Final exam on the final day.

I have had the same translator both times I have been to Semey. She is an extraordinarily gregarious woman who is also a colleague and a member of the faculty in the Department of General Medicine. She has a round open face with an easy smile. Hers life is a struggle as she is caring for her husband who has renal failure and is now on dialysis three times a week, her teenage son (always a break even endeavor at best) and her demented elderly father-in-law. She is a MD/PhD and is paid a pathetic salary from the national government. And yet she refers to her situation with a wonderful joie-de-vivre.

Consulting

When I am giving master classes in Semey I lobby hard to visit local polyclinics so as to mentor docs there. Semey is one of just two locations in Kazakhstan where Family Medicine has a foothold. None of the docs are trained in Family Medicine per se but all act with a level of creativity and integrity that equals and often surpasses many of us in the U.S.

The class, my last after two weeks, was a final exam of sorts. Per the last post you know that the head in phone thing really gives my chain a hard yank. So I wrote a very complex case presentation with some obvious gaffs. Then split the class into eight groups of ten or so. I stated that “Those in your group are no longer your friends. They are your colleagues, your true professors. Learn from them.” Then had them participate in what amounted to a grand rounds- M&M-case presentation and a hard one at that. It incorporated all the topics of the previous two weeks into four patients, all members of the same family. Family Medicine. Get it?

Introducing the subject of the "exam" It's a big hall.

Testing for Rhomberg

Conferencing before demonstrating

These poor interns sweated bullets and held each other to account. There was lively discussion, laughter when they discovered my “mistakes” and coaching from all corners when they were asked to demonstrate how to examine various regions of the body. They still acted for the most part like high schoolers but this time the power struggle was tabled for some real life learning. I’d ask a pointed question, would of get both a “Da” and “Hey (nyet)” and then ask them to defend their choice. I kept emphasizing that this was the best place to really screw up as there were no consequences and very slowly I became trusted and, as happens in these classes, all spoke at once. Somewhere in there the answer was given and we would laugh and proceed.

Testing for Cranial Nerves 3,4,6

Cardia exam team. Almost got it right.

At the conclusion I thanked them all and challenged them to practice evidence based medicine. Then about twenty of them lined up to copy my presentation onto a USB key. I think that was one of the better complements of my experience in Semey.

Then off to SCAT Airlines to hope and pray that it stayed in the air long enough to get back to Almaty. It did and as I walked to the terminal, for the first time since I have been in Almaty, I could see clearly the close proximity of the Tien Shen Mountains. The temp went from -6C in Semey to +22C here. I can see green, no jacket or vest for the first time since late October. Nice.

Mud Season

Back in the days of my misbegotten youth (seven years ago) when I would hop astride my trusty motorcycle and head out onto the Oregon high desert, I would stop at diners in various small towns, strike up a conversation and marvel at the beauty of the area. More than once someone would say something like, “Yeah its nice but you should be here during mud season!” “Mud season?” “Never mind, you have to live it to understand it.” I get it now.

I am back in Semey teaching at the Semipalatinsk State Medical University where the students are motivated and engaging. Of course there is the same “head-in-the-phone” behavior and I even caught one couple passing notes. As I have always done, I cross the boundary from the stage to the floor to the aisles so that the students and colleagues have a chance to be more engaged. It also tends to dampen the mobile phone power struggle.

The temperature at home in Almaty has climbed well into the teens and twenties (about low 60-70^oF) but here it has just risen above 0^o C (32^oF) for the first sustained time period this winter and are we ever in mud season! There are ponds in KY that are smaller than the collected muddy water here. Navigating around these “puddles” on the slippery ice at the water’s edge makes for some new acrobatic dance moves on my part. I was walking around the university hospital when I slipped and muttered to myself, “this is bullshit!”, only to have a very sweet student say in her very lyrical voice, “it isn’t bullshit professor, its ice!” She giggled, then laughed with her friends as she walked (without slipping) off onto and around the muck. I have learned that I can be more stable if I stand erect and don’t look down. Funny how much more you can see if you decide that your feet will do fine navigating through the slippery mess without the input of your brain.

I have come to love Semey and its 300,000 inhabitants more than other places I have visited in Kazakhstan. I really can’t put my finger on why…the people, the architecture, what? The town is gritty, dusty, and full of old and abandoned factories. It is the place where you can stand on a small bridge and see no less than nine stacks belching thick, sooty coal smoke from central water heating plants. The texture and vibe of Semey is one of a town that is at once growing up and growing younger, healing from years of nearby nuclear testing. I find myself enjoying all the log dwellings, peeling paint in bright colors, feral dogs, newer parks that are becoming dilapidated before their time, all of it.

I feel about Semey like I did about the Appalachian towns where I worked in back in college. Perhaps like the Garrison Keillor settlements out on the prairie, there is an innocence and naiveté here that is at once charming and worrisome.  Those traditional towns in S.E. Kentucky became an afterthought once the Wal-marts and KFCs appeared, thus provoking both the culture and its waist lines to radically change. I come from a country that students and colleagues here want to emulate, yet one from which I find I want to protect them. There isn’t any American fast food in Semey (yet), and there aren’t any guns on the street. Gun violence is present (8 shootings, no deaths, last year here in Semey), but it doesn’t come close to the gun violence in the US. 

A mosque built entirely of wood dating back to the turn of the 19th century

More grafitti. Very artistic

Men and women here are in many ways similar to US with some notable exceptions (and I know this is tiresome to both of you that read this blog); the voices of all of the people here are musical. No vocal fry, smokers voice popping texture (yet). People here are modest perhaps due to their Muslim heritage. I was with an American friend of a friend as we all walked around the Nauryz celebrations in Almaty. She was dressed in a tank top and yoga pants and birght shoes straight out of your local gym. Women here wear yoga style pants with very short skirts all the time, but somehow pull it off with a bit more sophistication and modesty. In any case another acquaintance of mine leaned over to me as we were walking and said, “Mike she is the most American person I have ever seen!” I’m not sure what exactly he was saying but I didn’t take is as a complement either to me, her, or my country.

Before I came to Semey, I was attending what would amount to a crafts fair at the National Museum of Natural History as I wanted to see the beautiful hand crafted felt, clothing, wood goods, rugs, and the like. Virtually all there in attendance were expats, most of them Americans. I found myself a little embarrassed and put out as I walked by mothers talking loudly (people here talk in quiet voices) to their adolescent daughters who were dressed in pajama bottoms holding stuffed animals as they whined about whatever. That simply isn’t part of the culture here and I don’t miss it.  The expat conversation is often at the expense of the Kazakhs. People here talk in quiet conversational tones. Even in my presentations when someone asks a question or makes a comment it is such that I have to stain to hear.

There is a new market here (“mahgahzine”), the “Optomarket”, where one can get much of what one can find in an early Wal-Mart, and is a point of pride for the Semey commerce community although it is outside the commercial center of the city. But it has less variety than in my local tired old grocery store in Almaty. It has a huge inventory of a limited number of items. Conversely the bazaar is in the center of Semey and is where everyone does their shopping. You can get anything you want, truly. The Optomarket will have to wait for the culture to change first. I hope is does so deliberately.

I had forgotten that the public “toilets” here are cleaned and kept by a worker and therefore cost the equivalent of a nickel. Last weekend I availed myself of one in the bazaar and left without paying the attendant who cussed me out in Kazakh. Being me I wasn’t going to tolerate being publicly shamed, so I kept walking. Yesterday I revisited the scene of the crime and left her 200 Tenge (186 Tenge=1USD), and walked away. No yelling this time, just laughter.

Neighborhood stand-pipe

I had been anticipating this: a log home made from railroad ties

Mud season 

I have been in Semey for Christmas and now Easter. I was a little morose this morning as I was missing the family centered holiday and the attendant feasting. I was going to celebrate with some quiet contemplation and then my usual fruit, cheese, and bread. Then a colleague, Zhazlan, called and asked if I would like to visit his home. What perfect timing..a delightful photograph taking walk across an area of old Semey where there are stand-pipes, no running water, then across the rail yard and through some alleys to his home. His is one of a few stand-alone homes I have visited. It is old with sagging floors and doorways, but all very clean and happy. They heat it with a coal fired water heater than circulate the water through radiators in the walls so heat radiates in two directions and keeps everything quite cozy. We had bishbarmak, the traditional Kazakh dish of meat (mutton, beef, or lamb) with a horse and fat stuffed intestine (kazy) all of which is boiled and places on a bed of pasta, potatoes and onions. The root vegetables were home grown and fantastic.

Zhazlan on the L with his fiance', Saiya, and his mother seated

next to me. His nephew and aunt round out the rest. It was taken 

by his sister.

The cheery trees on the right

They made cherry juice from cherries they grew in the summer. As I was eating Zhazlan looking rather chagrined apologized that they didn’t have any alcohol to offer as they were Muslims, “but only at home”. In truth he and I have shared several beers in a local tavern, one where I am sure I have been the first American to visit. Amazing.