Four months in and it feels like cruising altitude

I have been here long enough that the intimidation factor has been mitigated somewhat. Yet it's interesting to me that I have such a narrow tolerance for help. I went to a Samsung store this am as my phone is on the critical list and was grateful that there was an English speaker there. That was the good news. The rest is as could be predicted...it seems I need a new phone. Oh well another adventure.

And yet when I'm treated like a celebrity as I have been at times I find it rather un-settling, dis-orienting perhaps. I am grateful for the help with translating and the hosting to be sure. But after that I get a touch, what, overwhelmed by all the attention. I'd like to be treated like an ordinary member of a faculty.

Many "Fulbrighters" relate how it took them three to four months to find some economy in their daily activities, valued familiarity, and routine. I feel I have become acquainted with Almaty such that I can look past the day to day challenges and concentrate on teaching. There are new and novel happenings on a daily basis to be sure, but the frequency and amplitude of them seems to be widening and decreasing.

And I find myself already missing Kazakhstan and her people. While I wouldn't pick Almaty to live as it is very crowded and concentrated, not my gig, Kazakhstan is a beautiful country, something like the US from the Rockies to the Appalachians. The rural areas aren't more rural nor is the weather more challenging than the plains of Kansas north to the Canadian border. And while they say how the weather is tough in the winter, it is comparable to the border states of the north plains. Still when it is -40C (=-40F), it is face biting cold. It really makes one appreciate the genius of the felt lined warmth of a yurt.

The people here stay close to tradition with their guests; sharing meals and  gift giving. I always feel a little awkward as it seems it is I who benefit the most from my visits for teaching; so many novel stories, experiences, and medical challenges. The traffic is a nightmare here in Almaty with speeding and honking due to a huge influx of cars on narrow roads, a situation that has only been present since the early '00s. Still the Kazakhs remain a kind and light hearted people. Lots of laughter, although less so here in Almaty. They are justifiably proud of their country and find themselves in that awkward adolescence wherein they aren't sure what they want to be when they grow up. All seem to just want to be different than where they find themselves now. That conversation is often followed by how they long for a chance to go to or return to the US. I tell them that I am safer here than at home (no guns and a culture that is more inclusive) and that we tend to generalize across cultural lines such that if you speak Russian you are immedicately suspect. Also look at us, we are morbidly obese and unless you get your hands aroung the KFC's, Hardee's, and Burger Kings and attendant fast food your life is going to be very differrent in the next generation.The next 10 yrs will be key of course as the administration here will be assumed by those that weren't heavily influenced by "Soviet times".

It is important to this culture to have their photo taken at any venue or with anyone who crosses their peripheral field of vision so I have had my ugly crooked mug photographed more times in the last four months than in the last 40 years, truly. Groups, single individuals, faculty, parties, selfies, all of it. Sometimes it seems that I am the only one smiling. Getting a candid picture of a group of people is difficult as it is customary to ham it up and look directly at the camera.

I have dined many times on the favorite and traditional foods of Kazakhstan. Meals traditionally begin with a large variety of "salad" but more, and more complex, varieties than you can get from the standard western salad bar. It includes horse meat and fat packed inside small intestine and boiled then served cold. Many root vegetable dishes with shredded cabbage. The honored guest is seated at the head of the table facing the door of the room, or yurt, and then served bishbarmac; a delectable dish of slowed cooked (by boiling) horse meat and onions on flat pasta with savory sauces. This is served with kumys, fermented mare's milk. It is a little like sour cream with a 3.5% alcohol kick. It is loaded with probiotics and is the go to "good for what ails you" remedy and URI prophylactic here. It seems that all food here is high in fat, I arrived with a very favorable cholesterol and while I eat much less volume it is higher in calories. Like so many cultures the food dates back to the pastoral era, not that far back in the case of Kazakhstan, when the next meal wasn't assured and sitting to dine with ones neighbors was good for filling ones belly and for mutual security. All the traditional foods are high in calories..

Finally I have some photos of the winter celebration and miscellaneous others. Happy New Year!

Intestine packed with meat and fat, then boiled and served cold.
I've had this a bunch and it is really tasty

Root vegetables and shredded cabbage. Good stuff

All the meat is handled with bare hands like ours was a generation ago

This will give you a sense of scale. All are adults are average height

Consulting in a rural clinic. The physician is Pakistani.

The infamous Actovgene, them most prescribed med in  KZ. It
is supposed to improve metabolism, Not one shred of credible evidence.

"Hey, its -30C outside. And I still have another layer to go!"

 

A new bird house in Panfilov Park.  It reminded          New Year celebration, in Russian so I don't completely get the 

me of my father who used to go all over the                  costumes. Doesn't matter. They're were having a great time.

west Bay Area putting up blue bird houses.

The cup at the bottom is the bottom of a drink bottle with seed in it.        

 A video of the one class cut up, in her element. She is smarter than she lets on....

This gentleman fought in WWII and presented in his best for a consultation. He is 89 and when told that I thought he had earned the right to do whatever he damn well pleased including eating more of anything, he cried. I told him it would be a privilege to take his picture and the whole class stood out of respect

This is soot from the stack pictured below. It is from a coal burning heating plant. It is about 500m away and up wind! There are 9 stacks by my count but that is only a few of the many according to what I am told.

 Old Semey, note the  mud packing and the tight joinery

                                                        

The outside is gray like all the big buildings here. The inside....well you decide. (Pics at the bottom)

The tour began in the peds ward. I had asked to be shown the hospital to which the Family Medicine Department is attached. It is the Regional Hospital in Semey and is the referral center for what we would call primary and secondary hospitalizations. The exterior is classic Soviet era functional grey concrete block, 7 floors, 200m long and not particularly inviting unless one has no other option, and one doesn’t.

We visited the peds ICU and adult and peds general wards. The rooms are large with five beds, a sink but no bathroom, and quite warm. Folks can receive what amounts to folk medicine or meds used off label as there isn’t a shred of evidence for its use other than anecdote and that just has to change. This hospital is huge and covers all the specialties a western one would. However it needs to be huge as the average length of stay, while I’m not sure of this, must be > 10 days. It is usual to be admitted for two weeks for a problem that is poorly understood by the patient as well as staff, have unending tests run, and leave without a clear sense of why you were there in the first place. Hospitals aren’t safe environments anywhere in the world and as I recall the US has tens of thousands of deaths from hospital error per year. It must be as least twice that here but there are no records kept for this so who knows. Regrettably an acquaintance of mine contracted Hep C from dialysis here.

 I will consult on a patient with the students or interns after a lecture and generally the patient’s physician. Larger places like this one toss patients my way out of a desire to teach and respect for me. Word soon gets out and folks line up to “see the American doctor”. Such was the case today. She is 73 and here for no other reason than she heard that I was. Without her doctor’s blessing she wants to be seen for the Kazakh equivalent of being “checked out”. Full disclosure, I hate this, both here and in the US, as with some folks no amount of reassurance or invocation of common sense will be enough and if they don’t leave without an antibiotic or pain med the doc is detested for practicing evidence based medicine. Here the dance is to be careful to offer a learned opinion without undermining the physician she sees. Well it turns out she doesn’t see one very often so the brakes were off as it were.

She was feeling poorly so she called a physician to her home for evaluation. Many folks here take their blood pressure at home and note that if they feel uncomfortable they have elevated BP, but not by any significant amount. So if their BP is elevated they start looking for symptoms and see if any stick; both the patient and the physician. Well it turns out that she was complaining of everything from headache to jock itch to athlete’s foot. So without touching her the home treating doc ordered an EEG, EKG, abdominal ultrasound, and endoscopy. Now I have been here long enough to have my gene for cynicism rear its ugly head. Without looking at the chart I predicted that she had; chronic pancreatitis, chronic pyelonephritis, and would have had chronic cholecystitis if she still had a gall bladder. On the money. Everyone laughed. And the EKG showed “ischemia in one lead”, yep. And the endoscopy showed “atrophic gastritis”. Man I’m headed to Vegas next.

I had the students do the history and physical and they were outstanding. They really are starting to get it after only two weeks. They are intimidated by a huge, overstaffed, officious, authoritative, Soviet hangover that is the medical establishment. To be sure there are bright lights out there but until more docs and officials retire, there won’t be substantive change. Like my father used to say after a glass or four of wine, “Not enough people are dead yet!”

My point to the interns is that you are as obligated to undiagnose as you are to diagnose, and try not to be intimidated as you are well within your rights to simply play dumb and ask your colleague why she (medicine here is a total matriarchy) thinks that is the diagnosis. Now to be sure too many docs in the US order way too much lab without indication and for the same reasons that they do here; fear and ambivalence. So here she was with all this confusing lab and no one to interpret it for her.

I always tell my students here that the lecture hall is a safe place to be wrong, so commit (dammit!). They slowly are willing to take that risk and today was a true break through as all 35+ coached, laughed, stumbled, farted, and fell down but got the job done. I was giving fist bumps all around. Our patient was having a gas and was showing her 8 gold teeth widely to all of us.

And of course it turned out she had none of the above. But rather had mild hypertension and well-earned osteoarthritis of her knees. Interestingly she had ordered one of those magnet bracelets off the internet (whod’a thunk?!) and used it for her hypertension. So I had the students weigh in on its benefit. We took it off, checked BP, and replaced it, and checked again. I asked if there was any evidence that this worked, anywhere. One of the students said she had seen it on TV so it must work. We howled as I gently cited the difference between anecdote and evidence.

So “now what”, I asked. One of the students brilliantly and gently informed her that she was truly OK and that while we couldn’t predict how long she would live she should look forward to a healthy life. My jaw dropped and I welled up. Wow. She looked at me and held out her fist for a bump, I gave her both fists and the students applauded. The patient loved the attention and left satisfied.

Back to the hospital. It is a step below Princess Marina in Gaborone, Botswana and even primary hospitals in Botswana. Until the whole central control BS vanishes it will always be that way. But today I saw a very distant shining light on the medical education front that validated my purpose here and had a brilliant intern demonstrate the art of medicine to her peers as well or better than I have seen.

With friends after X-country skiing. I was in the snow more than on it

A Russion folk character whose name I forget.

They really do it up for the New Year.That's my hostel
in the background

Steppe'n out (photos at the bottom)

Things here in Semey are amazing and at the same time a little uncomfortable for me. I have been wined and dined out of unearned respect and not a little pity given my (preferred) living situation. The meals are typically banquet style with "salad" consisting of many meat based dishes with vegetables and fruit, followed by a huge meat dish, followed by a huge desert tray with tea. Out of tradition, as soon as my plate seems at about 90% capacity someone heaps more food on it. I have taken to becoming a touch animated when pleading no thank you but to no avail. The meals are delicious and hearty to be sure. And you think turkey can put you to sleep? Try a huge mid-day meal of most any meat! Then try to stay awake while being shown the city in a warm car!  Kazakhs are rigthfully proud of their food. American produce really doesn't come close especially the carrots (markov) they are sweet and crunchy. No funny after taste

Semey has become bichromatic: the gray of the concrete apartment buildings and sky against the white of the ice and snow. There are numerous black smoke belching stacks here such that the snow has a layer of "concrete gray" soot less than half a day after it falls. Festive lights line the streets to break the gray and they are welcomed. The temp here is hovering around -20C, about -5F. Not a big deal in my mind but it seems to be the talk of my circle as they wonder if I am OK. Truly an honor but still a little uncomfortable.

People here are typically either Muslim or Orthodox. Sunday I was fortunate to be invited to worship in the only Orthodox cathedral left in Semey after the Soviets demolished the others. I had been invited to an Orthodox service one other time in Sinjar, Iraq and remembered enjoying it. This experience was in rather stark contrast to Iraq as it was quite informal. In Sinjar we sat and were read a proper sermon. Here one enters the church and can purchase candles and other paraphernalia. You can then advance to any one of 15 separate icons, light a candle, kiss the icon or the picture frame of one, and pray. I was blessed by a priest in the reception and icon area, then spent an hour in the main hall where another priest chanted in Russian and Kazakh while people came and went. On two occasions a priest would pass by with incense. Another would give a holy blessing via a taste of wine (same spoon), a kiss on the cross (same spot for all comers) and dispense some bread. All was very choreographed, solemn, and rather informal at the same time.

After the mass I was invited to breakfast with the priests. All are in the middle of a fast until Orthodox Christmas; no meat or wheat, only vegetables and fruit. To say the least it was an honor to be invited. One of the priests is a physician who asked if I like incense and then gave me some of the resin used in the blessing.

That afternoon we went to the forest to a sacred spring to draw water. People come from hundreds of kilometers away to worship the icons there and take from the spring. They also will go to a little cabana just downstream and immerse themselves i a pool three times. This "keeps us healthy Mike and we don't need you!" We had tea in a classic Kazakh home turned truck stop. Lots of home made food, cheap, with good tea.

Monday I was invited to old Semey to visit the Central Mosque. It was warm and most welcoming.

And I finally got out onto the steppe. I felt like I could breathe again. We visited a physician in a village with a clinic that was very reminiscent of those lonely outposts in Botswana. The doc there was excellent, and lonely. When I said that I had lived his life in both Botswana and less so in Menifee County we bonded and talked about life for an hour.

Teaching is going famously and I love the medical community. I find I am able to offer insight into most cases as physicians here make the same mistakes as all over the world; inadequate history, diving too soon into lab, very poor physical exams, and letting someone else tell you what the diagnosis is. There is considerable intimidation from the "government" which can fine you if you don't follow protocol and the patients use this against you. As I don't have a license here I am a touch untouchable, and while not cavalier, I tend to blow all that off.

Yesterday my host asked me to write a quick speech for "the dinner". Uh, dinner? There is a dinner on Sunday, paid for by Abbott, that will have about 100 folks....in my honor. While I am indeed honored, I am a touch terrified as well. I may have become a bit of a recluse what with living by myself and all. I enjoy my community, but don't want to be the center of it. Since I have apparently already drunk the Abbott cool-aid I'll do what B tells me to do, "Smile and nod, Papa, smile and nod"

Large Muslim cemetery out in the steppe from Semey

same

A colleague showing me the emergency kit for allergic reactions
He is out in the middle of no where and has a kit for many
contingencies

His village from a distance

In his home for a feast, and this was just the first course

The steppe, a deep clean breath, and what the hell is this statue doing here

A orthodox gazebo with icons to worship

Where one can take of the waters, just down stream from the
spring. I needs to be full immersion and three times for it
to have the desired effect on ones immune system.

Eurasian Red Squirrel

Ah the French, the *&%$# French. Rated R (L)

This post may appear a little different as I don’t have reliable web service at the moment so when I find it this will be old news but still relevant. I am in Semey, located in the NE area of the country just east of Astana. It is my second visit here. Semey, Kazakh for Semipalatinsk, is the location where the Soviets exploded no less than 500 nuclear weapons. There is a moving memorial to those that were affected by the radiation, which is directly or indirectly all who were alive during the late 40' to the late 70’s and/or their offspring.

Add caption

I found this very moving. It was at the base of the monument.

A monument in the same park to
the landscape that was also damaged.

You don't need to guess at the theme of this monument

 

I’m ensconced in the med school dormitory where I have my own pad, cheaper than a hotel and friendlier. I arrived a day late as the snow prevented travel (see last post).

The day after the snow storm I got a panic email from my host here stating that the plane was leaving at 0930 instead of 1300. Since I was already packed from the day before I called a taxi and finished securing the apartment. I figured if someone wants to climb five floors to break in only to find nothing, well, it’s just one more story.

Him: “Hey Mike, are you here?

Me thinking that this guy had to be from the US: “Be right down”

Him: “You aren’t in the *** Hotel are you? (Rather seedy joint near my building).”

Me: “Nope”

Him: “Good”.  I’m starting to like this guy.

It turned out he was Kazakh, figured me for an English speaker and thought he’d try it out on me. Off we went to the airport, with me informing him that I would pay another 500T if we made it there in half an hour. On a Monday morning it is a break even bet.

Him: “How you say…..No sweat?” I am really starting to like this guy.

We are 10 min from the airport and hit an epic traffic jam. All the cars are stopped at a roundabout that is used by no less than 5 roads. He looks disgusted and wonders aloud what could be causing the delay. I see some cars with diplomatic licenses pass on the wrong side of the road and one has a French flag waving. I tell him that the French president is in town for some reason and that all the roads near me have cops on them acting officious if not of any real use.

Him: “The police..” (emphasis on the first syllable), reaches down to his crotch and mimics that time tested male way of taking care of one’s self. I start to laugh and am REALLY liking this guy.

15 minutes pass he asks when the plane leaves and what airline I am flying. I tell him SCAT and in 30 minutes.

Him: “Mike, you worry too much. Everyone knows that SCAT never leaves on time!”

 Now he is getting genuinely angry.

“Those French, they are all fackers! Who do they think they are?” I KNEW I liked this guy. “Fack you, you French! Hey Mike my friend, how do you say in English, you know……female dog?”

Me laughing even now as I write this: “Bitch?”

Him: “That’s it. You are all beeches you French fackers!” He is now officially my long lost brother!

He went on, “You police are all crocked motherfackers and the French will bugger you! You know “bugger” Mike?” By now I have stopped breathing as I am laughing that laugh that just doesn’t let one breath and laugh at once!

Oh dear Lord what a great male bonding experience and a belly aching laugh, and at the expense of the French no less! I gave him a 1000T tip just for the fun. The whole trip, about 25km, was all of $21.97US. Cheap to be sure and what a great story! We made it in time, and he told me to “tell those French that they are all beeches!” I assured him that it would be my pleasure, and made the flight.

I’m being treated with a measure of deference and respect here that is unearned and a touch uncomfortable. I can’t even carry my own groceries. All the faculty have a hard time believing I am staying in a modest dorm, but that is the way I enjoy it. I bought some groceries but have not been able to eat many as I am always being hosted for lunch and dinner. Sometimes there is a huge spread and I sit down with everyone anticipating a meal and conversation and am invited to eat while they watch and talk in Russian, awkward to say the least.

There is a more familiar, what, vibe here than in Almaty. This is a town of 300,000 but there is more laughter. And the students are fantastic. All are attentive, engaging, and firm in their conviction that medicine is their calling. The comparison to KazNMU is both stark and reassuring. We often get into very animated conversations and my host faculty members will apologize. I always say I enjoy it and think that patients ultimately benefit from it.

The blonde woman in the foreground
was the one with the eye roll.

I know there are a lot of these cheesey pics but this
is customary here. 

Today I got an eye roll from a student that you could hear 20m away! She was firm in her belief that Family Medicine was too broad and that we couldn’t know it all. The old “jack of all trades, master of none” BS. I acknowledged that while that was true, it was also true of any specialty. She was upset that as of all of three weeks from now all of the primary care docs will be seeing all ages and both genders and as she did so teared up. I gently reassured her that there hasn’t been a day since I entered medical school back the dark ages that I haven’t been scared. Knowing what you don’t know is a good thing. Then challenged her and her class to meet me out of the classroom to discuss their fears and discuss clinical medicine. We’ll see.

So a German, an Italian, a Lithuanian, and an American all went out for lunch....

Today my university, Kazakhstan National Medical University Named After SD Asfendyarov (KazNMU) is holding University Days, a celebration of its founding in 1930. Like many countries in this part of the world KazNMU loves pageantry. One enters the foyer of a grand theater and is greeted by beautiful women dressed in traditional clothing with tall peaked hats. There is music and song at the invocation. All of the singers here have amazing voices. As a "visiting Professor" I am some how a bit of a celebrity, unearned in my opinion. Yet it gives me a podium from which to advocate for better training of post graduate medical scholars.

Now stop me if you have heard this before...I and my fellow guest faculty gathered for lunch at a local hotel. I sat with an Italian consultant who advocates for a western model of hospital governance, a Lithuanian physician who teaches master classes at the School of Nursing, and German thoracic and abdominal surgeon. Conversation turned to the EU. The Italian gentleman lamented that Italy once had a central bank whose funds now reside with the EU and that any time she wants to borrow money it is taxed. And she is forbidden from printing more if she needs it. The German lamented that what the EU needed was a dictator but that had been tried in his country with disastrous results and anyway he was fine with the EU. I mentioned that from across the pond the EU seemed like a delightfully dysfunctional family that at once hate each other and then will sit down together for a meal. The Italian, looking for some support from the Lithuanian asked what could possibly make a stable country like Lithuania with a sound currency want to join the EU. She looked at him and said, "Russia?" The three of us howled and the Italian went back to his food.

Last week I was in Semey, due East of Astana. You know Astana,"The coldest capital in the world". I was warned that it was cold up there. I still remember the conversation Lynne and I had before I left. Something like:
Her:"I hear its cold there, shouldn't you get a proper jacket?"
Me:"Nah, I checked and the temperature in Almaty is about they same in Madison, WI. If Bethany endured the weather there than so can I"
Her: "Are you sure?"
Me: "Yep".

I didn't take into account that I might travel north and my ten year old jacket, perfect for Oregon or Louisville, just wouldn't cut it in -30C and 25km/hr wind. Screw the "Real fell", "bloody damn cold" is what is was. I went into a coffee shop to warm up and the barista asked if I wanted it "to go". I felt like saying: "Not unless I want iced coffee after walking 10 meters!" So I politely asked to have it "to stay" and savored the heat if not the taste.

We have had lots of snow with periods of thaw in between so net accumulation is minimal. The other night I was travelling across Panfilov Park and took this cozy little picture:

After being in country for ninety days one registers with the Immigration Police, a truly biblical adventure. It is a bit of a distance away, still I decided to walk there and meet my colleague who is incredibly patient and helpful. We queued up and were told I needed an HIV test. No test, no number. Off we went to the official clinic where this could be done, also across town, but in the opposite direction. Yelena was very circumspect about it all and stated that nothing happens here that takes less than three days. She is a dedicated bus rider so wasn't interested in a taxi. Any car here can be a taxi and all one needs to do is hold your hand out and quickly a car will stop and you can negotiate a price. I always over pay by about 100T which is all of ~75cents. We got there just as the clinic closed of course so with the help of another kind friend I returned the next day to have my blood drawn. That evening he returned for the results and the next day I went back to the Immigration Police.

The worker behind the window couldn't have been more officious. Neatly pressed uniform, no engaging, no help, arbitrary, offering information in incomplete snorts. She would be perfect for the any DMV. Oh and silly me,  I didn't have some infernal document that I needed from the university. So Yelena, still with a smile on her face, and I went to the office there and got what by my count was the fifth document, along with one hole in my arm, and returned. She said she would have it ready by five that afternoon.

I have mostly been on my best behavior here but really have trouble with officiousness. I smoldered as we took the bus back to the Green Bazaar to pick up a package, two as it turned out, from the post. Both werefrom Lynne (!); somw dried apples and some home made peach jam that about exploded out of the jar due to fermentation. I for an instant thought "maybe I could just scrape the bad stuff off the top". Nope, but there were more goodies and it was delightful. Back to the IP and there she was only this time was smiling, gave me the document and indicated that I was, at last, finished. I am registered and now have yet another number that identifies me.

Well it must be 5 o'clock somewhere

Scene: Friday last, office of my host at Polyclinic 3 where we always have tea and a substantial snack after class, typically around 1pm.
Host, Dr. Malik: "Dr. Mike you like cog-nac (pronounced with a hard "g'")
Me, thinking fast and knowing both that I wasn't sure I did like it as I had managed to live this long without having cog-nac to my knowledge, and, while it was Friday, I wasn't sure that I wanted anything to do with hooch before I rode the gaseous and overcrowded bus home. That thought lasted a micro-second....Oh what the hell:  "Uh, sure."
Out come glasses and a bottle that looks innocent enough, like a wine bottle. A couple of fingers worth are poured into each glass, toasts are made, and I sip it. Nope. It was pointed out that "here in Kazakhstan we drink it all at once!"
Me, thinking my man-card was on the line, smiled and uttered the Russian word for "cheers" and knocked it back.....All of my veins dilated at once and I realized there wasn't enough tea in the CIS to erase this hot flash/buzz/presyncope that I was feeling.
Malik: "You like?"
Me, now slurring my words and thinking myself a true light weight: "Sure". Big mistake.
Malik, grinning and laughing: "Then have some more!"
I crawled out of the office to catch the bus home. The 500m walk to the bus stop did me some good but not enough. I hung onto the bus hand rail for dear life. Later I had a massive headache but knew I had damn well earned it so lots of water and some ibuprofen later I was OK.

 Medeo, the largest rink in the world

The next day I went to the mountains with my colleague Zhamila. We  took a bus to Medeo, the largest skating rink in the world, then started to walk up the hill to the trail head where we were going to find her favorite water fall. We were speaking in English and were approached by an ethnic Kazakh who is a Chinese national and is fluent in three languages (Chinese, English and Russian) in three different alphabets no less.
We passed some members of the international weight lifting team from the PRK (North Korea).

The snow was so soft that for me it was like walking on greased sand dunes.  Zhamila is light enough that she pranced up the mountain while I and our new found friend navigated the waste land below.

The scenery was breath taking. We encountered another trio on the way down, a Swiss, a Kazakh Kazakh, and a Russian Kazakh. We all had coffee on our return to Almaty. I always marvel at the ehtnic and national permutations I encounter. Seated around the table at the coffee house were two ethnic Russian Kazakh nationals, one ethnic Kazakh national, one Swiss, a Kazakh Chinese national, and me from Kyentookyshadt.

Weight lifting team from the PRK. Note the minders on the left.

This week has been with a new set of interns at Polyclinic 16 on the far side of town. The country is young struggles with ownership of patients and responsibility shifting. The morning begins with a presentation on a topic that is germane then we see a couple of patients in a grand rounds format. It becomes difficult as there is no vertical integration such that the words of exquisite wisdom I utter ever make it back to the referring doc, not unlike Botswana.  I was a grump and lets just say it was not my finest hour. I was reminded by a very sweet student that she liked me "when you smile".

Consulting on a patient ground rounds style

The first time I have worn a white coat in decades

Next Thursday I head to Semey in the NE corner of the country to hold master classes for the med school faculty there. I'll check in from there.