A refreshing break

Sometimes I forget that Almaty, in particular where I live, is more densely populated than any place I have lived before. As the air is smoggy and the folks here tend to look straight ahead, it can become a touch claustrophobic. I have been fortunate to have made a friend close to my age and today he took me to "Big Almaty Lake" up in the mountains above the city.

glacial blue

We were asked to pay a "toll"
at the bottom of the road then
were stopped about 5km from the top and informed that we would have to walk to the top as this is the water supply (one of them) for the region.

The walk was bit of a climb and reminded me of some of the epic climbs I have done as a Team Bag Balmer, both Pottershop and Doolittle come to mind. At the top, about 3,000m elevation, a guy on a mountain bike cruised up and wasn't the least out of breath!

The view was beautiful and stunning. A cream blue lake due to glacial runoff. On the way down we saw dozens of families cooking shash-lik (shishka bob) by the river.

Moon set.

Polyclinic #2

The last week has been another one of getting a sense of what I will be doing here. As there has never been a purely clinical visiting professor here there is some maneuvering about how best to use my talents. I mentored my colleagues out at the Polyclinic #2 this last week.  The first patient we saw was a woman with probable hypertensive cadiomyopathy. She had lost considerable weight, was dyspneic and was told she had cirrhosis. My colleague wondered if she should be referred to a cardiologist. This of course is precisely the reason I came. I stated that we really didn't need to as we had what we needed "right here". And without getting into detail I showed how we could estimate ejection fraction, detect pleural effusion, rule out cirrhosis, and not change medications other than to trim back on some of the useless ones. She left with fewer diagnoses than when she arrived and on fewer meds.

Street art

A  word about how I'm coming to realize how medicine is integrated into the fabric of the culture. The country is quite young and as such is prone to lack of political modulation and can therefore embrace grandiose ideas. Early in the century there was a mandated effort to increase the number of family docs trained in KZ. The next health minister was a surgeon and allowed politics to enter into the debate and the idea of augmenting primary care was quashed. Presently care is tightly governed by law such that my colleagues don't have or use percussion hammers as this is a tool that only neurologists can use and if we were to do so it would be a touch dicey.

More

 Physicians readily default to hospitalization, something (else) leftover from the Soviet model. I have heard about numerous instances where hospitalization was going to be or was used completely without indication, The most noteworthy was a child with ring worm. Her mother was told that she needed to be hospitalized for a month so she could get IV medications. The mother is a friend of a friend who is an American lay person. She took a look, got some terbinafine and advised the mother that this was all that was needed. Out of fear alone the mother cane close to hospitalizing her daughter meaning she would have to pay (read bribe) for everything from meds to sheets, hence the frequent and lengthy hospitalizations.

A tired babushka with grandson on a leash

In addition family members are dissuaded from seeing there loved one.

In a post Soviet satellite like this one everyone of my colleagues has clear memories of  lack of transparency to say nothing of the abject fear. I had heard about the "kitchen conversations" wherein that was the only place that people in the USSR (CCCP) could be spontaneous and even laugh. My colleagues still have clear memories of these times. As a result there is still temerity and frustration in the professional medical ranks about caring for the entire being. There is an air of severity here that I last noticed in Tajikistan. When we crossed into Afghanistan, even though it was only a river's width away and the ethnicity was still Tajic, the lightness of being in the Afghans was remarkable. The difference of course is that Tajikistan was a Soviet satellite and Afghanistan wasn't.

Zenkov Cathedral on a crisp fall day.

The sense of professional contentment is the US is declining among physicians due to a host of things. I have clear memories of the respect my town had for me and hence the family. Much of it was unearned but was generously afforded. Many physicians, for many reasons, are stating that they are unsatisfied with their professional lives and are contemplating leaving medicine. They should be here...One expat physician I know has a cardiologist as a receptionist and an internist as a lab tech! Another Kazakh colleague stated that he is aware of classmates that are driving taxi. Less than 10 people in his graduating class are still in medicine!

The next patient I saw had Takayasus and Lariches syndromes. I spent a bit of time assuring my colleagues he didn't, for and a number of reasons couldn't have them. He did have a BKA,  an MI with a CABG and two stents in each iliac artery. We spent the time discussing smoking cessation. My colleagues looked at him and stated that he should stop and the next topic was discussed, not unlike back home. His wife lit up when smoking was mentioned as if to say something to the effect "See what have I been telling you?!" The guy said he was going to drink 500gms of vodka instead while his wife stood in back of him shaking her head and smiling.

There is definitely a bit of a bite in the air. The heat "turns on" on October 15th. It is generated in three places in the city and then piped to each dwelling as hot water. If it's too hot you can open a window, there is not control. So I can have heat or not. I'll take heat, it already takes forever to get hot water, also generated centrally, to make it up 5 floors!