In Search of Kazakhstan Book review part II

Just wanted to share with you guys another selection from In Search of Kazakhstan. Apparently Kazakhstan is the source of not only apples, but Egyptian rulers and possibly King Arthur himself!

I was amazed to learn from an offhand remark made by Yermek that the fearsome Mamelukes of Egypt, whose rule spanned 300 years, were descended from enslaved Kazakh warriors of the nomad Kipchak tribe. He related a tale of murder and intrigue as gripping as that of the Caesars.

 

The mamelukes came into being when the caliphs of Baghdad decided to use nomad slaves to strengthen their armies. They probed to be fine soldiers and rose to high positions in the military, until in AD 870 one seized power in Egypt. In less than ten years the Mameluke sultan had conquered the Mediterranean coast from Egypt to Syria.

 

Although early Mameluke rule was short-lived, they regained power in 1250, and from then on grew in strength. The Mameluke sultans were not a family dynasty but warlords of a military oligarchy, plotting and struggling against one another to gain power. Their loyal troops and administrators from the steppe spoke their own Turkik language, as well as the Arabic of their masters, and their numbers were constantly replenished with nomad warriors. The greatest of the Mameluke sultans was Baybars, an enslaved Kipchak brought from the steppe to Egypt, who rose to become a general and killed his own Mameluke sultan to seize power in 1260. During his rule he crushed the Assassins in their last strongholds in Syria, drove the Crusaders from Antioch, and extended Mameluke rule across the Red Sea to Mecca and Medina. The Mameluke sultans remained in power until 1517, when their yet more powerful Turkik kinsman, the Ottomans, captured Egypt and hanged the last of them. But the mameluke soldiers and administrators were useful to their new masters and were allowed to live, although a wary eye was kept on their power. When it once again grew to be too great in the early nineteenth century the Ottomans massacred them to a man.

One of the interesting things about this story to me is how I have heard of most of these historical events before, but never heard of the connection to the steppes. Ottomons, Assassins, Antioch- these are events at least given a cursory nod in American history books or (when they are not portraying the life and times of “ancient aliens”) the History Channel. However, the connection is never made between these events and the wild and organized warriors from the steppes. I suppose in a way maybe the current military junta in Egypt could use historical lessons from the former Mameluke regime in their mission to solidify control in contemporary Egypt.

Which brings me to another historical event with a Kazakh connection. Who has not heard of King Arthur and the Knights of the Round Table? Everyone at least knows the mythical pulling of the sword from the stone. Apparently, even this even is pure piracy from an earlier myth from the steppes!

The rich Sarmatian heritage of legend, describing an epic tradition that flourished in ancient Scythia in the first millennium BC, seems to have been shamelesssly plagiarized in the stories of Arthur. Just as the young Arthur draws the magical Excalibur from stone, so the Scythian god of war is symbolized by a magical sword thrust into and drawn from the earth. Similarly, just as Excalibur was thrown into a lake on Arthur’s death, so the magic sword of a great warrior chieftain of the Steppe is thrown into the sea on his death. And just as Arthur is said to have led his knights to the continent, so the real Artorius led an expedition to Armorica (Brittany) to put down a local rebellion. A legend on the origins of the Scythians also tells of golden objets falling from the sky, one of which was a golden cup – suggesting the Holy Grail. The numerous similarities and parallels with the stories of King Arthur begin to make the hypothesis seem obvious.

 

Just a note- Artorius is the hypothesized Scythian mercenary general hired by the Romans to fight in Brittany. His soldiers and he ended up settling the island after their tour, which is the historical event that proponents of this hypothesis say prompted, or at least added to, the legend of King Arthur, as well as this cross cultural mythical connection.

If you guys are still interested, I really encourage you to pick up the book. I’m having a great time reading it, and I’ll be sure to add more later.

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Excitement and Update

Friends, Advisors, and Partners,

Excitement is quickly rising at the Santos household. Emin and I are slated to leave in a little over a week, plans are being made, clothing is being packed, and I am looking forward greatly to my coming journey to Kazakhstan. I want to publicly say thank you to everyone who has helped me thus far in this endeavor- from the experts I’ve talked to in the fields of Public/Mobile Health, my fellow classmates who have helped me put together this project, and especially to all those in Kazakhstan and at the Embassy in Washington who have seen potential in me and Mobile Health as a project in Kazakhstan and worked so hard to put this trip together. Although I am nervous about this endeavor, knowing I have such a great support network helps. Thank you so much.

I just had an itinerary sent to me yesterday, and found out that I’ll be travelling through London on my way to Kazakhstan. Speaking of London, did anyone see the Vinokourov victory yesterday? How dramatic!

With summer school done and the trip so apparent, I plan on updating this blog plenty often, so please tune in. I’ll admit, other obligations have left me otherwise indisposed. Regardless, this is going to be a great trip, and a great adventure. Again, thanks so much to everyone who is involved.

 

Charlie Santos

Medical Information Infrastructure

The more I learn about the pace and scope of development in Kazakhstan, the more I’m struck by the importance of information infrastructure systems in effective healthcare delivery. In one of it’s strategic planning initiatives, Kazakhstan’s government identified “(the creation of) a new model of healthcare management and a unified information network for the sector” as an important goal in the National Programme for Health Care Reform and Development 2005-2010. To this end, Medical Information Centers were established (2008) in all oblasts of the country (for the uninitiated, an oblast is a type of administrative unit, like a US state).The goals of the Medical Information Centers include

  • coordinating the implementation, maintenance and development of the unified health information system according to set goals and objectives;
  • ensuring the functioning of the health information infrastructure;
  • developing a unified system for medical and statistical reporting and accounting, using new data collection and processing technologies;
  • receiving and processing statistical reports from health facilities, and monitoring the statistical reporting and accounting in oblast health facilities, particularly in rural areas;

Effective management of data in healthcare allow for significant returns to scale in healthcare delivery. Currently,Kazakhstan has no comprehensive mechanism for human resource management and planning that takes into account the distribution and allocation of staff to facilities. Strategic development of information management systems have the potential to alleviate this problem in the future. Public health professionals and planners will be able to organize resources for effectively as data collection improves.

Further, providers are not immune to the data bug. In a recent presentation, I heard Dr. Brent Egan of Medical University South Carolina’s OQUIN network talk about the effect that quantitative data had on primary care physicians. Many physicians were initially reluctant to turn over patient data due to potential HIPPA violations and the increased workload it entailed. However, many were convinced when they could literally see the data organized in front of them in almost real time. Accurate and timely feedback enabled doctors to address patients problems on a macro level as they occurred.

By extending the data collected through the Medical Information Centers to primary care providers in rural areas of Kazakhstan through cell phones and mHealth, physicians are likely to have a better on the ground response to health conditions. By making this a two way system, Medical Information Centers stand to benefit from the increased data collection that widespread mobile use can provide. This can help alleviate the shortfalls in personelle allocation that currently occur.

Finally, the United States is not immune to this problem as well!

Citations, for anyone who is interested:

Katsaga A, Kulzhanov M, Karanikolos M, Rechel B. Kazakhstan: Health system review. Health Systems in Transition, 2012; 14(4):1-154

In Search of Kazakhstan Book Review

Aside

Last week I wrote a post about the historic signing of “The Declaration of Alma-Ata” in modern day Almaty. I’ve spent my time since then reading more contemporary reports from the WHO and Work Bank concerning disease and health investments in Kazakhstan and global mobile phone technologies, which make for considerably less interesting blogging. However, I picked up a copy of “In Search of Kazakhstan” by Christopher Robbins, which has thus far made a fascinating read.

Robbins, a writer associated with the Daily Telegraph and various other magazines and newspapers in Britain, describes his initial fascination with the country:

The subjects of my books always come to me obliquely, from stage left – so to speak – disguised as something else. In this case it was my near total ignorance of Kazakhstan that was the hook. I sat beside a man from Arkansas on a flight to Moscow who was on his way to marry an Internet bride. It struck me that the only things I knew about the place were that it has a lot of steppe, nomads, and was on the Silk Route… and that was it! As my travelling companion left for his connecting flight, he said, “Apples are from Kazakhstan!” The phrase stuck with me… and somehow captured my imagination. And I ended up writing a book about the place.

The focus was the question – How did a country the size of Western Europe disappear out of sight and mind of the West for 150 years? And I discovered the quick answer is that the Tsars closed it to European travellers in the 19th century, as they ruthlessly pushed their empire south, and then the Soviets sealed it tight, so they could send up their sputniks, test their nuclear weapons, and built their Gulag. So Kazakhstan had a whole secret, untold history, which was fascinating. Pay dirt for a writer.

I can certainly relate to the ignorance on the country (in fact, I plan on writing a blog post soon about the perspective on Kazakhstan I’ve seen as I tell people about my trip. More soon!). The book is written as a travelogue, and is a highly engaging for any westerner interested in seeing Kazakhstan as described by the various people Robbins meets along the way. One person in particular, Baurzhan, is an ethnic Kazakh businessman whom Robbins meets while out clubbing in Almaty. Baurzhan describes the hectic days soon after Soviet independence:

Inflation was running at 30 per cent a month at least. So you took a loan from a bank in local currency, used it to buy dollars, and waited. You’d pay off the loan and borrow twice as much money the next month. And buy more dollars. And so on. Easy money!..

…You go to Uzbekestan or Kyrgyzstan and there are a few very rich people, Richer even than our rich – and we have half a dozen billionaires listed in Forbes. But in these other countries it’s unbelievable. Crazy rich. But they have no middle class. People have no hope for a better life. Ever. So it’s a mess. A middle class was made here- you make a middle class, you make a country.

While I can’t speak with any authority (without doing some serious research) on the comparative wealth inequalities of Kazakhstan, Kyrgystan, or Uzbekistan, nor do I assume that Baurzhan’s experience was in any way common or universal to the post soviet state, I think this quote by itself tells us a couple interesting things. The first is the perspective it gives us on the transition from Soviet to self governance. According to Baurzhan, the days of shady dealings ended about 1996, five years after independence. The second thing this quote shows us is a reverence and respect that even business oriented Kazakh’s have for a broadly shared prosperity, which, for all intents and purposes, has been and is being enacted in Kazakhstan.

The question is whether this occurs in spite of or promoted by the over two decade rule of President Nursultan Nazarbayev. Kazkhstan’s constitution calls for a limit on presidential term limits, but has excluded the first president, Mr. Nazarbayev, from this requirement. While most of my classmates might balk at the prospect of a 20 year presidential reign, it appears that his regime has provided a continuity of power than has stabilized the country as it made the transition from Soviet to Post-Soviet systems. Under his watch, Kazakhstan has turned over its nuclear arsenal (a soviet heirloom), developed extremely well economically, presided over a religiously diverse but tolerant society, and advanced the role of women in society and politics. Robbins had this to say in an 2008 interview with The Book Depository:

Kazakhstan is run by a highly-intelligent and pragmatic president who has brought the country into the 21st century, and attracted the sort of western investment necessary to exploit its vast oil and mineral reserves. President Nazarbayev enjoys excellent relations with Russia, China, the dodgy southern Stans – and the United States and Iran, for heaven’s sake! He is in charge of an enormously rich, moderate Muslim country that actively promotes religious tolerance. You’d think we’d cosy up to him a little. By our standards Nazarbayev’s style is paternalistic and authoritarian, but he’s moving the country in the right direction. As they have only had a democracy for less than 20 years – and we have had one for a thousand – they are doing rather well.

I encourage you all to look up some of the Op-eds in the New York Times that President Nazarbayev has penned in the last several years. He’s an interesting character, and undoubtedly the transition from Soviet to Post-Soviet economic and political structures is a fascinating and vast topic stretching from northern Europe to central Asia. Further, the book “In Search of Kazakhstan” is an excellent read for anyone interested in or travelling to the country. I’ll be sure to quote from both in the coming weeks!

Kazakhstan’s Legacy of Public Health

Kazakhstan faces a historical legacy of promoting the healthcare and well being of their citizens beyond the emergency room. In fact, the first international declaration of the importance of primary care was made in Almaty, Kazakhstan. The 1978 “Declaration of Alma-Ata” was instrumental in the development of a variety of contemporary organizations and initiatives, from the World Health Organization to the UN’s Millenium Development Goals. From Wikipedia:

(The Declaration of Alma-Ata) expressed the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all people. It was the first international declaration underlining the importance of primary health care. The primary health care approach has since then been accepted by member countries of the World Health Organization (WHO) as the key to achieving the goal of “Health for All”

Importantly, the the 1978 declaration of Alma-Ata reaffirmed that health is “a state of complete physical, mental, and social well being and not merely the absence of disease or infirmity.” Public health seeks to actively promote the well being of a nation or region’s citizens. Evidence and experience suggest that this is an improvement over traditional disease oriented systems. Dr. Margaret Chan, Director General of the World Health Organization, speaking in a converence on rural health care, defined Public Health thus:

“First, the highest duty of public health is to protect populations from risks and dangers to health. This duty belongs to government. It includes the performance of basic public health functions, such as ensuring the quality of medicines and the safety of the food, water, and blood supplies.

It also includes a responsibility to ensure that populations have the information and the means to protect their health. Obviously, it includes regulatory functions and requires the investment of public funds.

Second, the highest ethical principle of public health is equity. This can be expressed in simple terms. People should not be denied access to life-saving or health-promoting interventions for unfair reasons, including those with economic or social causes.

Third, the greatest power of public health is prevention. Medicine focuses on the patient, but public health seeks to address the causes of ill health in ways that provide population-wide protection.

All of these principles are embodied in the primary health care approach.

Within the speech, which I’ll link to at the end, Dr. Chan also identifies the broad economic gains that nations are able to achieve by adopting the primary care/public health approach. First I’ll mention the savings. Widely available primary care enables citizens to address illness before it becomes a more serious (read: expensive) problem. The savings to a health system in the category can be enormous. Second comes the health of a worker. Dr. Chan, quoting a doctor in Argentina working on micro financing schemes for women, had this to say:

“The human body is a unique tool for productivity that even the poor possess.”

Healthy workers mean less sick days and a more productive populace. A third benefit is for entrepreneurship and worker mobility. Adequate public health safety nets mean the ability to risk starting a new business, or the safety of moving to a better job. In the aggregate, this means more a more efficient economy. The third point is particularly important in Kazakhstan. The population migration of the last decade have meant a shift to the urban centers of Almaty and Astana and the oil fields of the west. However, as my fellow fellow Emin Hasanov has pointed out, Kazakhstan holds an incredible abundance of natural resources all over the country. In her 2002 book “Kazakhstan: Unfulfilled Promise,” Martha Brill Orkut noted that population shifts have meant:

“…a shortage of qualified workers in East Kazakhstan, West Kazakhstan, North Kazakhstan, Karaganda and Kostanai oblasts. If the pace of investment were ever to pick up dramatically, this shortage could create severe problems for the country.”

Public health in general, and mobile health in particular, represent not a drain on valuable resources, but a potential boon for quickly developing Kazakhstan. Although the 1978 Declaration of Alma-Ata was made when Kazakhstan was still a Soviet republic, the spirit of the declaration and its location should serve a galvinizing force in Kazkahstan’s public health efforts. More to follow soon!

Dr. Chan’s Speech

Discovering New Kazakhstan: Proposal for a Feasibility Study of mHealth Implementation

Lakshmi Venkatachalam, Asian Development Bank Vice President, makes a great observation: “Investors in rapidly growing enterprises are no longer satisfied with long and gradual processes for upgrading of infrastructure services. Instead, they are ‘leapfrogging’ such long transition periods through the quick implementation of new technologies, so as to faster achieve competitive positions in the world market.” Implementing smartphone technology performs exactly this type of “leapfrogging.” The government of Kazakhstan’s investment in the National Medical Holding proves it actively seeks medical technology investment. A medical communication system that integrated smartphones certainly fulfills the general strategic objective of the State-Run Program of Reforming and Development of Healthcare.

The World Health Organization explains mobile health services: “…(T)he system is a proprietary push delivery and review platform allowing remote review using the internet and cell phone network of EKG’s/medical images. Medical data is recorded at the point of care and then uploaded to the system’s server from which it is then delivered to a physician’s smartphone or PC. The transaction is fully traceable and secure.”3 Using smart phones eliminates slow, non- traceable systems such as faxes and paper mail, and offers concurrent modules for medical services, patient management, administration and finance. The mobile system can easily reach to any area that offers telecommunications access. The Embassy of Kazakhstan’s page on infrastructure indicates that telecommunications developments from 2006-2008 resulted in a great number of cellular subscribers: “87 per 100 citizens.” Therefore, the innovation fits with existing systems.

Ting Shih, the CEO of mobile health company ClickMedix has described to me over the phone several modules that could be useful in Kazakhstan. While in Kazakhstan I plan on researching steps to implementation. There are three solutions I want to explore:

  1. Chronic Disease Management: Kazakhstan’s biggest killers are chronic. Mobile health enables front-line health care workers to provide real time updates on patient care and screen for health risks, meeting the government of Kazakhstan’s priority for increased primary care responsibility.
  2. International Specialist Collaboration: The government of Kazakhstan has identified “international treatment standards” in diagnostics as a health priority. Mobile technologies enable fast transmission of patient diagnostic information to a specialist audience.
  3. Expansion of Training: International research has indicated that mobile health can assist in the training of resident physicians. Mobile health allows for international collaboration in training while building Kazakhstan’s internal Doctor capacity (Chang, et al., 2011), fitting with the government of Kazakhstan’s priority to increase medical training.

I will identify existing stakeholders and produce a feasibility study of implementing mobile health technologies to increase in-country physician and health staff training, extend medical reach to rural areas, and speedup overall healthcare delivery. I would like to meet with Kazakh physicians, including Dr. Dana Sharman of Kazakhstan’s Academy of Preventative Medicine whose work in rural provinces appears incredibly promising, government officials, and medical technology experts of Kazakhstan.