Oh Sh*t!

So close, so close.

I have had several “Oh sh*t!” moments in my ventures, but this one was out of a bad movie. Generally I try to put these episodes into the context of just one more of life’s adventures and move on. I had said goodbye to friends and colleagues, packed, arrived at the airport nice and early so as to navigate my way through Ukraine Airlines and passport control. Check, check, check, check, and……..oh sh*t!

I was standing at the passport window as the agent looked at me, looked at the computer, looked at my passport, me, the computer, my passport, me, my passport……this was not going well. He excused himself and came back with his supervisor. I was invited out of line into an office and informed that I was going to miss my flight. I seems I wasn’t “registered” or that my registration had expired.

Registration here is direct hold over from Soviet times. It's done but it seems no one can cogently explain why. One who is going to stay in country for longer than 90 days should register every 90 days, except when it isn't necessary. I was given several different opinions regarding how and when, and how often. To add to my confusion there apparently is a difference of official opinion as ti the if and how often between Almaty and Astana. Because registration the first time was a 2 ½ day experience of exquisite, ambivalent, indifferent, multiple visit pain, I chose to listen to a colleague who stated that, with my type of visa, once I was registered it was good for the duration of my stay. Nope. So I had an extra week in Almaty while I visited the border police and was charged with lack of registration for which the penalty is a 10 day stay in the slammer, deportation, or a fine of no less than about 166USD.

I made than cancelled multiple plane tickets and hotel reservations as I tried plan how I would catch up to the Trans-Siberian railway. It and my friend were headed across Russian without me. I appeared before the judge with two heavy weight members of the US consulate and was duly fined. I really don’t know how it would have gone had I not had the consular people there.  I could very easily be examining the interior paint scheme of a Kazakh jail at this moment.

I booked a flight to Irkutsk in Central Russia and am here now in the train station waiting to board.

On departure from Almaty the second time, I made it to the international area only to have a baggage official approach me and ask for my passport. HELL no. I asked why and she accused me of trying to pack an electronic cigarette. "Uh, I don’t smoke!" She insisted it was there. I followed her back through passport control (sh*t!) and down to the bowels of the airport to the baggage screening area. There to discover that my travel oto-ophthalmoscpe was the culprit. I emptied it of batteries and headed back to…..passport control (sh*t!!!). As I was moving across the lobby to stand in line, now with about 20 minutes to boarding, I felt a touch on my shoulder, turned around and saw yet another official asking me to come with her. I about lost it. I thought, “Look all I want to do is leave this *&!#!! country, why has that become such a big damn problem?” She quietly led me to a gate where I could bypass the passport area. Heavy sigh...

We shook hands and that was that.

The extra week in KZ, while frustrating gave me a chance to travel around to areas in Almaty I had wanted to visit but hadn’t. I rented a bike and glided along tree shaded paths throughout Almaty. My friend and colleague, Zhamila, and I went for a hike in the Tien Shan one last time. I was without obligation, just not pre-occupation.

So I leave Kazakhstan enriched and blessed immeasurably. I have been privileged to see Kazakhstan at very intimate levels and have never felt unwelcome or at risk, ever. I leave content.

The Tien Shan from 1st President's Park

Glacier at the top of Shimbulak ski area

Proof that even when old and well marbled I can still climb to 3500m

I was in Red Square for all of two hours during a layover in Moscow
There was a national book fair with so many tents the the square was
for all practical purposes not visible

The Bolshoi

Central Irkutsk

Train station where we wait to board the TSR

Built in the late 19th century

Beautiful cathedral overlooking the Angara River in Irkutsk

Heading out today

At times like these, eloquence fails. Within the confines of my moth eaten brain I have begun this post on many occasions only to lose it once my mind’s eye dwells on the next experience of the day. Perhaps a cliché:

• The days seemed long but the months were short.

Being American and a physician, I hit the ground here ready to teach and consult. And while I’m slightly embarrassed to admit this, it became clear that I was in what seemed like a time warp; new language, new pace to life, new colleagues. This of course has been the status quo for many a Fulbrighter. In fact it would seem I was one of the more fortunate as I had the opportunity to teach and mentor throughout my host country. Most of my Fulbright colleagues from this part of the world were consistently in one location. Once I was teaching, the weeks flew.

There is a saying in relief work that week 6 is where things seem to compress and condense into what will characterize your experience. This was certainly true with all my relief experiences in the past. Here the first six weeks were ones of relative inertia. I questioned if I was in the appropriate place, with the appropriate university and faculty. Naturally in a country where there are something like 120 ethnicities and nationalities there was miscommunication. In beautiful retrospect, even though my aggravation was in the red zone, the time spent with little to do was of value. I could gauge the rhythms, pace, cultures. So in random order:

• First impressions are nothing more than first impressions.

And mine were superficial to be sure. What made this experience most enjoyable was that I had a chance to have many firsts. Most everyone is employed and while there is little adult levity on the streets, their children will bring it into the future. Kids are kids; laughing, teasing, squealing, flirting. They will free their parents from the sobriety inherited from Soviet times.

• American health care is in chaos.

No news to those of us in the industry (notice I didn't say, “profession"). One gets a valuable opportunity to compare and contrast when abroad. The US spends twice as much on health care as the UK. Yet our quality of care ranks 37^th in the world by most metrics while the UK regularly ranks in the top three. Here the US out spends KZ by more than twenty times. Kazakhstan, while it is still in relative infancy as a nation, is steadily improving and its health care should be in the first rank by another generation. With a single payer system there can be rampant corruption as exists here in KZ but access, prevention, and quality are more efficiently affected and sustained. 

As an American, when I disembark from the plane in Hawaii and am greeted by 80% obesity and 10% diabetes (worse in Hawaii), I will be at once glad to be back in what is familiar and will find myself shaking my head thinking, “If only…”

• Personal space is not personal here

In a country where women routinely walk arm in arm, and men look straight ahead, there is a definite lack of Western culture-type courtesy. No door holding, queuing, deference. A door will open and people will pour through. Cars will engage in play where they will come as close to you as possible and at a very advanced rate of speed when you are crossing a street. Never mind that you are with the light or in a cross walk. To be fair, this is true in almost all places I have visited over the years, Vietnam being the best/worst example. I am not sure why I find it more annoying here. Age? God forbid.

• Legacy

I set out on the Fulbright process simply thinking that it would be cool to do one, nothing else. As the process evolved it became clear that this would be a chance to actually define my legacy, my gift back to medicine if you will. In false modesty, I feel that I have done so. I have done some of my best work here. I learned from my experiences in Botswana, and other places that sustainability is both key and at best fleeting. Kazakhstan is on the threshold of what seems like a simple binary decision; spending resources on primary care specifically the most pragmatic of specialties, Family Medicine or on more sexy and easily attained equipment.

One of the most pressing problems is that Kazakhs live in what amounts to a benevolent dictatorship. Sure there are elections, the most recent being in April. But when Nazarbayev won with 98% of the vote one suspects the fix is in.

• Heritage

There is an intense pride in the heritage of this country. Kazakhs have asked me what my country was like 500+ years ago whereupon I confess that most Americans have very little awareness of our indigenous heritage. Kazakhs celebrate it and are reminded of it daily. Yurts, horse meat, beshbarmak, kumyz, all of it is ancient and revered.

• Farewell

This is my final day here and not only eloquence by simple vocabulary seems to fail. The Kazakhs are a kind and gentle people. They can be out spoken but things don’t escalate as they do in the US. I have never felt as safe as I do here, even in Botswana. There are thugs to be sure, but they aren’t armed with hand guns. I have never seen an animated conversation end in anger except yesterday when I was buying an item and a man was trying to return one for his money. The sales lady balked and he started to shout. In Louisville this could rapidly escalate into a confrontation dutifully documented by countless bystanders on their smart phones. Somehow, people here have the ability to ignore and feign naiveté. Communication is often through softly spoken conversation so much so that I strain to hear.  The social rhythm here, even after 10 months, seems undecipherable.

So I will miss Kazakhstan; her people, history, her emergence into young adulthood in the family of nations. I will return for more master classes as it is key that outside endorsement of Family Medicine continues. 

The US has all the physical features for which Kazakhstan is famous. I think those in the US are more grand. We have a “steppe”, huge mountain vistas, remote back country, canyons, and are bordered by four oceans (Alaska). Yet we lack patience and a kindness of being that is a treasured part of the fabric here. 

Many Kazakhs, and all of the medical students, I encountered want to visit or immigrate to the US. I do my best to disabuse them of this notion. There are more violent deaths in my home town per year than there are in the entire country here. People here, like in Botswana, get along because they must.  They have social tools to do so, tools so subtle that I become aware of them only on reflection.

So I leave tomorrow morning, early. As has become my habit I won’t look back. I will miss friends and colleagues. But those relationships will cool as they always do in my life when I re-enter the US. Painted with broad of strokes, Kazakhstan has been that kind person who you meet when you are new to the neighborhood. The one who invites you to share meals, family, and friends. Who seems to selflessly indulge your needs and guides you through early assimilation. And who seems to do so with little effort and with a kind and gentle lightness of being.

The countdown

But first a quick shout out to the Karaganda State Medical University. I have now visited and lectured at all the public medical schools here in Kazakhstan. KSMU is one of the elite. Students are in the midst of exams and are taking them very seriously, unlike here in Almaty. Visiting the other schools projects context on the culture that is KazNMU. With but two weeks to go I won't say anymore.

I have less than two weeks left here before I, hopefully, head to St. Petersburg, then to Moscow-Irkustk-Vladivostock-Seoul-Hawaii-Bellingham, WA-Walla Walla, WA -Portland, OR-home.

I find I have little to say at this point although I will attempt to sum up the last year before I depart. Until then, I will post a photo a day on Facebook. I know, a little lame but more folks read it than here.So for now please head over to Mike Pendleton on FB.

A group of 5th (out of 7) year students who per usual wanted
a photo with me.

Getting a laugh from students demonstrating the neuro exam

Street art that is updated each year

A statue and memorial to the coal industry, major employer in Karaganda. It is said that the guy using two hands is Kazakh and the one with only one is Russian

An Orthodox cathedral

Locks on a bridge signifying undying love

A KFC, the first in Karaganda is being built about 2km away 

Bike shop at the bazaar

Today in the Tein Shan