Coughs and sneezes, bloodshot eyes, rashes … all telltale symptoms of a potential allergy

As regular readers of my postcards will be aware. I have a number of cats – the number varies from time to time – it’s been down to one and as high as eleven.

The original, (Synock – sonny), was a gift from a friend and got on with everyone … but one day whilst playing in the yard two ladies took a fancy to him, picked him up and carried him off.  Everyone in the office and among our neighbours was distraught but one of our staff took pity on me and brought me a pair of kittens – brother and sister from one litter – and said “Choose one”.  My immediate response was “One?”, thinking that it would be good for them to keep each other company.  Sure enough, I kept them both.

Over the years, others have arrived, either as strays … or simply abandoned by people who seemed to know that we would take them in and look after them until we could find them a home.

I know that cats are extremely popular subjects for posting as photos or video clips on the internet … they are so cuddly and cute.  They are not, however, universally admired.

For a start, the domestic cat has been identified as a voracious hunter, responsibly for the decimation of bird populations ion many rural areas … oddly enough, although that seems to be frowned upon, their use as “mousers” usually gains them admiration and praise … so long as they don’t bring their prey home and proudly display it to their “owners”.

Back in the UK, I had a friend who was very fond of my cat, Rosie, he would always shoo him away.  (Yes, Rosie was indeed male – a Tom cat but when he arrived as an extremely young kitten it wasn’t so obvious and … well … I made a mistake … and was too lazy to correct it once it did become obvious).  The problem was that Rosie would wander – cats do … there is some research which shoes that cover an immense amount of territory (which they may share – cohabit) along with other neighbouring cats.  The social interaction may have been beneficial to the character development but it also exposes them to other things – including cat fleas.  Apparently Rosie became infested.  They were very strange fleas, however, because they didn’t seem to affect Rosie, me or anyone else who came to visit – just Jeremy.  They really developed an appetite for his blood.  Because they were such fussy feeders and selective in their choice of victim, it took us a while to identify the source of his problem – and to eradicate it.

As it happens. It is not just a case of treating the animal itself, (for example, washing it with special shampoo …), you have to treat the whole premises because the flea lays its eggs off the animal, for example, in the carpet.

In fact, pest infestation, annoying though it may be, is not as serious as another reason that some people are less than enthralled to see them – some people are allergic to cats … and the effects of the allergy can be quite serious – and even debilitating.  One person actually said that his allergy made him feel like a social outcast – as many people, even close friends, do not understand and realize how serious a problem it presents.  Some sufferers report, for example, that the allergy is so sensitive that they don’t even have to come into contact with the cat – but can tell when meeting someone for the first time if they have a cat … the allergens contained in the cat’s skin and fur transferred to the clothes of their owner and eliciting a response in the sufferer.

Although some visitors to the office are enraptured by the cat’s presence, there are others who find their presence unnerving.  That seems to include quite a few Kyrgyz – I suppose that might have something to do with the fact that, (even if they are good hunters and useful for catching vermin), being territorial and nocturnal creatures, cats, unlike dogs, are not really adapted to the nomadic lifestyle that the Kyrgyz have practiced over the Centuries.

Some people are simply not used to cats,  others dislike anything small and furry, and in a couple of cases it seems to be a phobia … but, occasionally, they tell me they are allergic to cats … and when that happens, of course we move from the office to a new location.

Allergies have been in the news quite a lot recently.  So many stories have appeared that I was little surprised to discover a “World Allergy Day”, aiming to raise awareness among the population and focus attention on the problems that it causes for sufferers and measures that can be taken to help them.  Of cause, if it is just a case that my research was not particularly effective – I am sure that someone will tell me.

One of the news items that caught my attention referred to research that claims to have discovered how allergic reactions to cats are triggered – and which raises hope of being able to develop some form of preventative medicine.

Another told of a father of four who died as a result of a reaction to a bite from a horsefly.  Apparently it all happened very quickly – he probably died within about 15 minutes of having been bitten … Fortunately, it is also very rare.

Allergies come in many different guises – but it is not just animals that can provide the trigger.  These triggers cause “reactions” as the immune system respond to what are actually, to most of us, harmless substances as if they were a threat to the body.  Typical symptoms can include sneezing and rashes … and unfortunately, in some cases, what can be life threatening anaphylactic reactions,

Perhaps the most common form of allergy is Hay Fever … which causes an inflammation of the nasal airways when an allergen such as pollen, dust or animal dander (particles of skin and hair) is inhaled by someone who has a “sensitized immune system”.

Some people are also allergic to certain foods, such as: Milk, Fish and Shellfish, Eggs, Peanuts, Soy, Wheat and Kiwi Fruit.

It seems that allergies are becoming more and more prevalent.  One survey conducted in 2007 suggested that the number of hospital admissions for people suffering the effects of food allergies had increased by a factor of five over the previous 20 or so years.  Scientists are not sure what are the reasons for such a marked increase but among the various theories I have seen, are suggestions that it is a result of changing way of life; that our urban environment creates a greater exposure to substances which provoke an immune reaction are much greater than they used to be … conveyed, for example, by air pollution or in modern products.  Indeed, modern hygienic practices in such environments may actually deprive us of access to microbiota, (yes, I had to look that one up – apparently it is a word), which are beneficial for the development and maintenance of the immune system.

For the record, another recently published piece of research also found a link between the lack of “green spaces” in urban environments with higher levels of stress among the population.

Oddly enough, when we do venture out into the countryside we find ourselves at risk – even for those who don’t suffer from allergies.

There are plants that secrete chemicals which can cause reactions.  The “stinging nettle”, (Urtica dioica), is perhaps the classic example.  Yes, we do have stinging nettles here in Kyrgyzstan

Another is Fraxinella – known as Kupina in Russian – with its light rose coloured flowers, is sometimes associated with the burning bush found by Moses on the slopes of Mount Sinai. Glands in the plant exude essential oils and when a lighted match is brought near to the plant, the air around it seems to ignite with a light blue flame – but leaving the plant intact. In fact the air around the plant carries a mix of particles which help protect it from the heat of the sun during the day and extreme cold in the night and it is this that burns.  As Fraxinella is known to gro here in Kyrgyzstan, I think that calls for two “words of warning”:

• Do NOT try this for yourselves – it is NOT a good idea to take a match to a piece of vegetation – especially in the heat of the summer as there is a great risk of fires which can devastate the environment as well as endanger property, life and limb – and
• The plant needs to be handled with care – protect your skin – those same substances given off by the plant can also burn the skin and, unfortunately, the effects are not immediate but only appear after the passage of some time. It is best NOT to pick the flowers.

Then, there are insects … Mosquitoes and other biting insects have probably done more to ruin a wilderness experience than anything else known to man or woman.  But mosquitoes and other blood-feeding insects are more than a minor annoyance. According to the Centre for Disease Control and Prevention (CDC), diseases transmitted by mosquitoes, ticks, biting flies, fleas, gnats, and other biting insects are becoming a major public health problem. Mosquitoes can carry such serious diseases as Encephalitis, Yellow Fever, Malaria, and Dengue Fever.   Both Tick borne Encephalitis, and Malaria known to occur in Kyrgyzstan, so it is best to be prepared.

Methods of Protection

• Use an insect repellent:
  • Always follow the label directions carefully.
  • Apply only to exposed skin and/or clothing as directed on the product label. Do not use under clothing.
  • Never use repellents over cuts, wounds, or irritated skin.
  • Do not apply to eyes and mouth.
  • Do not apply to the hands of young children who are prone to putting hands in their mouth. Also, use a lower concentration product for children.
  • Use just enough repellent to cover exposed skin and/or clothing. Saturation is unnecessary for effectiveness.
  • After returning indoors, wash treated skin with soap and water.
  • Always keep insect repellents out of reach of small children.
• Dress in
• light-coloured clothing to spot ticks more easily. Wear collared long-sleeved shirts and long pants/trousers with cuffs for maximum protection. Tuck your shirt into your pants and pants into your socks or boots.
• loose clothing –  to help prevent bites from bugs that can reach their biting apparatus through tight clothing.
• Look for ticks several times during the day or before you return indoors. Check especially around the scalp, nape of the neck, behind the ears and knees, and under the armpits.
• • Remove ticks completely with tweezers or tick remover. Grasp the tick close to the skin, as close as possible to the tick’s mouth and pull outward without twisting until the mouthpart is released. Avoid the tick’s bloated abdomen, which can act like a syringe if squeezed.
  • Don’t use heat or suffocation methods. Petroleum jelly, nail polish, rubbing alcohol, cigarettes, or lighted matches will only serve to sicken the tick and may increase the chance of a host tick injecting you with dangerous bacteria.
• If bitten by an insect or tick, treat the area with a bite relief formula for relief of pain, itching, and swelling. If symptoms persist, consult a doctor.
• As some insects, especially mosquitoes, feed primarily at dawn and dusk, and sometimes throughout the night, if you are camping then if possible use a tent with adequate insect netting or sleep under a mosquito net.

Just a couple of weeks ago, I was surprised when I happened, by chance, to run into an acquaintance here in Bishkek … I say “surprised” because I knew that he was supposed to have been in the mountains helping his grandfather to collect honey from the family’s beehives.  So what was he doing in Bishkek.  It appears that he got stung by one of the bees and experienced a serious reaction so he was rushed back to the city for treatment.  He was equally surprised when he was told it was an allergic reaction because, up until then he didn’t know that he had an allergy … to anything, yet alone Bee stings.  (As he told me the story, I couldn’t help but think of the fate that befell MacCauly Culkin in My Girl.)  Fortunately, he quickly recovered … but I don’t think he’ll be helping Grandpa any more in the future.

Traveling with food allergies:

Another form of allergy which can be debilitating and ruin a holiday, (if not actually lethal), is when someone suffers reaction to certain foods … whether it be to Soy, Nuts, Lactose, Cholesterol, Eggs, Fish …

For those who suffer such an allergy, then the first thing to do when planning a trip is to do some research … find out what foods are likely to be available in the area so that they have an idea of what dishes to avoid ….

Secondly … tell someone.  If, they are traveling with a tour operator, then it should be stadard practice to let them know about special dietary requirements – life “No nuts” … so that they can inform the service providers along the itinerary.     In addition, without necessarily “making a fuss” about it, it would be a good idea to make sure that their traveling companions are also aware.

In addition, it’s a good idea to carry a “card” listing the “forbidden fruits” whatever they happen to be in the appropriate languages.  Not  only can this be shown to waiters in cafes and restaurants in the case of any uncertainty – it can be invaluable if an emergency does arise.

They should make sure that they carry any medication with them at all times … just in case.

It’s a good idea to carry some “user friendly” snacks – whether it be a special Granola bar or even fresh carrots or apples.   That’s fairly good advice for anyone – not just those who suffer intolerance to some particular foodstuffs.

High in the mountains

The other day I came across some new research … well, it was new to me, although the paper is dated April 2011.

What attracted my attention in the first place was the “teaser”: “Living at a high altitude can protect you from certain diseases“, which was accompanied by a link to a short article with a slightly more worrying headline: “Living at a high altitude can protect you from certain diseases, but increases your risk of suicide!”  The article had another link – this time to paper giving the report on the research.

As it happens, this was just one of a strong of reports that I have come across recently on the subject of Altitude Sickness (a condition triggered in people who experience difficulty in adapting to the reduced levels of oxygen as they ascend higher and higher in the mountains - causing mild sickness, headaches and life-threatening problems affecting the heart, lungs and brain).  There was, for example:

• the report of new research that suggests that Altitude Sickness is actually a combination of two different syndromes which interact in different ways in different people – balancing symptoms like headaches and fatigue and sleep disturbance … some people experience serious headaches but have no problems sleeping whilst others cannot sleep but report splitting headaches … with a whole array of combinations in between;
• the possible development of a test that may help predict the people who may develop Altitude Sickness. By measuring the heart rates and conducting a series of tests – including ultrasound – at different altitudes, researchers think that they may have identified a common factor in the heart’s action in those that go on to develop the condition … which may help in both the diagnosis and selection of the most suitable form of treatment for individual patients  who fall ill;  and …
• how studying people who different people who develop the condition may help in determining show to care for patients in intensive care units … especially those who have low levels of oxygen in their blood.

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Depending upon the sources you read, something like 20-25% of the earth’s surface is classified as mountainous, (in Kyrgyzstan it’s over 90%), and about 20% of the world’s population live in the mountainous regions – but at least one source claims that about half of the world’s population depend on the mountains, “one way or another”, primarily as a source of water resources.

The main issue affecting people living in at altitude – whether as permanent residents or temporarily, (for example, nomads migrating with their flocks, people working at special locations such as the Kumtor Gold Mine, those on military service … or even mountaineers scaling a peak or two), is hypoxia, the lack of oxygen in the air, which can cause a variety of symptoms and even life threatening situations.

Over the years there has been considerable research  into the effects of living and working at high altitudes and the effect it can have on people’s health and bodily functions; adaptations – both long and short term – to the climate and conditions of living in high altitude environments; as well as social and psychological phenomena of living in such surroundings.

The literature on medical and giological aspects of human life in the mountains tends to divide altitude into five different categories or zones:

Low altitude: 500-1500m a.s.l. – where there is basically no difference in the social and climatological factors affecting health when compared to the surrounding plains … and the course of most diseases are described, at least in one account that I have seen, as “ordinary”

Moderate altitude: 1500-2400m a.s.l. – where serious altitude related illnesses among otherwise healthy people is rare, although some people may experience more pronounced symptoms, (especially the elderly), and there may be implications for people’s diet.

High altitude: 2400-4500m a.s.l. – which is where most altitude related problems are observed, even among otherwise healthy people.

Very High Altitude: 4500-5500m a.s.l. – which are normally encountered only by relatively few mountaineers and trekkers.   There will be frequent “base camps” where people might stay for a few days  and it is important to approach these altitudes gradually to allow for acclimatization.

Extreme Altitude: above 5500m a.s.l. – which very few people ever attain.  It is very difficult for the body to adapt to conditions at these altitudes, and there are other problems resulting from the landscape and weather, (such as avalanches, frostbite and  hypothermia), which also play an important role.

Apparently the development of altitude related illnesses are associated largely with the altitudes at which one sleeps rather than highest elevation reached for a short time.

Living and working at high altitude is recognized under Kyrgyz law as having particular aspects which need to be recognized.  People living and working in high altitude regions, for example, are entitled to additional salary supplements, and can retire earlier than their counterparts living in the lowlands.

I know that I sometimes feel the effect and need to take things easy for the first couple of days when I am in Naryn, (altitude 2041m a.s.l.), usually having driven up from Bishkek, (770m a.s.l).      

Here are some notes that we put together a few years ago  in response to an inquiry from a concerned client, on the subject of Altitude Sickness, based on medical advoce that we received at that time:

Altitude Sickness:

Remember that even in Kyrgyzstan you may travel at over 10,000 feet (3000 meters) and at even higher altitudes in some places.

There are inherent risks in traveling at high altitude. High altitude is generally reckoned to be above 2438m (8000 feet) so that includes places like the Ala Archa, the Dolon Pass, Naryn, Son Kul and Tash Rabat. Very High altitude is considered to start at 3658m (12000 feet) and that would include the Torugart Pass. Anything over 18000 feet (5500 m) is considered extreme altitude – but it is unlikely that any of our tours will ever go this high.

We are not doctors and we cannot advise you. We suggest that you should consult your doctor and ask about altitude sickness, particularly if you are elderly or have breathing problems, asthma, etc.

To the best of our knowledge, very few people suffer from altitude sickness while travelling in vehicles and if they do, the best cure is a prompt return to lower altitudes.

There should be little or no problem for most of our clients, (for example: if you are in a vehicle or even while walking gently at 3000 m.) However, even one of our younger and more athletic staff may reported feeling tired after running a short distance at an altitude of over 4000 meters (just why he was “running” at that altitude is a good question … he had wandered off to take a photo for a client and was returning to the vehicle … forgetting exactly where he was … next time, he said, hewill walk!). Also, a 48-year old and quite asthmatic passenger felt a little uncomfortable when travelling with us over the Torugart Pass, but was no more than a little uncomfortable and aware of the height at which he was travelling.

There is no way of telling who may be affected by altitude. There are no simple factors such as age, sex, or physical condition, which can be used as indictors. Most people are able to go to 2500m and feel no affect – whereas others are taken ill very quickly. For people who are accustomed to travelling at altitude, caution is the best advice. Even for those who have been – proper acclimatization is important.

Altitude sickness arises because there is less oxygen in the air – and to get enough oxygen into the bloodstream, the body has to adjust and the rate of breathing increases (even when at rest). The main cause of altitude sickness is going too high, too fast.  Given time to adapt, the body is able to cope with the changes necessary to copy with the changed conditions – this process is known as acclimatization and usually requires between 1 to 3 days at a given altitude. It is important to remember that different people acclimatize at different rates – so it is important to consider the group as a whole – and not to be guided by the first few individuals to acclimatize.

Over 10000 feet (3048 m) – most people will experience some symptoms. The onset of symptoms is normally delayed for about 12-24 hours after arrival at altitude. Symptoms include headache, dizziness, fatigue, shortness of breath, loss of appetite, nausea, disturbed sleep, and a general feeling of malaise. They tend to be more marked at night because the body activity is decreased and more relaxed. It is important that any symptoms to be reported by clients as soon as they become apparent.

Although some medications are available to help prevent altitude sickness – they should only be taken under medical supervision – and the only cure for altitude sickness is to descend. Medication may help to relieve symptoms but they cannot resolve the overall issue.

If possible, travellers should not drive or fly to high altitudes. It is best to start at below 10000 feet, (3048 m) and walk up. It is important not to over-exert yourself – and if possible to remain at the same altitude for about 24 hours. Ideally further ascents should be at the rate of about 1000 feet, (about 300m) between sleeping altitude per day, with a days rest at that altitude, or at least one rest day every third day. It is best NOT to sleep at the maximum height reached that day (although at places like Son Kul this might be difficult to achieve). If symptoms develop, then no further attempt should be made to go any higher – indeed the advice is to descend. Every person in the group should keep hydrated – drink copious amounts of water and avoid alcohol (also tobacco and other depressant drugs – including sleeping pills). The diet should be high in carbohydrates.

If we are informed beforehand that altitude sickness may be an issue for a particular group of individual, then it may be possible to make arrangements to carry oxygen cylinders. These should only be used by people that have received proper training and are in possession of the appropriate certificates. It should be remembered that these are only an aid – and cannot solve the problem. The only cure for altitude sickness is descent.

Remember:

DESCEND, DESCEND, DESCEND!!!

The particular research being highlighted in this new article examined data about suicides in the mainland continental United States.

The authors point out that altitude seems to show some correlation with the incidence and severity of certain medical illnesses … for example, an apparent decreases in mortality among certain types of patients disease receiving dialysis, coronary artery disease, and stroke, but an increase in some psychiatric disorders such as panic attacks.

They wanted to see if there was any sign of correlation between living at altitude and suicide rates …  and discovered that there was indeed – strongly … and, they suggest, in a way that is not explained by differences in demographic factors, income or geographic isolation,.

They also point to possible areas for further research to focus upon – the situation in other societies, individual differences between different levels of altitude … including physical measurements rather than just data analysis … in order to see what the cause is, if any – social, physological or psychological, for this apparent relationship.

They have already considered (and ruled out), for example, the fact that firearms are a more common in such high altitude communities than those at lower altitudes … it seems that the method of commiting suicide, (use of firearms as opposed to other ways of taking one’s own life), does not play a significant role in the statistics.  The correlation is just as marked when other techniques are considered as it is with the use of firearms.

I am sure that a careful reading of the paper, and consideration of the data sets that they present, will raise other questions … for example, they only consider successful suicide attempts – not those that fail – either by chance, (such as the intervention of “third parties”, poor imlpementation of the plan of action … or because the attempt was simply a cri de couer … which seems to me to be a another valuable source of evidence worth exploring.

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They. 

A literal interpretation of “green fingers”

If I say that I have “green fingers” then, back home in the UK, people will think that I am goof with plants … house plants or garden plants … but here it can have different connotations.

As it happens, as I type this I do indeed have “green fingers” … but it’s because I cut myself opening a can of cat food as the cats mewed and meandered around my feet in eager anticipation.  That’s not to say that I blame them, (or, for that matter, anyone else), for my misfortune … it was just one of those things … as I lifted the lid off the can my index finger brushed against a sharp edge which cut into the flesh.

At first, the blood flow from the wound was slow and seemed insignificant … but as I put it under the tap to wash it it started to flow quite copiously … a bright red viscous liquid.

I opened the medical kit and looked for the antiseptic … and found a bottle of zelenka – which roughly means “bright green” in Russian – and poured it over the wound … before I could mop it up with varta (cotton wool) and bind it with bint (gauze) it had ran freely down the finger and onto the middle finger and the palm turning everything it touched green – hence the name.

I had never come across zelenka until I came here … although, apparently, it is known and accepted as an antiseptic agent – it is not widely used; here in the former Soviet Union, however, it is quite common …  it is not unusual, for example, to see young children with green patches of skin where it has been applied to a wound and there’s even a phrase used to describe a child with cuts that have been painted with zelenka following, for example, a fall:  ”green leopard”. 

It’s used for the cleaning of post operative and post traumatic scars, cuts and abrasions … for the treatment of inflammatory conditions and also staphhylococcal infections, and is applied externally and to the surrounding area of the wound.

It is usually rubbed, for example, into the navel after the freshly cut umbilical cord is knotted on a newborn infant, as a protective measure against infection.

I an told that it is based on a dye used in textiles and it’s antiseptic qualities may well have been discovered accidentally.

It seems that at one point William Perkins, (1838-1907, a child prodigy who entered the Royal College of Chemistry at the tender age of 15), was researching a treatment for malaria – working with coal tar and acid.  One of his experiments produced a purple substance moveinom which was bright purple in colour.  Following this he moved from medical research into the field of dyes, producing syntetic dyes which could replace the expensive natural dyes such as cochineal and indigo … and was so successful that he was even knighted in recognition of his achievements.

The first use made of these new dyes by doctors was to colour preparations of different microorganisms … so that they could be easily examined under a microscope … and it was then that it was noticed that these substances were killing germs on the spot.  .

It’s cheap and effective which might help to explain why it is used so widely here – but according to at least one source, there has been little or no research into it – for example into possible side effects – which may help to explain why it has not been widely adopted in the West with our culture of “test, test, test”.

Apparently it is also used in veterinary medicine.

As well as in it’s liquid form, it is also available as a “pencil”.

One of the advantages of zelenka over iodine, (the other major antiseptic often used here), is that it doesn’t dry the skin out … but …

Useful though it is as an antiseptic, it has one big problem … if just a drop of the solution gets onto your clothing or skin, it’s going to be there for a long time.  Imagine the mess if you knock a bottle over and it spills its contents onto a table or something … or worse still, you drop the bottle and it breaks …

Fortunately, once exposed to sunlight, the stain starts to fade … but it will still linger and it is best to “attack” it as soon as possible with bleach or “saturated soapy water” … on the skin then alcohol or lemon juice … to dilute the liquid.

A set of dentures

When I first came here back in 1995, one of the first things that I noticed was the number of people who sported “gold teeth”.  Believe me, it took some getting used to.

You still see some examples these days, but far fewer and they tend to be worn by members of the older generation.  The use of ceramics for crowns is now much more common and people seem happier with the more “natural” look.

However, to be honest, it didn’t fill me with with confidence when I first had to pay a visit to a zubniy vrach, stomatolog or tish doktur – in other words … to the dentist, and to be frank, I have had more contact with dentists here than I would have preferred – either seeking treatment for myself, for the kids and even for tourists … but, really, I needn’t have worried.

According to a report by the World Health Organization, (WHO), published in 2011, in the soviet period, dental care services were divided into those provided at primary health care facilities, (clinics), and inpatient facilities such as the Dental hospital here in Bishkek.  Nowadays, services are provided by both state run (public) and private clinics – which tend to be located in the capital and oblast centers.  Patients have the choice of attending either the state run facilities or private practice – and another report (also published in 2011) suggests that the numbers of people attending the state facilities are declining.

The network of public facilities consist of some 37 specialist dental polyclinics and 97 dental surgeries which operate under the Family Group Practices and General Practitioner Centers, delivering services under the State guaranteed benefits package … which is quite limited covering:

• preventative work;
  • biannual examinations of teeth and oral cavity of children in preschool facilities, pupils in secondary schools and pregnant women;
  • oral health education to the population;
• urgent dental care to all citizens, including the required medication; and
• dental prosthetics (false teeth – dentures) and orthodontic prosthetics – free prosthetics (except those made from precious metals – e.g. gold) are available for certain categories of the population such as war veterans, survivors of the Chernobyl nuclear disaster and those with certain disabilities.
• Services to correct anomalies of tooth position, occlusion (the manner in which the upper and lower teeth come together when the mouth is closed) and jaw which are provided for free to children under 14 years of age.

Any services not covered by the package are paid for by the patient themselves.

(One of the reports suggests that “Currently, free dental care in public stomatological polyclinics is provided only to pensioners, people with disabilities and children”.)

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A few years ago, I was approached by a travel agent based in Britain who was thinking of starting a new service – a sort of medical tourism, which is all the rage in some parts of the world as doctors and clinics offer treatments which cost less than similar treatments might cost abroad – even taking into account the cost of travel and accommodation.  He was thinking of offering Dental Services to be provided here in Kyrgyzstan.

To be honest, my first thought was “What?” … but I could see his point.  As he put it to me, only basic treatments are available “free of charge” on the National Health Service and many treatments are extremely expensive … I know that even eighteen years ago the cost of dental treatment in the UK was quite high – and I understand that it has soared since then.  In addition, it can be very difficult to get onto a waiting list for treatment and many people are, he said, looking for alternatives.

I was still concerned … not about the level of treatment – most of the dentists that I have met here, (I won’t say all … but, then could I say that back in the UK? – probably not), are competent and I presumed that he would have vetted the choice of dentists that he planned to use so that he could be confident that they were indeed competent.

The main concern I felt was … language … I am sure that there must be some, but I wasn’t sure how many bilingual (English speaking) dentists there were in Bishkek … and to me, that seemed important.  I remember the occasion when I was sitting in the Dentist’s chair with my mouth wide open and my eyes tightly shut, the dentist, (who was new to the practice), stopped the drill and asked me why I had screwed up my eyes … “Because I don’t really want to see what is going on,” I said.  She asked if I was scared, and I answered something like I suppose so – it just isn’t comfortable.  She stopped and then said in a matter of fact way that she thought it would be easier if I could see what was going on because then my mind wouldn’t be working in overdrive, fed by weird sounds and sensations.  I thought, “That makes sense …” and decided to give it a go … and – she was right.  It might have helped that she actually talked me through what she was going to do … what she was doing and what she had done.

As it happens, a lot of the dentists I have been to here have adopted a similar approach … and I think that the ones who didn’t simply refrained from doing so because they thought I wouldn’t understand what they saying … and, who knows, they may have been right!.

However, I asked myself, if I was a potential client, then how keen would I be to open my mouth and let someone loose on my dentures if I didn’t understand what he was saying and doing … no matter how good I was assured he was and the presence of an excellent interpreter?

Anyway, we talked about the possibility of Celestial Mountains acting as an agent handling services (apart from dental services – that is, accommodation, transport, activities when the clients weren’t actually being patients), here on the ground in Kyrgyzstan … but I don’t think he had had much success in drumming up potential business, so maybe my concerns had been correct.

One of the main criticisms I often see and hear about the medical services available here in here in Kyrgyzstan is the lack of modern equipment and medicines … but that situation is changing.  Back in “the good old days”, when I first came here that may well have been true but there are now a large number of private dental clinics which have seen considerable investment – but that, of course means that they are more expensive than the ones run by the government.

Once, when I had reason to visit a state run clinic I was surprised that I was seen in a large room where there were several chairs – each with their own dentist and dental nurse in attendance … and it stuck me like being on a factory floor.  Please don’t misunderstand me, although it didn’t appear as sparkling and shining white as I was used to back in Britain, it was perfectly clean and the staff were perfectly profession and competent.

The one difference that I noticed in the treatment that I received was that, back in Britain I would probably have been given a pain killing injection  as a matter of course before drilling began but here, although I was asked, the implication was, “Don’t be silly – you won’t need it” … and I didn’t.  That’s not to say that they wouldn’t administer an injection if they thought it was necessary and in a later session, when the dentist was addressing a particularly deep root canal, they did give me one – but not until they had asked me a host of questions about allergies and my previous experience with such treatments.

The main reason, it seems to me, that pain killing injections weren’t the normal course of events was simply one of cost.  Here, only basic inspection is free of charge, and everything else is paid for by the patient … and they tend to be extremely cost conscious.

Indeed, the main problem with dental care here seems to me to be one of cost.

Although there are excellent dentists in the state sector, many have moved into the private sector and work in clinics which, as I said, have been the subject of considerable investment … with some of the most up to date equipment imported from the four corners of the world and offering a wide variety of treatments … hence the charges are considerably higher.

Well, today, (September 6th), the dental clinics in Bishkek are conducting a special campaign: “Bekem Tish“ or ”Healthy Teeth”

According to the city’s chief dentist, Mirkazima Bashirova, the purpose of the action – prevention.  After all, as the saying has it: “Prevention is better than cure”

Apparently, according to her, preventive dental care costs fifteen times less than curative treatment … and, of course, it leads to a decrease in the loss of teeth, especially in children and young people.

Everybody who goes to a dental clinic today will receive useful tips on:

• how to choose the right toothbrush and toothpaste
• how to brush their teeth
• how to care for their teeth and oral products for which they are useful.

In short, it is promised, the answer to all the questions of citizens about their teeth and dental care.

Brughel's The Triumph of Death

There were a couple of very sad items in the news last week … and one of them led me to a shock discovery and a “moral dilemma”.

It concerned the death of a fifteen year old boy.  Tragically sad in itself, the article was even more poignant because it went on to report that it was thought that the boy had died of bubonic plague and all the people that he was not to have had contact with had been placed in quarantine – isolated and under medical surveillance and the village is cordoned off by police and health workers.

It seems that he lived in a remote region at the extreme Eastern tip of the country, and had been his father, a working shepherd, when he complained of feeling ill and returned home to his village.  After a period when he didn’t seem to get any better, indeed he became feverish and developed swellings in his armpits … they family took him to the local hospital where the doctors diagnosed the likely cause and tried to treat it.  Unfortunately, however, it was already too late – the disease was too far advanced and boy died the same day.

The authorities were quick to react, not only setting up the quarantine but also establishing a regional control center and dispatching the necessary medical supplies to treat all those possibly affected.  A statement was issued which hit the local and regional news – but I haven’t seen any mention of it in the international press – so far.

In a way that doesn’t surprise me.  Although, when a squirrel was discovered to be infected in park in Los Angeles earlier this year, there was quite a bit of coverage, but that may well have been because the authorities there immediately closed the park.  In fact, there are something between one and two thousand cases diagnosed around the globe every year … even in the South Western states of America …  and they don’t all get covered in the media.

For someone who was brought up on stories of the Black Death,  the Great Plague of London in 1665/6, and reading Albert Camus’ existentialist novel The Plague, the images that sprang to mind when I heard the news were quite alarming … after a little research, however, I began to feel a little more at ease.

For the record: Bubonic Plague is a disease caused by bacterial infections carried by fleas.  The name comes from the Boubos which refers to one of the classic symptoms – swollen glands under the armpits or in the groin.  It, along with two forms of plague, are thought to be the cause of the Black Death which swept through Europe in the 14th Century and is said to have wiped out something like a third of the world’s population at the time.  It is not only contagious, (conveyed by flea bites), if it isn’t treated then most victims will die within days.

The symptoms are numerous and diverse, including: gangrene of the extremities such as toes, fingers, lips and tip of the nose; Chills; a general malaise, (ill feeling); a high fever (39° Celsius or 102° Fahrenheit); muscle cramps; seizures; smooth, painful swellings of the lymph glands commonly found in the groin, but may occur in the armpits or neck, most often at the site of the initial infection. Sometimes the swellings may be preceded by a pain; color changes of the skin – to a pink hue in some very extreme cases; heavy breathing; continuous vomiting of blood; aching limbs; coughing, and extreme pain; extreme fatigue; gastrointestinal problems; black dots scattered over the body (which led to the name Black Death); delirium, and coma.

Treatment is possible, however,  if administered in time – the sooner the better but preferably within 24 hours of the appearance of the first symptoms. Several classes of antibiotics, for example, are known to offer effective treatment.

In fact, the Center for Disease Control, (CDC), seem to think that preventative measures – especially avoiding contact with wildlife – don’t pick up dead animals, etc. – is a good preventative measure.    The also advise educating the public in likely areas of infection of the risks; regular surveys of the wildlife population, controlling rats on ships and docks and in warehouses; wearing gloves whenever handling carcasses and immunization.

In the event of an infection such as this one, they advise immediate reporting to the authorities so that remedial action can take place: isolation and quarantine (for seven days – the incubation period of the disease) and delousing of contacts, their clothes and belongings, disinfecting surroundings, and administering medical treatment.    Further steps are advised to be taken in the event that it is not an isolated case but develops into an epidemic scenario.

Normally, when researching a topic, I am delighted to discover that Central Asia in general, and Kyrgyzstan in particular, may the home of something: tulips, for example, or rhubarb; apples or walnuts … and so on.

I wasn’t so happy to discover, however, that Issyk Kul could be the home of the original Black Death which swept through Europe in the fourteenth century.

Apparently, the news reports of this case included a comment that the remote region where his father was tending his livestock “is considered a natural focus of the plague” with occasional outbreaks – but the last reported case was in 1980.

The Issyk Kul region is certainly a prime habitat for marmots, which are known to carry a virulent form of the plague.  (It seems that the family had caught and eaten marmot).

Unfortunately the course of the disease in Asia is not as well documented as its history in Europe.  Many scholars seem to think that the disease began in Western China, and some actually point the finger at Lake Issyk Kul and that it spread Westward along the Great Silk Road together with the Mongol hordes who, according to some sources, even used it as a form of what we would call today “biological warfare” – catapulting infected corpses over city walls of Kaffa in the Crimea to spread the plague among the defending population.

Archaeological excavations on the shores of Issyk Kul reveal that the Nestorian Christian trading community there was ravaged by bubonic plague in 1338-39 when the settlement’s  death rate shot up from a 150-year average of about 4 people per year, to more than 100.

It is also possible, however, that traders from further east brought diseased fleas with them to the shores of the lake.

So, what was the “moral dilemma” that I faced? – whether or not to write a postcard about it.

I work in tourism and aim to attract potential clients to visit Kyrgyzstan and its mountains.  Bad news like this may be enough to cause them to think twice about Kyrgyzstan as a possible destination – if not actually positively dissuade them.

On the other hand … I have a moral duty and responsibility (if not a legal obligation) to inform clients of any material risk that they may face.

Also, on a purely practical point, it is likely that people may get to hear about the case and so, I decided, we need to be prepared to answer any and all questions that do arrive.

As a result, I decided to write this postcard.

The Ten Commandments exhort us that we should “not bear false witness against thy neighbour” … which is frequently simplified to “Don’t Lie” … which, it seems to me, is actually much stronger.

I keep telling people that this should also be a fundamental rule of marketing … don’t let people think that they are going to land in the seat of luxury but be honest – although there are five star hotels in Bishkek, for example, and some good quality accommodation around Lake Issyk Kul, most of the accommodation in Kyrgyzstan is fairly basic – Bed and Breakfast or akin to camping, (for example in a yurt).  Tell the clients “up front” so that there can be no misunderstanding and they know what to expect.

It’s not even a case of “put a positive spin” on the story.  Be honest and realistic – Tell it as it is – “warts and all”.

In this case where someone has died of bubonic plague … tell people … tell them what the risks are and what precautions they need to take to avoid exposure to the disease … and plan accordingly.   As it happens, none of our tourists are likely to visit this particular region so the risk they face is fairly minimal … but if there was a serious risk then we would inform them and make alternative arrangements.

Although this is the first time time I have come across plague – Kyrgyzstan is an area where Rabies is known to exist … and we occasionally get questions from prospective clients about the risks.

I have written a postcard about that in the past … indeed, I have been bitten by a stray cat, myself, and had to have injections of anti-rabies serum.  Once, also, I was bitten by a dog in France – although it wasn’t a particularly serious bite it did break the skin and I admit to being quite concerned at the time.

In fact, the risks pretty negligible – at least for most tourists, especially if they follow the basic guidelines of avoiding contact with wildlife – for example, refraining from picking up dead animals.

Beautiful but Deadly???

Many of the Petroglyphs of Saimaluu Tash depict sun figures suggesting that sun worship was a common religion in the region at that time.

In a way, that’s not surprising – Solar deities and sun worship can be found throughout most of recorded history in various forms.

The sun, of course can be beautiful – but also dangerous.

Here’s some advice that we put together a few years ago for:  Preventing Sun Related Problems

UV Rays – What You Don’t See Can Hurt You.
Sun-related problems are among the most preventable of outdoor illnesses and injuries. Here are some tips to help you do so:

• The first line of defence is what you wear. Tight-weave clothing blocks a large amount of ultra violet radiation, especially if it stays reasonably dry. Choose darker coloured fabrics because they tend to block more ultra violet rays than lighter-coloured clothing.
• Wear a hat.  A “sun-visor” may help to shade the eyes, but it does not protect the top of the head from the sun.  A full-brimmed hat will shade face and neck, and a floppy brim breaks up scattered ultra violet better than a rigid brim.
• Sunscreens dramatically reduce the chance of skin problems. Although most experts agree that screens with a sun protection factor (SPF) of 15 sufficiently protect most skin, recent studies show that higher SPF numbers offer additional protection, especially in the first few hours of exposure. Sunscreens are most effective if applied when the skin is warm and allowed to soak in for about half an hour before extreme exposure. People with very susceptible skin types might do better to completely block ultra violet radiation from exposed skin with an opaque substance such as zinc oxide.
• Limit your time in the sun. Ultra violet A bombards the earth at an almost constant rate throughout the day, but approximately 80 percent of ultra violet B rays strike between 10 a.m. and 3 p.m. For minimum exposure, plan to be in the sun early and late in the day.
• Smoke absorbs ultra violet radiation, but clouds do not. Cool, overcast days in the summer are dangerous because ultra violet radiation penetrates the densest cloud cover, while heat-carrying infrared waves are filtered out. People feel cool, fail to take precautions, and often get severe sunburns.
• Wind will dry skin, removing the natural skin protection. Wind does not truly burn skin, but it makes skin more susceptible to sunburn and irritates already sunburned skin, a problem often called “windburn.”
• Activities associated with water increase the risk of serious sunburn since sunlight bouncing off the water’s surface attacks exposed skin. The more directly the sun is overhead, the more the reflectivity. Rough, choppy water is much more reflective than calm water. Snow is also highly reflective, reflecting as much as 85 percent as much light as water.
• Altitude is another factor. For every 1,000 feet above sea level, ultra violet radiation increases about five to six percent.
• Consult your doctor or chemist about medications that make skin more sensitive to sun: tetracyclines, antihistamines, sulpha drugs, diuretics, and some oral contraceptives.
• Wear sunglasses that absorb or reflect ultra violet light. Ultra violet light damages eyes as well as skin. The conjunctiva can swell from ultra violet exposure, sun-induced cataracts can form from repeated exposure, and direct ultra violet radiation will burn the retina.
• Teach children about the dangers of sunlight. According to some research, 80 percent of lifetime exposure to skin-damaging ultra violet light occurs during the first 18-20 years of life.

Using Sunscreen

The most important rule when playing, working or sitting in the sun is to use a sunscreen. Choose a sunscreen with a Sun Protection Factor (SPF) of 15 or higher. Following these guidelines should help you enjoy the sun:

• Use sunscreen for protection, not in place of it.
• Choose a water-resistant sunscreen that will not wash off as easily.
• Reapply sunscreen every two hours or after swimming or rigorous activity.
• Sunscreens work best if applied liberally on warm, dry skin and allowed to soak in 15-30 minutes prior to sun exposure.
• Protect your lips, nose and face with a sunscreen.
• When venturing into areas of higher insect infestation, apply sunscreen under insect repellent or use a combination sunscreen/insect repellent.

Dehydration

Clothing:

Understanding how the body loses and gains heat will help you to stay comfortably dressed in any environment.

How We Lose Body Heat

To understand how to choose the best outdoor clothing, consider how the body loses heat. There are four ways in which this happens:

• Conduction, – Whenever the skin touches a surface warmer than itself, heat is transferred from the object and warms the skin – and vice versa. The greater the difference in temperature, the faster the heat transfer. Clothing needs to create a protective, insulating, barrier between the skin and anything that might touch it which will conduct heat away from the body.
• Convection - The body constantly maintains a thin layer of warm air next to the skin. Wind slicing through clothing tears away that thin layer which the body immediately replaces. In a high wind, it is possible to lose a substantial amount of heat in a short period of time. You will need windproof clothing to prevent losing body heat this way.
• Radiation - Exposed skin radiates a significant amount of heat into the surrounding environment, and on an average day, more body heat is lost through radiation than through any other means. Since the blood vessels in the head do not constrict when exposed to cold, a lot of body heat is lost through an exposed head on a winter day, and wearing a hat allows heat to be transferred to other parts of the body, keeping it warmer overall. Consider the advice from one experienced traveler: “If your feet are cold, then put on a hat!”
• Evaporation, the escape of heat through the vaporization of moisture, constitutes the major source of body heat loss. Breathing accounts for up to one-third of evaporative heat loss. On a hot day, the evaporation of sweat from the skin keeps the body from overheating.  Pour on a little water, and evaporation cools the body even faster. On a cold day, the evaporation of sweat or water can suck a tremendous amount of heat from the body. Clothing needs to allow sweat to exit without vaporizing and taking body heat with it. Ideal clothing needs to keep rain or snow from adding moisture to the skin at the same time it allows sweat to exit.

Clothing Material

Shops that specialize in outdoor clothing offer a wide range styles and materials.  Generally, outdoor clothing is manufactured from three different types of materials: cotton, wool and synthetics.

• COTTON - cotton ranks as the most comfortable fabric next to the skin. Because cotton “breathes” well, it allows perspiration to escape easily into the air. Cotton also absorbs a lot of water, and that increases evaporative heat loss. Cotton, therefore, rates as an excellent choice for hiking in desert regions in the daytime in the summer. But cotton’s tendency to cool you rapidly, makes it a poor choice for cold environments.
• WOOL For centuries, wool has been worn by people around the world who spend time outdoors and offers many advantages over cotton. It is not an accident that traditional Kyrgyz costume includes many woolen items.  Wool fibres conduct heat poorly, which means they provide excellent insulation – even when wet. Furthermore, unprocessed wool retains oil from the sheep, allowing it to dry much faster than cotton. It is possible to wring water from wool clothing, put it back on, and wear it all day without losing much body heat – and, if the rain stops, it will dry while you wear it.  Wool is more durable than cotton, but does have drawbacks in that it tends to be heavy and bulky compared to cotton, and it takes more care. Wool, for instance, shrinks when washed in hot water or left in the clothes dryer. Also, some people can’t stand the feel of it against their skin.
• SYNTHETICS - Synthetics, in simple terms, are made from plastic which has been woven into a thread, which is then woven into all kinds of clothing. Synthetic garments generally fall into three classes:
  • underwear,
  • mid-layer garments (such as sweaters, jackets and what the Americans call “vests”), and
  • outer-layer garments.  Synthetic fibres are stuffed into synthetic shells to make parkas for extreme cold climates.

  Synthetics conduct little heat, even less than wool, which makes them a good choice for staying warm.  They absorb almost no water and actually transport moisture away from the skin, which makes them a good choice for staying dry. They are lighter than and compress more than wool for easier packing and they stand up fairly well to hard use. As a result, garments made from synthetics is generally the best choice for outdoor comfort and for surviving the unexpected.  There are disadvantages to synthetics, however, including that, being plastic, they melt at relatively low temperatures and unless they are specially designed, they allow icy breezes through.  Also, they tend to hold onto bad odours such as those produced by a sweaty body.

Choosing the Right Outdoor Clothing

The general advice is: “Go prepared for the worst possible conditions you can expect in your area of travel.”

Clothing should provide comfort and ease of movement.  It should not restrict circulation. Although loose-fitting clothing is typically the best choice, some new stretch synthetics fit the body snugly whilst still providing the same comfort and ease of movement as loose-fitting clothing.

Clothing should provide insulation. Clothing works as insulation by creating dead air spaces, air trapped between the fibres of the garment, which protect the wearer from conductive and radiant heat loss. The best clothing does not lose its ability to insulate even when wet with water or sweat.

A windproof and waterproof outer shell should be available at all times to protect from convection and evaporation. Windproof does not always mean waterproof. Read the label.

Double-stitched seams, strong zippers and reinforcement at areas of stress (such as elbows, knees and seats) are usually are a good idea.

Functional designs that include large pockets that fasten and unfasten easily, roomy hoods on “parkas”, leg zippers on wind and rain pants, and adjustable closures on wrists and ankles are usually worth the additional expense over simpler options.

November 14 : World Diabetes Day The Blue circle is a global symbol for Diabetes - the circle symbolizing life and health, the colour reflecting the sky which unites all nations and the entirety representing "the unity of the global diabetes community in response to the diabetes pandemic". The logo is available in over 60 languages - including Kyrgyz

World Diabetes Day is part of a global awareness campaign which is held on November 14th of each year.  The event is commemorated in over 145 countries around the world – including, of course, Kyrgyzstan.

This date was chosen as it marks the birthday of Frederick Banting – who, along with Charles Best, first conceived the idea which led to the discovery of insulin in 1922.

The day was first inaugurated  in 1991 by the International Diabetes Federation, (IDF), and the World Health Organization, (WHO), to draw attention to the alarming rise of diabetes around the world.  In 2007 it was adopted as an “official United Nations Day”

Each year, World Diabetes Day is centred on a theme related to diabetes.  For the period 2009–2013 the overriding theme theme has been Diabetes Education and Prevention but in the past topics have included: Diabetes and human rights, Diabetes and lifestyle, The costs of Diabetes, Diabetes and obesity, Diabetes and Footcare, Diabetes in the disadvantaged and the vulnerable, Diabetes in children and adolescents and Talking about Diabetes.

In 2012 the organizers hope to link the need for action  with the protection of the health of future generations under the slogan Diabetes: Protect our Future.

It seems to me that we probably do need such days as this because, until recently, I didn’t really know much about it.  I knew it was a disease which involved blood, sugar and insulin – usually involving injections; that the onset of the disease can originate in childhood or in later life … and that it can be life threatening.

Kyrgyzstan occupies First place in the world for insulin related deaths

Indeed I know one person who died a few years ago because the syringe used to give him his insulin injection was the wrong sort … apparently it needs a special sort of needle and the one that was used happened to be a general purpose syringe … the mix-up caused quite a scandal.

In fact, on of the recent Daily Figures featured by the popular newspaper Vecherinye Bishkek was the statistic that “Kyrgyzstan occupies First place in the world for insulin related deaths”

Apparently Diabetes mellitus, (or more simply Diabetes), is a group of metabolic diseases in which a person has high blood sugar.  This could be because their body does not produce enough insulin, or because their cells do not respond to the insulin that is produced.

Although there are other forms of the disease, the three main types of diabetes: the first (type 1) resulting from the body’s failure to produce insulin and requiring either insulin injections or wearing an “insulin pump” in order to provide the body with the chemical;  the second (type 2) results from “insulin resistance”, where the cells fail to use insulin properly … as I understand it this is hereditary and usually affects older people – typically over 40; the third is known as “gestational diabetes” and occurs when a pregnant women with no previous diagnosis or record of diabetes develop a high blood glucose level.

All forms of diabetes have been treatable since insulin first became available in 1921, and type 2 diabetes may be controlled with medications, however, both types 1 and 2 are chronic conditions that cannot be cured.   Without proper treatment, diabetes can cause many complications, and some serious long-term complications include cardiovascular disease (leading to heart attacks), chronic renal failure, gangrene and diabetic retinopathy (retinal damage).  As a result, it is important for sufferers to get adequate treatment, as well as controlling blood pressure control and other “lifestyle factors” such as smoking cessation and maintaining a healthy body weight.

According to a Press release from the Ministry of Health, about 250 million diabetes cases have been registered all over the world, but the real number of diabetics is two times higher.  In addition, the incidence of the disease grows annually by 5-7 percent in all countries, which means that it doubles every 12-15 years. Consequently, the catastrophe growth in the number of diabetes patients is turning into an epidemic.  ”If three years ago the statistics said a person dies from diabetes and 2 new people are diagnosed with the disease every 10 seconds, this now happens every 7 seconds.”   Amongst the other startling statistics that were quoted in the statement were that:

• over 1 million lower limbs amputations take place due to diabetic diseases and
• almost half of the blind are people who lost their sight from diabetes.

Here in Kyrgyzstan …

• according to the International Diabetes Federation, the prevalence of diabetes in Kyrgyzstan, among people aged between 20 and 79, will grow from 4.3% in 2003 to 5.8% in 2025;
• a rate of 4.3% suggests a total number of people with diabetes of around, 224,000 – however a report issued in 2007 said that officials estimated the number to be just 25,500! Another report in 2009 quoted 28893 – with 2238 requiring insulin. Specialists working in this field point out that for each person represented in the official statistics there are as many as ten who were as yet undiagnosed … There aren’t any more recent studies on diabetes in Kyrgyzstan and there doesn’t appear to be a National Registry of people with diabetes … so most of the statistics seem top come from the State Statistical Committee;
• amongst the people diagnosed as persons with diabetes in that report, it was estimated that 10% had type 1 diabetes;
• prevalence rates vary greatly between different regions with a range of 503 to 1550 cases per 100,000 population.
• rates of type 1 diabetes amongst children under 14 in Bishkek are 8.4 times higher than those in rural areas
• deaths attributed to the condition have almost doubled (from 6.5 per 100000 in 1990 to 11.3 per 100000 in 2002), with a larger increase in Chui oblast;
• a survey reported in 2004 suggested that complications were common – 40% with foot problems and 30% with kidney problems – which are considerably higher than equivalent statistics for the US.

In theory at least, although diabetes is not included in the priority list of the Ministry of Health people with diabetes are not ignored as there law that addresses the free provision of all aspects of care including insulin, oral medicines, consultations and laboratory tests.

Since independence in 1991, outpatient care for local residents, the development of policy, monitoring statistics on people with diabetes and their insulin needs and implementation of services nationally, has been the responsibility of the City Endocrinology Dispensary (or clinic) in Bishkek. Care outside the capital is usually provided in regional and district hospitals.  One report has suggested that in rural areas there is a lack of training and knowledge amongst health care professionals.  There appears to be little use of self-management techniques with patients being referred for treatment, often invasive treatment, for relatively minor complications.

As is usual in health care, there are complaints about the lack of funding, (which apparently saw no increase in a ten year period and so failed to keep pace with inflation yet alone increased “demand” for services), the failure of that budgetary finance to be protected, the state of the available equipment, the lack of basic laboratory supplies (such as test strips and blood glucose meters), irregular and supplies of medicines (insulin) – which can lead to delays, low salaries for health care professionals.

A report in 2007 also highlighted the fact that donors were at that time beginning to withdraw from Kyrgyzstan – or adopting new priorities, and that there was poor enforcement of the existing legislation – for example the supposed free access to treatment which by some accounts is largely ignored in the rural regions.

There are many organizations which are active in the fight against diabetes, such as:

• the charity Help Age International
•  Danish Church Aid,
• Diabetes Association of Kyrgyzstan,
• the Resource Center for the Elderly and
• ADRA Kyrgyzstan … as well as
• the World Diabetes Foundation (WDF) and
• the Ministry of Foreign Affairs of Denmark (DANIDA).

Each year events and activities are organized to mark World Diabetes Day, such as a Mass Exercise Session in the main Ala Too Square in Bishkek, with Glucose levels tested before and after the exercise.  Help Age International and the other organizations are not only working to raise awareness of diabetes, in order to try and prevent its onset in vulnerable groups – particularly amongst older people – they have also implemented projects aimed at trying to improve the quality of life for those who are already living with the disease.

This year, in the lead up to World Diabetes Day, the Diabetes Association of Kyrgyzstan held free testing over the last couple of days in October and at the start of November for all of Bishkek’s residents to determine the level of sugar in their blood; thematic debates; exhibitions stands of pharmaceutical companies and even a flashmob, which should all help to draw attention to the problem of diabetes … but I am not sure how many people heard of the action or took advantage of the testing … Oddly enough, however, the Ministry of Health gave some 10 days advance notice of the events with a press conference on November 5th.

Finally … here is a video posted on viemo by HelpAge International about fighting Diabetes in Kyrgyzstan:

Fighting diabetes in Kyrgyzstan from HelpAge International on Vimeo.

Depression: A Global Crisis - the theme for this year's World Mental Health Day : Click the image for the WFMH report prepared for WMHDAY 2012

Yesterday was another one of those days … as well as being the International Day against the Death Penalty, October 10th is also World Mental Health Day,(or WMHDAY).

WMHDAY was first celebrated twenty years ago, in 1992, at the initiative of the World Federation for Mental Health, (WFMH - a global mental health organization with members and contacts in more than 150 countries).  The aim of the day is to raise public awareness about mental health issues, promoting an open discussion of mental disorders, and investments in the prevention, promotion and treatment services.

Now, I maybe simply exposing my own prejudices and misunderstandings, but quite honestly, the topic of Mental Health doesn’t really seem to be one that demands a huge amount of kudos.  We all know it is an issue … but hope that if we ignore it then it will go away.

According to the World Health Organization,  the term “Mental Health” refers “to the promotion of well-being, the prevention of mental disorders, and the treatment and rehabilitation of people affected by mental disorders”.

To be honest, the record of provision for patients in Kyrgyzstan who suffer from mental health problems leaves a fair bit to be desired.   A report issued jointly by the World Health Organization, (WHO), together with the Ministry of Health in 2008 painted a fairly positive picture …

• a mental health policy, plan and specific legislature existed;
• financing for mental health care was provided, at the level of 4% of the budget for health care – with provision for primary care, hospital provision, (including provision for “out patient” services);
• three psychiatric hospitals existed, complete with out patient facilities, provision in outpatients departments in other centres and also in day treatment centres;
• the State guaranteed patients with mental disorders free treatment and care in psychiatric hospitals, including free access to essential psychotropic medicines;
• there were acknowledged shortages of staff, supervisory oversight and limited provision for treating children and adolescents and the number of beds was being reduced;
• the state provision was supported by over twenty voluntary organizations;

However, a report almost a decade ago, in 2003, whilst it recognised the existence of a national programme for mental health, spoke of the “dreadful conditions” experienced by patients: being poorly fed; housed in overcrowded conditions with a lack of qualified medical staff.  It went further, saying that their rights being systematically violated: patients being incarcerated without written consent; use of physical restraints; being used as a labour force.

The main concern seemed to be the lack of adequate funding in the budget – citing provision of just one tenth of what doctors said was required.

The report also made reference to a tendency that the incidence of mental illness was increasing, specifically referring to the number of patients diagnosed with schizophrenia in the republic.

A press report issued in early 2010 suggested that little had changed.  It repeated many of the charges of the 2003 report, but added that “patients kill themselves to escape mistreatment” and  also patients that “repeatedly suffered from physical and sexual abuse”.

Since the events later in the year 2010, however, the question of mental health seem to have received greater attention … and support from the international community … especially in terms of  helping children and communities cope with the traumas arising from their experiences.

As is usual for these designated days supported by UN agencies, a theme is chosen on which events around the world will be focused.  This year the theme for the day is “Depression: A Global Crisis”.

Because of it’s use in everyday language, the word “depression” can easily be misunderstood.  It is not simply a case of feeling a little “down in the dumps”.  Depression is, unfortunately, a fairly common condition, affecting more than 350 million people of all ages, in all communities, and is a significant contributor to the global burden of disease.

There is a clinical understanding of the term as “mental disorder”, which is, characterized by a sense of sadness, a loss of interest or pleasure, feelings of guilt or low self-esteem or self-worth, disturbed sleep or appetite, feelings of tiredness, and poor concentration.  It can be a long-lasting or a recurrent condition, which substantially impairs a person’s ability to function at work or school and to cope with daily life.

When mild, people can be treated without medicines but when depression is moderate or severe they may need medication and professional talking treatments.   At its most severe, depression can lead to suicide.

Depression is a disorder that can be reliably diagnosed and treated by non-specialists as part of primary health care.  Specialist care is needed for a small proportion of individuals with complicated depression or those who do not respond to initial treatment.

Although there are known effective treatments for depression, access to such treatment is a problem in most countries and in some countries fewer than 10% of those who need it are able to receive treatment.

In theory at least, depression can be easily diagnosed and effectively treated but that requires adequate funding and facilities … something which is unfortunately lacking in a situation where the state experiences problems in providing basic facilities and provisions.

H-H-Hancock's Half Hour

One of my staff is approaching retirement age and is busy collecting the documentation in order to apply for a pension.  He was a bit worried the other day because he couldn’t find his copy of his blood donor record.  Apparently, in the Soviet Union blood donors were given a supplement in their pensions and the practice continues today.  It shouldn’t be a big problem because there will be official records of this sort of thing, but if can’t find his record book, it might take him a while to track down and obtain a duplicate of the necessary documents.

When he told me, I was reminded of the classic episode, “The Blood Donor“, of the TV comedy series, “Hancock’s Half Hour“.  ”H-H-Hancock’s Half Hour” was part of my youth, and I well remember the “Pom pom pa pom pom po-o-om” of the signature tune.

In this particular episode, Tony Hancock decides that he wants to do something for the country, his “patriotic duty”, and it was a choice between becoming a blood donor and joining the Young Conservatives.  He doesn’t understand how much he has to give, leading to the classic line, “A pint? That’s very nearly an armful!”.   He has second thoughts and refuses to go through with it until he is told that he has a very rare group.  After he has given the blood looks for his free cup of tea and biscuits and we get the impression that, maybe, this was all he was interested in in the first place.  He then becomes insistent on knowing where and to whom it has been given, repeatedly calling the doctor at the hospital to enquire.  In the end he has an accident and, having lost a lot of blood, he is taken to hospital … where he is diagnosed as being in need of a blood transfusion … and as he belongs to a rare blood group, there is only one pint of the right group in the blood bank … and so he receives his own blood back again.  ”It’s just like an ordinary bank,” he says, “you make a deposit when times are flush and withdrawal when you need it.”

It was the penultimate episode of the seventh and final series that Hancock recorded for the BBC and despite its age, (it was broadcast in 1961), and the fact that many people reckon that it was one of his worst performces, it has become one of the greatest and most recognisable of all British comedy programmes.  I even have a copy.  I brought a VHS cassette tape with me when I came out here, (containing three episodes: The Blood Donor”, “The Final Page” and “Twelve Angry Men” – of which, in my opinion, the Blood Donor is by far the best).

The writers, Simpson and Galton, were using the idea of donating blood as a vehicle to poke irreverent fun at British Society of that time and the sort of attitudes that were prevalent.   Despite the humourous treatment that they gave to the subject, however, the topic is actually quite a serious one.  As can be seen from the fact that the Soviet’s were prepared to put their money into rewarding people in their pensions, (whereas the British gave tea and biscuits as a reward).

The programme brought the Blood Donor programme to my attention and I felt strongly enough about it that when I became a student I gave blood on a number of occasions.  Not enough to get a “badge”, as Tony Hancock wanted, nor enough to add considerably to my pension if I had been born in the Soviet Union, and later on in life the opportunity didn’t present itself, (although I suppose I could have gone looking for it).

As it happens, today, the last Sunday in September, is Blood Donor Day here in Kyrgyzstan; a sort of professional holiday to draw attention to the need for blood donors and commemorate their contribution.  (World Blood Donor Day is usually marked on June 14th.)

Once again, it’s a serious issue here.   At least twice in my time here in Kyrgyzstan I have seen stories in the press about how stocks in the country’s blood bank are falling perilously low – in early 2005 and after the revolution of 2010.  Then there was the scandal where Children in the south of the country were given infected blood and contracted HIV as a result.  HIV/AIDS is not the only issue, some blood samples are also contaminated with Hepatitis and Syphilis and in 2009, for example. 4141 litres of blood, (that’s almost 14% of the total amount of the donated blood), were rejected, mainly as a result of positive results in tests for Hepatitis B.

There is, however, a major project under way in the country to improve the screening of blood to prevent further infection from contaminated supplies from occurring.   Amongst the issues that they seem to be addressing there are: the need to improve the infrastructure including obtaining up to date equipment, improving the training of staff and the testing procedures.

The Ministry of Health run the country’s Blood Transfusion Service, which includes the new, large, Republican Blood Centre, 5 regional blood centres, 39 local clinical transfusion departments and a “bus” for conducting blood drives.

According to the Republican Blood Centre, the country needs at least 45 tons of blood of year, but finds it difficult to raise more than about 15 tons from regular donors – and the figure is declining.  According to one source, there were about 150,000 donors at the time of independence in 1991, but by 2006 the figure had dropped to about 30,000.   Most people donate blood as and when needed for a sick relative – and I certainly know of at least one case where that has happened.

Although one report says that there has been insufficient promotion of voluntary non-remunerated blood donation and no public financing of safe donor recruitment programmes, there have been a wide variety of measures to help boost blood donations, promoted by the top management of the Ministry of Health and other departments, city and parliamentary officials, pop stars and the mass media.  In 2008, the “bus” of the Blood Centre made over 70 visits to educational establishments, dentist clinics, police departments, centres of certification and military departments.  At least one large company encourages it’s employees to donate blood.

According the director of one transfusion centre, normally speaking only about five people a day donate blood, although following the events last June, that number increased dramatically – at least for a time.  On the first day of the revolution, for example, 500 people came forward to volunteer and over 700 on the second day and the staff at the centre worked day and night to process them all.

Even if, as some reports suggest, (I wouldn’t know, I wasn’t here at the time), the Soviet system was wasteful with large amounts of blood stocks stored in the service being written off for one reason or another, (for example, being older than the 21 days shelf-life), at least they had donors.