Reports, Findings, and Conclusions

A substantive portion of my final report to the embassy:

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Use of Mobile ECG Units in Diagnosing Cardiovascular Disease

 

As a result of information derived from my travel experiences/interviews, I concluded that a mobile health application suitable for further research exploration and possible implementation in Kazakhstan would be the use of mobile ECG units in diagnosing Cardiovascular Disease.

            World Health Organization data suggests that 53% of deaths due to non-communicable (not contagious) disease in Kazakhstan occur due to Cardiovascular Disease (World Health Organization, 2011).  Cardiovascular Disease is an umbrella term that is used to describe a number of different disease patterns, including Coronary Heart Disease, Hypertension and Stroke.  Annual deaths due to Coronary Heart Disease (48,000) and Stroke (23,000) in Kazakhstan are great enough that Kazakhstan ranks 5 and 13 internationally for deaths due to these causes (World Life Statistics, 2010). 

             Cardiovascular Disease (CVD) presents a unique set of challenges and opportunities for prevention and treatment in Kazakhsan where there exists an emphasis on tertiary care and a high level of specialization. The majority of the risk factors for CVD are lifestyle related, such as unhealthy diet, physical inactivity, and tobacco use for both Coronary Heart Disease and Stroke, making nation-wide prevention strategies difficult to implement.[1]

             Kazakhstan’s health care system characterized by large hospital systems, overspecialization of physicians (Katsaga, Kulzhanov, Karanikolos, & Rechel, 2012), and central oversight by the Ministry of Health makes innovative strategies directed at preventing CVD challenging. Despite the focus on primary care that the 2005-2010 State Run Program of Healthcare Sector Reform and Development and the 2009 Code on People’s Health and the Healthcare System which specifies the “prioritization of prevention,” actual movement within the healthcare sector has been slow (Katsaga, Kulzhanov, Karanikolos, & Rechel, 2012).

             Beyond primary prevention of CVD through lifestyle changes, there are secondary and tertiary treatment options available for CVD; surgical approaches are available, but often the use of drugs such as ACE inhibitors, aspirin, beta-blockers, and lipid lowering medication can lower two year risk of acute illness by as much as 75%.[2] However, here again, an emphasis on tertiary care and a high level of specialization present obstacles to early diagnosis and treatment. A re-distribution of labor from physicians to nurses and other primary care workers has only partially relieved the problem of physician overspecialization. Physician extenders (i.e., nurses, community health workers, technicians) play a much smaller role in medical practice compared to many of their international counterparts and are often restricted on care that they can provide. Despite a progressive policy aimed at establishing a profession similar to Physician Assistant in the United States, current roles within the system are unlikely to be changed in such a way that will directly help in treating CVD. In addition, the payment of these health care providers (along with that of physicians) lags behind regional averages, and the ratio of health workers per 100 000 population is on a decline (Katsaga, Kulzhanov, Karanikolos, & Rechel, 2012). All of these factors result in obstacles to access including long wait times at hospitals.  

              Given these access concerns, diagnosing CVD can be problematic (i.e., correctly identifying the condition the patient is experiencing). It is often the case that patients experiencing symptoms of CVD would have stopped feeling the symptoms by the time they access healthcare in Kazakhstan where resources are stretched in hospitals and wait times are often long. An accurate diagnosis in CVD can often be made using an Electrocardiogram (ECG) to assess heart rhythm, which can then be used to structure a treatment. It often happens that when a patient feels the symptoms that signify an irregular heart rhythm, by the time they reach a hospital their heart beats as normal.

             However, a recent technological innovation has adapted small ECG units to be used in conjunction with Mobile (Lin, Wolf, Benjamin, & Belanger, 1995) (Governent of Kazakhstan) telephones, creating so-called “Mobile EKGs.” This provides an alternative to seeking a facility with an ECG when symptoms emerge, that is, the mobile ECG monitor can be carried around by individuals in whom CVD is suspected.  The devices are easy to use. They are the size of a mobile phone and fit into a pocket or handbag. One can register his or her ECG by simply putting two thumbs on the device and holding them there for 30 seconds. By pressing the send button they can transfer the ECG reading over a cellular network to a doctor who can check the result as long as they are within the coverage area of the network. 

             The units can be provided to patients by their physician to take with them to measure the ECG at exactly the right moment when they feel their symptoms. In many cases, the ECG will be normal and the symptoms probably caused by stress. In some cases, however, the ECG will show an abnormality requiring some form of treatment to protect the person from complications. Thus, the mobile-ECG holds the potential for early diagnosis and treatment of CVD, saving lives and reducing human suffering. In addition, loaning a mobile ECG unit to a patient can reduce the use of hospital resources in addition to enabling more accurate diagnoses. 

Technology and Infrastructure Investment: Mobile ECG

             At the 24th Plenary Session of the Foreign Investors’ Council on Bringing New Technology to the Infrastructure Sector via Private Investment in Astana, May, 2011, 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 (Venkatchalam, 2011). 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.” Venkatachalam continues, “All over the world, governments are turning to private infrastructure investors as a key means to upgrade technology, particularly in sectors which are experiencing major research advances in efficiency and cost reduction.”

            Implementing smartphone technology performs exactly this type of “leapfrogging.” The broader array of technologies that mobile ECG is a part of is called mHealth. Various mHealth applications have been used worldwide and their efficacy has been well documented. Mobile ECG in particular has been successfully used in environs as diverse as the Philippines, Sweden, Guatemala, and Norway, and has recently been approved for clinical use in the USA by the Federal Drug Administration (Mobile Health News, 2012). 

             The “Compendium of new and emerging health technologies,” published by the World Health Organization, explains, “the system is a proprietary push delivery and review platform allowing remote review using the internet and cell phone network of ECG’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.” 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 Kazakhstan Embassy’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 units can be used within existing systems.

[3]

Nazarbayev University and National Medical Holding

            Hierarchical decision-making causes innovation in combatting CVD in Kazakhstan difficult. Most care is specified by the Ministry of Health under the Guaranteed Benefits Package. Doctors often look to the Ministry of Health first before trying any new treatment or procedure. Recognizing the importance of innovation, the government of Kazakhstan recently purchased the National Medical Holding, a large hospital system in Astana, in order to merge its functions with the academic and research mission of the newly built Nazarbayev University with internationally aware medical personnel, an emphasis on research, and national influence. The partnership will seek to implement various aspects of the Kazakhstani government’s goals in healthcare, including new diagnostics methods, adherence to international treatment standards, and clinical trials and research, and will serve as a model hospital for the rest of the country.

            The government of Kazakhstan’s investment in the National Medical Holding on behalf of Nazarbayev University proves the partnership actively seeks medical technology investment. A medical communication system that integrated smartphones certainly fulfills the second general strategic objective of the Holding: “to develop research and innovation activities and ensure efficient transfer of technologies to Kazakhstan’s public health system.” It would also further the first objective, especially for rural citizens: “to meet the patients’ demand for high-tech, quality and accessible medical services.” A research-oriented mission distinguishes Nazarbayev University and National Medical Holding as a good site for research.

–                     –                         –                          –                         –

 

Also included in the full report are notes/observations from the various interviews conducted and a proposal for further research. For more the full protocol, send me an email at cjsantos@live.unc.edu.

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Summer Research Highlights

As I wait to provide a link to my final analysis (hint! hint! think with your heart!), here are some interesting notes and insights from a couple of my healthcare related meetings in Kazakhstan this summer:

  • Drs. Almaz Sharman and Dana Sharman have been leaders in efforts to bring
    Dr. Sharman without his wife.

    Dr. Sharman without his wife.

    Telehealth technologies to Kazakhstan for years. During this meeting, several cultural impediments to mobile health were raised. The guarantee of free medical care by the state causes many Kazakhstanis to ignore preventative measures in favor of acute responses to illness. This could be an impediment to implementation of mobile health services aimed at chronic disease management. Dr. Almaz Sharman suggested that Kazakhstan’s doctors are resistant to change unless supported by the Ministry of Health, possibly an inheritance of the centralized Soviet system of health.

  • USAID (Arman Dairov, Ashley M. King, Leslie Perry): An overview of the efforts of USAID in Kazakhstan were discussed, including Maternal and Child healthcare, Tuberculosis and HIV epidemiological research efforts.
  • Ministry of Health (Professor Murat Teleuov MD PhD): Dr. Teleuov was able to provide
    Emin and I with Dr. Murat Teleuov

    Standing with Emin, Dr. Murat Teleuov of NU and Min. of Health. President Nazarbayev looks on in the background.

    excellent ideas on the project, including the rejection of several previously considered initiatives. Suicide Prevention Hotlines were rejected due to previous unsuccessful uses, although the problem of lack of advertising was discussed. Efforts aimed at Rural Health and Maternal and Child Health were rejected due to a perceived lack of problems in this area. The greatest interest was in the use of mobile training modules for a new rural Physicians Assistantship program and the use of mobile ECG units for diagnosis of Cardiovascular Disease.

  • Nazarbayev University and National Medical Holding: A tour of Nazarbayev
    Outside the Emergency Care Unit at the National Medical Holding

    Outside the Emergency Care Unit at the National Medical Holding

    University and the National Medical Holding was conducted. National Medical Holding, a large hospital in Astana, was recently purchased on behalf of Nazarbayev University by the Government of Kazakhstan. This collaboration will be the research nexus in Kazakhstan to explore and export healthcare innovation and best practices to the rest of the country. While touring the National Medical Holding, it was clear that many departments routinely sent physicians abroad to receive additional international training, actively sought out new technologies from the developed world, and had an open mind when in came to research and innovation. Additionally, Telehealth operations are already being conducted by the department of Neurology through an online stream of surgical procedures. The research based mission of Nazarbayev University and progressive orientation of the physicians who serve there suggest this facility could overcome the cultural barriers earlier cited by Dr. Almaz Sharman.

To summarize: there is a lot of interest in technology, in particular new and innovative technology, from healthcare practitioners and development experts in Kazakhstan. Experts disagree as to where such technology can be best applied and also what kind of a solution is necessary.

More informally speaking, I think the pace of medical reform and development reflects a lot

The wonderful Nursing staff in National Medical Holding's Maternity and Neo-Natal unit

The wonderful Nursing staff in National Medical Holding’s Maternity and Neo-Natal unit

of the economic development of the past twenty years: quick, disparate, and remarkable. I say quick because it was obvious from talking to many people that there is a lot of energy. Projects are rattled off at the drop of a hat. I say disparate because at the same time stakeholders are very aware of shortcomings and candid in describing these shortcomings to an outsider. Success in implementation still largely depends on the energies of a few key motivated individuals. I say remarkable because of how interesting it is to see successful, thoughtful, and ambitious projects, such as the National Medical Holding’s efforts to provide a

Standing next to a board describing plans for the Nazarbayev-National Medical Holding partnership

Standing next to a board describing plans for the Nazarbayev-National Medical Holding partnership

live electronic video feed of brain surgery for physicians around the country to view and learn from, or the compassionate care in an advanced biomedicalsetting of the Nurses in the neo-natal intensive care unit, or the excitement with which my tour guides explained the research goals of the new partnership of the National Medical Holding and Nazarbayev University- to see these things right next to, say, a piece of radiological equipment that is, by the radiologists own admission, in need of modernization.

Kazakhstan Update

Many of you have likely been wondering “Where’s the content! What happened in Kazakhstan!” I’ve been putting off posting, mostly due to a rigorous school schedule and it’s demands on my time, but also out of respect to my colleagues and the process of transition occurring at the embassy in DC. Since former Ambassador Idrissov is settling in well in his new role as Foreign Minister, I thought I’d provide a couple updates and highlights:

  • For those of you that are new on Kazakhstan, check out the Foreign Minister’s new article reflecting on 20 years of Kazakhstani Independence: http://www.diplomaticourier.com/news/opinion/1281-kazakhstan-reflecting-on-21-years-of-independence
  • Incredible performance by Kazakhstani Athletes in the Olympics (more from startled Londoners here: http://www.csmonitor.com/World/Global-News/2012/0806/Olympics-2012-Among-the-top-gold-winners-in-London-Kazakhstan)
  • More up the alley of my friend and colleague is an innovative new solar energy project in the southern part of the country: http://www.kazakhembus.com/in_the_news/solar-energy-coming-to-kazakhstan
  • A round table “Health Reforms toward Social Modernization” was held on November 15, 2012 with comments from my friend in Kazakhstan-US healthcare partnerships, Dr. Almaz Sharman. While in Kazakhstan I heard analytics and data cited over and over again as a major barrier to strategic healthcare delivery, and I think efforts like National Household Health Survey are a step in the right direction. This project was funded by the World Bank and Kazakhstan’s Ministry of Health. Check out the discussion proceedings here: http://healthproject.kz/en/page/460 and Dr. Sharman’s presentation in particular here: http://healthproject.kz/sites/default/files/RT-3%2C%20APM%20WB%20Presentation%2CNov%2015%2C%202012%2C%20ENG.pdf
  • And Kazakhstan was officially honored by election to the UN Human Rights Council in November. This is fantastic for the public image of Kazakhstan and a recognition of the work that has been accomplished over the past twenty years, but many critics out there exist. In my opinion a very sober and enlightening article largely free from political pandering or reactionary obstructionism from the Eurasian Daily Monitor here: http://www.jamestown.org/single/?no_cache=1&tx_ttnews[tt_news]=40129&tx_ttnews[backPid]=7&cHash=60872a40b2ca17822b6a28b55ba4e118

Soon I’ll be updating with some research and trip highlights, and eventually a link to my final report!

Religion and Ecology in Kazakhstan

A lot of people have been asking me “What religion is Kazakhstan?” This is no easy question to answer. Yes, most of the country identifies as Muslim, but there are also ancient Jewish communities that have been isolated from the rest of the diaspora for a millennia and Eastern Orthodox Christianity is widely observed. Further, the official state posture is not merely one of tolerance, although there is certainly plenty of that, but the aggressive promotion of interfaith dialogue and cooperation. For example, in the newly built capital city of Almaty, one of the most impressive new constructions is massive pyramidal cathedral, over sixty meters in height, that houses chapels for all forty-six of the countries major religions.  Conceived by the president as a meeting place for the world’s religious leaders to promote tolerance and understanding, the 90,000 square meter Palace of Peace and Harmony is a 200-million-dollar testament to the palliative effect of getting human beings from different backgrounds under one roof. (And it houses a 1,500 seat opera house to boot!)

 “The pyramid is extraordinary both in concept and in structure, a modern multi-faith cathedral, described by Lord Foster as ‘A contemporary reconsideration of religious architecture … dedicated to the renunciation of violence and the promotion of faith and human equality.'”

An architectural journalist, visiting the construction in 2006 described the process  as a “shrieking fiery pandemonium (being transformed into) a mysterious kind of heaven … The interior, all swirling smoke and deafening clamor, shot through with torrents of sparks, was William Blake crossed with Piranesi … more Inca than Egyptian; like a temple … a place to wonder at.” The Palace of Peace and Harmony was built around the clock from prefabricated materials constructed in Turkey during the winter months, designed by British architects, funded and constructed by Kazakh workers in a city that has appeared out of no where in the desert, all in little over a year. In Christopher Robbins’ 2006 interview with Kazakhstan’s President Nazerbayev, the president describes some of the thinking behind the project: 

Akbar the Great had a dream of building one big temple for everyone. He was Muslim himself but was tolerant of all religions. His vision was that everyone would enter the great temple through one big gate, and once inside they would have their own temples in which to pray – Christian, jewish, Hindu, Muslim. So everyone entered and prayed to their own God, but they arrived and departed through the gate shoulder to shoulder. I’m building that temple now.

All the major religions insist there is but one God. Well, in my opinion that is so – but we all approach him in our own way. The Koran states that if you kill one person you have killed everyone in the world, and the prophet Mohammed has said it is the duty of Muslims to spread love among people. I want to disprove the Huntington theory which says that the clash of civilizations is inevitable because we are all different. Yes, you can prophesy disaster and apocalypse, or you can think that humans are smarter than that and will not push themselves to that confrontation.

We have forty-six different religions in Kazakhstan operating in peaceful co-existence. No one is restricted from building his own house of prayer. No one is afraid to pray to his own God. And there is not a hint of one group deliberately offending another. The Kazakhs of the twenty-first century should be tolerant, modern people. I tell young people here that they should be citizens of the world and that for them there should be only one nationality – humankind.

 Critics could call these words naively idealistic and triumphant, but to me they are quite inspiring. It is refreshing to see a head of state speak with such rhetoric and actually put money and policy behind such a vision. I look forward to attending a worship in Kazakhstan and seeing how it really comes about.

 

Another huge problem faced by the country of Kazakhstan is an inheritance of ecological disaster from the Soviet Union. During the Stalin years, the Soviet central planners embarked on an ambitious project to transform the steppe into a breadbasket for Russia. The area around the Aral sea in particular, a dry region always, was selected to grow cotton for the rest of the the Soviet Union and it’s satellite states. To accomplish this, water was drained from the Aral sea, formerly the largest freshwater lake in the world. At first the project was a success, cotton was produced at impressive rates and indeed supplied populations as far away as Cuba. However, it soon became apparent that there was an unintended victim – the Sea Level.

 As water was drained for intensive agriculture, the huge body of water known as the Aral began to drop in volume. Simultaneously, fertilizer and pesticide run-off made its way into the remaining reservoir and groundwater. As the water drained, increasing the salinity of the water, and the pollutants poured in, aquatic life began to die by the ton, destroying a thriving fishing economy and an ancient way of life. In a tour of the region in 2006, president Nazerbayev described the situation:

Look, the land around the Aral Sea is already so contaminated that the most rational solution would simply be to move all the people and abandon the area as a wasteland. Kazakhstan is so vast and Sparsely populated there is certainly no shortage of land elsewhere. But we do not have the resources to build enough houses for everybody. And even if we did, many people would simply refuse to go. The Kazakhs are very conscious of tradition. They want to die in the place where they were born.

However, many efforts are currently underway for environmental restoration. In his visit to the area for “The Land that Disappeared,” Christopher Robbins  describes seeing such projects:

“Halfway along the shore of the lake we dropped down to visit work in progress on an eleven- kilometer dam being built by the Chinses with money from the Kazakh government and the World Bank. In previous years the local population and regional government had experimented with sand dykes which had been washed away in storms. The dykes however, had proved that both the level and the quality of the water could be improved significantly by damming.

 

‘This dam is the eight wonder of the world,’ an excited engineer told me. ‘No one has done something like this before. It’s working! In a year the water can be raised four metros. It might not be possible to raise the lake to its previous level, but we should be able to get another five metres- enough to bring key harbors back to life and revive the fishing industry. Where else in the former Soviet Union has there been such success in cleaning up an ecological disaster?’

Indeed these efforts are inspiring. Kazakhstan has already had success building a capital where once there was nothing (Astana), and are tackling even larger problems, environmental degradation and religious tolerance. If they go at it with the same voracity and enthusiasm that they have displaced in their mere quarter century of independence, I have no doubt they will succeed.

Understanding Mobile Health

Following in the footsteps of my colleague Emin, I’d like to take the opportunity to give a bit of explanation regarding the function and workings of a mobile health platform. First things first, when I say “mobile health” or “mhealth” I don’t mean the use of mobile clinics. These are remarkable initiatives, but people are often confused when I bring up cell phones. mHealth refers to the next generation of “telemedicine” or “remote medicine,” and harnesses new technologies in the cellular industry to preform healthcare. Basically, it’s healthcare with cell phones.

There are three main advantages to using a mHealth platform, the opportunity for home visits, telemedicine/telereferals, and training or continuous training for improvements.

Using mHealth in home visits allow for many advantages. Cell phones equipped with mHealth technology allow a community health worker to take pictures to send to a specialist, refer to texts or auxillarly resources, and transmit patient information in a secured fashion. Home visitations themselves are great, it is often quite difficult for a person in need of constant medical care such as a pregnant mother or someone suffering from lifestyle related chronic diseases to travel to a clinic for routine treatment. It is more resource effective to utilize community health workers or local nurses to make home visitation than expensive specialists. Home visitations allow hospitals and other large institutions to monitor patients continuously and refer to specialists remotely for diagnostics when needed while still providing quality point-of-care treatment. Finally, home visitations coupled with mHealth allows local health worker resources to be leveraged, promoting a greater degree of trust and continuity of care between provider and patient.

Telemedicine or telereferals in rural clinic or during field visits, health worker or nurse can use telemedicine kit to send patient symptoms info to remote doctors to eliminate unnecessary referrals and transport of patients. Doctors can review prior patient history with ease. Coupled with community health workers or local nurses, this practice enables point-of-care diagnostics capability and shortens time to treatment through remote consultation with physicians compared to physical referral into hospital systems.

The use of mHealth for training is another often overlooked advantage to mHealth. Say a community has been identified as at risk for diabetes and all of it’s associated illnesses. The following graphic illustrates how mHealth assists in the training of local, place-based community health workers. As you can see, a key advantage to mHealth is not only in training, but continuous training, ensuring a consistently high quality of care.

For me the natural next question is what about HIPAA requirements? For those of you outside of the know, the Health Insurance Portability and Accountability Act is a 1996 law that regulates the use of electronic patient data. The aim is privacy, and information is subjected to a rigorous criterion of desensitization in order to comply. This means that any medical information on a patient, which is private, has to be unattached to any identifier for that patient, such as social security number or name and birthday. Wouldn’t mHealth and the free and open use of patient data open up a variety of HIPAA noncompliance issues?

In fact not. I’ve spoken with Ting Shih of Clickmedix about this exact issue, and their comprehensive system has worked within the HIPAA regulations in the US and similar regulations abroad. Her company’s system takes data captured at point-of-care by primary care doctors or community health workers- data that is attached to a patient’s personal information- runs it through their system in order to desensitize it, and then sends it to the necessary hospitals or to worldwide network of specialists already collaborating on telehealth issues. Then, once the appropriate diagnosis is made, the data is then sent back to clickmedix, which re-attaches the diagnosis to the particular patient, and returns it to the community health workers. The entire process occurs within five minutes.
In another post, I’ll outline why Kazakhstan is so open for innovation in this sector. For now I’ll leave you with this outline as to how mHealth actually works

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.

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