From the President: View from a mountain

December, 2010

On Wednesday, I climbed a mountain. I did not start the day expecting to climb. If I had known, I would have worn something more appropriate than a suit. Yet, Wednesday was the best day of a wondrous week.

The week began early Tuesday morning at the Dushanbe international airport (DYU). Arriving from St. Petersburg at 2:30 am, passport control at DYU was like a rugby scrum. Several hundred of us were packed so tight that we could have lifted our feet and remained suspended for the 90 minute wait to clear immigration. Most of our crowd appeared to be Tajikistani men, likely returning home from their jobs in Russia. Despite the claustrophobic conditions, everyone waited patiently and maintained good humor. When an arriving woman or young child approached the throng, the multitude parted magically, letting them pass to the head of the line. Welcome to Tajikistan – a nation that ranks in the lowest quartile among the world’s economies, but among the top countries I’ve visited when measuring generosity.

My week in Tajikistan was as a member of a delegation of Physicians With Heart (PWH), a program sponsored by the American Academy of Family Physicians Foundation, Heart to Heart International, and the U.S. State Department. Once each year, PWH delivers donated medications and medical equipment worth millions of U.S. dollars to one of the former Soviet states in central Asia. The program also includes medical education symposia with U.S. family doctors who pay their own way to provide educational sessions on family medicine and other topics requested by the local doctors. A third component is a Children’s Project that involves other volunteers who paint and renovate orphanages, bring clothing and other necessities for the children, and distribute goodie bags with sweets, balloons, and similar items.

View from a mountain in Tajikistan

Later the morning of my arrival, our group had a briefing at the U.S. Embassy. We learned of the glories of the ancient Samanid Empire and its prized cities of Samarkand and Bukhara. We heard how the Soviet Union in 1929 sculpted Tajikistan into its current bizarre borders, in order to reduce Tajik influence in the region. The Tajiks, historically a proud and urban people, were left with few cities and a landlocked country, 90% of which is mountainous. The eventual collapse of the Soviet system sparked a terrible civil war from 1992–1997, reducing Tajikistan to a mere shadow of its former self. Average income today is 85% of what it was 10 years ago. More than one third of the economy reflects remittances from Tajikistani workers in other countries, mostly Russia. Many Tajik villages consist of women with young children and the elderly.

The mountains of Tajikistan are quite beautiful, with several peaks in the Pamir range in excess of 7000 meters. The mountains provide fresh water and generate more hydroelectric power than Tajikistan can use. Yet, even these benefits are denied to the rural Tajikistanis. To get fresh water from the mountains to the people involves pumps, which require electricity. Much of the hydroelectric power is diverted to a large aluminum plant in the west of the country or sold to Afghanistan and Russia. Which brings me back to Wednesday.

Early Wednesday morning found me sharing a car with the driver and three other family doctors: an American woman from Montana, a Swiss man who helps in the family physician re-training program in Tajikistan, and a Tajikistani woman who also works with the re-training program and served as translator. Tajikistan’s one medical school has a six year curriculum. Traditionally, students would spend their sixth year concentrating on pediatrics or obstetrics-gynecology and then go out to the villages to practice. Over the past decade, Tajikistan has committed to the more comprehensive model of family medicine and has re-trained many of these village doctors to become family doctors. They have a parallel program to re-train nurses to work as family health center nurses.

We headed west past the huge aluminum plant and toward Uzbekistan, and the mountains. After leaving paved road, we bounced over rutted dirt roads and crossed bridges that seemed to have more gaps than bridge. The further we drove, the more I came to understand the meaning of “off road”. Even the goats began to look at us as if to ask, “Are you sure you want to go there?”

Dr Kurbonov on the street

At the end of the rutted road was our destination: a small health center in a remote village within sight of the Uzbek border. Doctor Abdujabor Kurbonov has been the only doctor in this rural region for more than 20 years. In addition to the health center, he also serves two rural “health houses,” six and nine kilometers away, which he visits once a week. Outside the health center waited a long line of women with young children and babies. Several old men sat beneath a nearby tree. We spent the morning watching Dr Kurbonov greet and then minister gently and efficiently to each successive patient that entered his office. Shifting fluently between Tajik, Uzbek, and Russian, his comforting tone, thorough examination, and efforts to make sure that each person understood and was understood were most impressive.

Dr Kurbonov talked about his life. While usual health center hours are Monday through Saturday, he has no time off. His home is 40 meters from the health center, on the other side of the rutted road. Patients or their relatives feel free to knock on his door anytime. Earning between 35 to 50 U.S. dollars per month, he is expected to buy his own equipment and even the medications that he gives to patients without the means to pay. He has nine children, including a son and daughter who are in medical school. He hopes his daughter will join him in his practice. He has encouraged her to take more courses in laboratory medicine as he would like to develop a small lab in the practice.

Each year, Tajikistani husbands get one month off their jobs in Russia and return to their villages to visit their families. Nine months later, their wives give birth to another baby. While contraceptives are readily available, husbands apparently prefer that their wives use pregnancy as their primary form of contraception. The health center averages 3–5 births each month, shared between the midwife and Dr Kurbonov. Testimony to his standing in the community is the fact that his Muslim neighbors trust him with the care of their wives during their 11 month absence. Each day includes several home visits, usually uphill – both ways. Which brings me back to the mountain.

Dr Kurbonov performing an antenatal check

At the end of the morning, we set out for a home visit. He pointed to a house near the peak, about two kilometers up an 8% grade. I said, “You’re kidding”. He grinned and started walking. As we ambled along, schoolchildren ran up to give him a hug or a ‘high five’. Old men waved and invited conversation. He knew which dogs, donkeys, and bulls to give a wide berth as we trudged through pastures on our ascent. Each homeowner we passed invited us in for tea and Tajik bread. Their hospitality was a consistent experience in Tajikistan – those with virtually nothing were generous in sharing nearly everything they had.

The home visit involved a woman who underwent cesarean birth two months earlier, and developed a wound seroma. She was staying in her mother’s mud home, while her husband was working in Russia. The home was swept clean inside, floors covered by the ever present red Tajik rugs. Dr Kurbonov also examined her infant son, whom he had been following for a respiratory infection, now nearly resolved. After tea, bread, and two improving patients, we started back down to the village.

During the rest of the week, I observed young family doctors in training, lectured at the medical symposium, met Health Ministry officials, visited an orphanage for the deaf, and enjoyed the culture and hospitality of the Tajikistanis. In short, it was an extraordinary and meaningful experience. My mind kept going back however, to a moment in the rural health center.

Baby with polio brought to Dr Kurbonov’s office

A young mother had walked nine kilometers to have her 14 month old baby seen by Dr Kurbonov. The baby was one of the more than 150 Tajikistanis to have recently contracted polio. He had been immunized, but the oral vaccine was likely ineffective because it required refrigeration – which required electricity. She reported that his left arm and bilateral leg weakness seemed a bit improved of late. She had taken him to Dushanbe to see a pediatric neurologist, as any despairing young mother would do. The specialist had written three prescriptions that were likely to be of no benefit, but reflected the standard cocktail given to every child with neurologic problems. Dr Kurbonov explained firmly and compassionately that she could not afford the medications; that they were not going to cure the baby; and that her massaging, exercising, and feeding the baby as she was doing were the best possible treatments. She was the best medicine for the baby. I felt like I was watching an artist at work to see this skilled family doctor pull together everything he knew about her, her family, and her community into practical and relevant advice, while giving hope to a woman in desperate need of some.

And that moment took me back to the mountain. As we left the home visit, Dr Kurbonov strode out ahead of the group, leading the way back to the village. Briefly pausing to soak up the warm sun and enjoy the vista below, I watched him side step down the steep incline. I was reminded of something that G K Chesterton wrote, “One sees great things from the valley, only small things from the peak.” I thought to myself, “Chesterton got it wrong.” Looking down, I could see something from the peak that was great – a family doctor who had dedicated himself to the people of his community. In that moment, I felt humbled and honored to have spent a day with greatness.

We later asked Dr Kurbonov if there was anything he wanted or needed. He said two things came to mind. It would be nice if his patients could have chairs to sit on while waiting to see him. They also need clean water to wash. The other American and I are working on that. It seemed the least we could do after having our spirits lifted and our life’s work reaffirmed by a climb up the mountain.

Professor Richard Roberts

All photos courtesy of Lisa Fleischer, MD.