More impressions. Warning, no pics

I’ll journey a little deeper into my hippocampus to further explore my impressions of Kazakhstan over the last five months. I’ll do this in bulleted format as it seems better suited to streams of consciousness. Formatting the blog on this site is awful so please bear with me.

• People here are kind and gentle. I have yet to see even a hint of hostility. In Botswana there was laughter and broad smiles that would disarm any conflict. Here it seems to simply be an unwritten part of protocol and seems to be deeply imbedded into the culture. The Russians can be cranky but in the main seem to behave and get along.

• I had mentioned early on how that there aren’t a lot of smiles on the street here. Well that was a very superficial and uniformed observation. Kids smile all the time, adults dote on their kids endlessly. Grandparents do a lot of the child care here and are quietly and extremely patient. And the smiles are there, I just need to offer my own to see them.

• I haven’t observed any one raise their voice to a child here and haven’t seen any tantrums. And I have been in many environments where I would expect it.

• Kids are bundled up in this weather such that they are round on all their corners. They still are placed in buggies in -10C weather but all seem to fall fast asleep with the warm against the cold. I can appreciate that. I leave my window open in -20C weather and like it that way.

• Homes get quite crowded as people of numerous generations and familial iterations call the same flat “home”. So much so that privacy to say nothing of intimacy is difficult to find. Thus one can walk down the street and see sales persons hawking furnished apartments for rent by the hour, cheaper than a hotel here. It can also come with your very own concubine, your chioce of gender, should you be so inclined.

• I pay 1000USD here for my apartment. Compared to the ones of other expats it seems about right. Some are far and away nicer and less expensive and are either subsidized or away from downtown. I live in what is known as the “golden rectangle” wherein there are numerous bars, restaurants, high end stores, and expat hangouts. I live just up (south) of a good grocery store where I have slowly become known as the only non-Russian speaking regular. So all the staff know to simply point. I will sometimes go with a list of items in Russian which makes everyone smile.

• There seems to be little sense of personal space here. I have been to numerous places over the years and this is not unique to KZ. Still lines are not 'lines" in the western sense, one does not “wait” for someone else to go first through a door or climb on or off a bus, etc. One just does moves. Were you to try that in the US it would cross numerous lines of propriety and angry words would be exchanged. The Vietnamese were the absolute worst at this. To each culture its own, and, while I don't (and will never) fully understand this one at least, again, there aren’t guns on the street.

• People use their horns almost as an alternate mode of communication here. But angry glances are rare. Road rage is unheard of in a city that now has approximately twice the number of cars it did 10 years ago. That is of course unless you are stuck in traffic with an American who needs to get to the airport and discover the cause of said jam are the French (see previous blog posted 12 December). I am chuckling about that epic experience even now.

• Medically it has become frustrating in that I see where things are and have the perspective to foresee the consequences of some of the decisions, many of them political, that can affect availability and quality of care for the next several decades.  Here, as in many of the places I have been, way too much lab is generated. This is a particular bone with me in the US as there really is no excuse for the added cost and risk if the lab isn’t going to influence care. Here so much inappropriate and extraneous data is generated that you become your lab results. And the forest (you) becomes lost for all the trees (the lab data). I have yet to see an abdominal ultrasound that doesn’t make diagnoses that have no correlation to clinical circumstances. People are told they have “changes in the liver”, “pancreatitis”, “pyelonephritis”, “cholecystitis” and the like all without any clinical circumstances that would indicate either the need for the test or that the test results were accurate. And, with props to Eli, I will state to the students or those that I mentor: “You can fish or you can hunt. Which is a better idea in this case.” I have said it so often that the students will finish it in broken English whereupon we all dissolve in laughter!

• There is very little precision to history or physical taking, a big sore point with this Luddite masquerading as a physician. I find myself getting hoarse, so often have I repeated the mantra, “If you don’t ask the right questions, you won’t get the right answers”. Folks think nothing of interrupting a patient encounter, no knock, excuse me, nothing. It annoys me to the point of TUMS, but it is the status quo. This happened in Bots, and a lot in other places but I don’t remember it having been as problematic. Maybe it’s age (mine), maybe the lack of endorphins (jeez I am out of shape), who knows. Again I harken back to my personal yogi master, Bethany: “Smile and nod, Papa. Smile and nod.”

• Men ask directions (!) here all the time. Sometimes of me and when I inform them I don’t speak Russian, they smile and move on.  

• There is little sarcasm here.

• People don’t say “I’m like, and then she’s like….” I like that. No vocal frying either. All the voices are melodic and genuine.

• As I walk down a busy sidewalk I see lots of black hair belonging to people of all ages. There is no gray hair here, everyone dyes it. And no one is bald. Ah, would that I had those genes.

• Like all the other places I have been there are a lot of medically unexplained symptoms here. In Botswana it was waist ache, dizziness, and generalized body weakness. In Vietnam it was general malaise, InTurkey it was always cough, same in Albania. Each had its own set of contextual and cultural concerns but it made for a long day for this doc. These symptoms are put forward as the individual feels a need for medical care since she has something similar to one of the maladies a family member or neighbor had who then was informed that they had  “XYZ”, received treatment, and 'recovered'. In short we are our own worst example with this craziness and we seem to reinforce this modality worldwide. Here it is tachycardia or bradycardia. 

•  I was whining about this to our Bethany, an ER nurse with an enviable intuitive sense of medical circumstances, and she replied that at least I didn’t have to deal with “patients with chronic fatigue syndrome and fibromyalgia with metastases to the eyelashes!” True that and then I thought about it. There is literature that states the above diagnoses occur where ever it has been studied. But I have yet to see it anywhere other than in the US. Just sayin’.

As of the end of January I will have been at this Fulbright gig for 5 months, half way through. I thought I would use this entry to try to thematically summarize the experience thus far.

Us and the FSPs at a local waterfall

By far the most fun was to surprise Lynne in Hawaii. I had cleaned my pad and had dinner and then rotted my brain on the web until it was time to call a cab and leave for the airport. The flight left at 2405 and it always takes a while to slide through customs and various check points. As I was waiting in yet another line a group of Chinese guys came through in full stereotypic (regrettably) form: talking loudly and belligerently, moving as a tight group. They had just come from the bar area and thought that I wouldn’t think anything of it if they cut in front. I had pretty well had it by then. I stood tall, squared my shoulders walked up to the closest guy, too close perhaps, and tapped him on the shoulder. He turned around and looked at me right in the chest, slowly moving his gaze to my face on which was a “WTF do you and your mates think you’re doing?” stare affixed to it. He melted (thankfully) and motioned to his guys that oops they needed to queue up at the back of the line, now some 25 deep. One guy wanted to stay put and I again straightened and sent him over “the look”. He went to the back and about 10 people applauded (!).

Jama, Cora, Asher, Grandpa, Judah, Malachi

I arrived a day ahead of Lynne so had a chance to get good and anxious. Forrest and his family took me to the airport where we bought leis and lay in wait. The FSPs spied her as she walked down the hall to baggage claim. Forrest motioned me to come out from around a wall and as she was glancing down, I slipped into view. The reunion was priceless. It was a good thing there was wall she could collapse into. We embraced a long and knowing embrace borne of 44 of relationship and all seemed right. It was 13 days of delight.

Getting in a birthday and farewell hug

The return was through Beijing. I spent the evening in a lounge with a bed and a shower one rents by the hour, cheap at twice the price.

I have been welcomed and embraced by an ancient, kind, gentle, and proud culture. Almaty is safer than Louisville-no guns. I was surprised at how that made such a psychic difference to me but it did and does. I live in a classic Soviet style apartment complex, on the top floor. The construction in that era didn’t include much reinforcing of the concrete so when the much discussed earthquake for which we are imminently due strikes I can ride it down.

I have made several home visits and can say that ALL the apartments of that era are virtually identical. I have learned how the Soviets controlled the Kazakhs at so many levels, large and small. Still many Kazakhs of my generation long for “Soviet times” as all the streets were clean, parks were beautiful and most services were free. Self-determination is tough when one awakens on December 17, 1991 to the realization that one campaign is over but the struggle continues; how does one govern, survive one devastating depression, then another, and protect that which is uniquely Kazakh. And here it is less than a generation later. Almaty is becoming a world hub.

Today in the mountains. That's Bill Shuey, a former Fulbrighter.

Health care struggles to become reliable. It suffers from “Soviet times” in that most doctors are of the generation where ambivalence reigned along with bribes (so called “informal payments”) as did bad anecdotal medicine. Children are still admitted to hospital for two weeks with a simple fever where they will receive twice daily injections of an antibiotic that is toxic to the kidneys, but only if the parents can and are willing to pay the bribes.

Evidence is slowly creeping into the lexicon of medicine here. I give a presentation (they prefer the term “lecture” which I resist) on colds and appropriate use of antibiotics. To my surprise, when the students are polled, not one is willing to use antibiotics in this case. It will take at least a generation go bring medicine into the rank of western nations. Kazakhstan has moved from somewhere near #120 to 60 in outcomes and other parameters measured worldwide. The US is stuck with devoting more than twice as much of its GDP on health care per capita than the next country in rank and, wait for it, it ranks 37^th. It is as scandalous as it is tragic.

I have fallen in love with this nation. The vistas are no more expansive than in Montana, the mountains no more beautiful than the Cascades, the cold no worse than Madison, WI with which Almaty shares latitude. It is of course the Kazakhs, like the Dinka, like the Tajiks of Afghanistan, the Kosovars, the Yazidis of Sinjar, the Kurds, and the Batswana that make this such a unique experience.

 

After a 900 stair climb to the top of a retention dam
that will  prevent a mud slide from inundating Almaty.

I have found that the evolution of Kazakh Family Medicine is about where we were in 1970; rigidly drowning in anecdote and territoriality. A primary care physician makes less than 500USD a month. A pharmaceutical rep makes 8050USD a month with a car, expenses, and living allowance. Of a class of 3000 graduates, less than 20 might be practicing medicine in 5 years. If they are paid more and are held accountable with less draconian consequences things will turn. There is little horizontal integration where one sees a physician within an ongoing relationship and no vertical integration where one visits a specialist (the term is used very loosely here) and returns to their primary care doctor for review and context. I contend, and think I am fairly accurate, that all the polyclinics could be condensed down and around to a handful of Family Physicians.  

I have made some lifelong friends here; colleagues in medicine in the public sector, private practice, and at the consulate. I get to practice enough medicine through consults to scratch that ever present itch. And my ideas are always welcomed, perhaps hotly debated (a good thing) and a consensus is arrived at which seems to satisfy my colleague, the students, the patient and myself.

More later this week.

Lynne: "I went to Hawaii to visit Forrest and Shannon and the kids and look what I found."
Me:  "ME!"

Truth to tell I and the rest of the family and many friends have been conspiring for the last three months to pull this off and it worked!

Happy New Year!