DISCLAIMER: I do not intend for these blogs to be seen as giving clinical advice nor as judging public health policy but rather to recount the lived experiences of family medicine physicians from across the world. I recommend you still follow your local guidance.
Date of interview: 24th August 2020
Number of confirmed cases at time of interview: 127,000
Number of deaths at time of interview: 1781
Population: 18.28 million
For this post, I got to interview Dr Yelena Khegay, a family physician from Kazhakstan. She is really exceptional, evidenced by the fact that, this year, she won the WONCA Europe scholarship – a fund to scout and stimulate future international leaders with a scholarship of €2000 per year for between two to four years – with an outstanding application. She currently works in a private clinic in Almaty, which was formerly known as Alma-Ata. For the true primary care geeks amongst you, this will trigger “the Declaration of Alma-Ata” where the WHO and UNICEF organised a conference in 1978 where governments and health and development organisations pledged “to protect and promote the health of all of the people of the world” via a robust primary care health system. You can read more here about it.
Initially, the Kazhakstani government were quick off the mark for covid-preparedness. They had been tracking the situation worldwide and were expecting to be hit hard. The first case was declared on the 13th March and a state of emergency was called on the 16th. On the 19th, a full lockdown was called in the big cities of Almaty and Nur-Sultan. The lockdown was only eased on the 11th May after almost eight weeks. The focus was very much on tracking cases, isolating and closing borders. For those who were coming back from abroad, they were forced into a two-week quarantine, initially in hospitals but now in hotels. So far so good and I was ready to congratulate Yelena on the relatively low number of official cases and deaths.
But Yelena tells me what has really been happening. Her biggest concern is the lack of robust government messaging to the citizens of Kazhakstan which is leading to a lot of misinformation. She has watched politicians from other countries give daily or weekly updates to their citizens on what they had to do as a nation to limit the spread of the virus. She feels that the explanations, communications and the building of trust, especially in this Post-Soviet country (where trust in government is already pretty poor) has left a lot to be desired. She feels that many Kazhakstani people are angry and frustrated as they have lost jobs and income with patchy government support and it has become a hotbed for conspiracy theories. When the lockdown was lifted, people felt that the pandemic was over and there were reports of queuing at shopping malls with no masks and no social distancing. The sudden jump in numbers between May 11th and July the 5th seemed hardly surprising. They have had to have a second lockdown from the 5th July which lasted six weeks. She’s noticed a huge resistance to wearing masks as if it was a human rights violation. She mentions that she personally takes taxis everywhere now to avoid public transport which are crowded but she has a hard time convincing taxi drivers to put their mask on. “Quarantine is over”, they tell her. She can only imagine that there will be another peak in a few weeks. To be fair, we are witnessing something similar across Europe and especially in the UK. The return to normal daily activities of the summer has led to a rise in numbers now in Autumn and we, in London, have just been upgraded to Tier 2 restrictions from Tier 1. This oscillation of freedom is a challenge for all but even more so when there is a rift between the ordinary citizen and those tasked to look after us.
I am so confused because, before this conversation, I thought Kazakhstan was a success story, given the official figures. But Yelena tells me that they don’t really know their true numbers. There were unnerving international reports of an “unknown pneumonia” that was sweeping its way through Kazakhstan in July this year that was killing thousands of patients but Yelena nonchalantly says that these were most likely undiagnosed Covid rather than a new killer disease. Poor reporting of statistics by poor media reporting. Until August 1st, only PCR confirmed cases had made it into official government statistics but, as of August, patients with Covid symptoms with a negative PCR test have started to be documented. With a false negative rate of up to 29%, this is a bit disconcerting. There is a real cultural susceptibility here as well since Kazakhstani celebrations involve huge numbers of people. Having 5-600 people at weddings and funerals is normal and there are many mass family gatherings. Although these are being discouraged, this has led to these celebrations being driven underground. This feels really familiar and reminds me of stories during the Ebola crisis in Sierra Leone where burial rites were done in secret by family members who wished to send their loved one on to the next world despite the fact that they were banned to prevent the spread of the virus. The lessons learnt from Sierra Leone was that community engagement is essential and patient education is the crux of public health.
Yelena works in an international clinic with two colleagues who had trained in the USA where using evidence-based medicine is the norm. The Kazakhstani health system is split between private and public but most doctors aspire to work in the private system due to better pay and better working conditions. She worries about the way that her colleagues across Kazakhstan are managing the symptoms of Covid based on intuition and hearsay rather than evidence. One of the things that really blows my mind from this conversation is that, in Kazakhstan, patients are able to get all medications over-the-counter without a prescription and any scan without a referral. This has resulted in a huge demand for CT scans as word has got out that it can diagnose Covid and Yelena suspects that many people became sick in the non-socially distanced queues. In terms of the medication without prescription, I can only imagine what a nightmare this must be for doctors in light of the mass hysteria and propensity to hoard that we all experienced at the beginning of lockdown. Yelena says that there is a copy-and-pasted list of medications that is circulating on social media and Whatsapp (which includes antibiotics, spironolactone, rivoraxaban and dexamethasone) which lay people have been taking to pharmacies, buying and taking to protect themselves from Covid. One of Yelena’s patients admitted to spending 1 million tenge (approximately 2000 euros) on a list of meds since the cost of these medications have sky-rocketed and are now being sold on the black market. However, this is not exclusive to Kazakhstan; there were shortages of salbutamol in Australia (a non-prescription drug there) as non-asthmatics started stockpiling them leading to a shortage for true asthmatics. It’s unsurprising given the panic that people have felt across the globe but, unfortunately, Yelena is having to deal with the fallout of patients taking these strong medications without supervision. Yelena tells me that the medical staff there has also been feeling the pressure and responsibility that we all have had worldwide. She also worries that many doctors don’t speak English and therefore struggle to keep up with the ever-changing research and instead rely on fake and trash news. This really made me think. I am eternally grateful that English is the international language and I am aware of the publication bias that we have as native speakers. However, this was the first time that I realised the barriers that other doctors face when shifting through an enormous volume of research when the data was changing every week. It’s easy to judge other people’s practice but we’re not all at the same starting line. So what can be done amidst this void of evidence-based information? This is where Yelena and her team have showed some incredible innovation. In Kazakhstan, social media is a commonly used communication tool. Yelena’s clinic has 250,000 followers and her team have been posting videos, aimed at both patients and doctors, with clinical advice that follows international guidance which has had several hundred thousand views with positive feedback. However, Yelena warns me about the perils of social media. She describes a video made by a rehab doctor who was spreading gross misinformation but yet was so convincing because she was emotionally weeping throughout. Neither of us can imagine what her motivation would be but we both put it down to an opportunity for her five minutes of fame. Again, I cannot imagine the dire consequences of this video that went viral which would undoubtedly have broken trust in the healthcare system. The UK GMC have guidance on the use of social media which I think is of utmost importance especially in times like these where we have to recognise that our words are having a more profound effect on the general public because we are perceived as being guided by the science. My recommendation to Yelena? She needs to counter the misinformation with her own video where she speaks her truth whilst sobbing and wailing and hitting the table a couple of times in a show of frustration! But on a more serious note, distrust in the government and the healthcare system is dangerous for public compliance and becomes a hotbed for conspiracy theories. Yelena confirms this as she has had some of her patients tell her that they thought that the virus was spread by helicopters. I’ve written a blog post on why conspiracy theories arise in pandemics which you can read here. The Kazakhstan Association of Family Physicians have also stepped up in this chaos by running free online consultations from mid-March, advertising their availability on social media. This was to ensure that everyone had access to healthcare without leaving their homes wherever in Kazakhstan they lived. These ran 9am to 6pm seven days a week and, at its peak, there were 250 consultations per day. Further to that, as a testament to her ability, Yelena was invited to the National Protocol Development Group to make contributions to develop algorithms for clinical care in response to Covid. She was hugely disappointed to see that there were none in progress for primary care and therefore submitted her own.This wasn’t a hugely successful venture, however. The feedback? It was too early to involve primary care (if you could see me now, you would see my eyes rolling) and Yelena has since put it on the back-burner.
So what next for Kazakhstan? Who knows? We have no idea in the UK either. What we do know is that Kazakhstan have already put themselves forward for the vaccine coming out of Russia. Do we trust it? In a time where distrust is the common currency – distrust in the government, in healthcare, in public health, in the police – a trust in a vaccine seems rather far-fetched. We can only hope.
Thank you to Yelena for her time and a fascinating interview. Keep up your amazing work and stay strong!