join us again next time for more "Story in the Public Square."

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