Stories From the Field:

KAZAKHSTAN

Neurology in Kazakhstan

Farrah Mateen, MD, PhD, Associate Professor, Dept. of Neurology, Massachusetts General Hospital

In summer 2017, I had the distinct pleasure and privilege of visiting the Nazarbayez University School of Medicine as a Visiting Professor of Neurology.  Located in the capital city of Astana, Kazakhstan, my trip involved a combination of clinical, research, and educational endeavors with the Kazakh people.

The Nazarbayez University has a new medical school and the number of neurologists is overall small compared to the population’s need. Kazakhstan is a relatively young country overall, with a history of traditional nomadic existence. In recent times, the country has experienced substantial economic growth and extraordinary urban development.

My trip focused on clinical ward rounds with the Medicine teams focused on neurology, didactic lectures, and diagnostic and treatment recommendations for challenging clinical cases who came to Astana specifically for evaluation. Patients’ cases were presented by the Kazakh medical students, residents, and staff.   Topically, I presented lectures on multiple sclerosis (MS) and neuromyelitis optica (NMO) with translation into Russian by local physicians.  I also discussed work I have done in the region, in Bhutan.  Although Bhutan and Kazakhstan are geographically and culturally different, their vast terrains and challenges for patients to reach health centers as well as the high prevalence of epilepsy are likely very similar. 

Multiple sclerosis in Kazakhstan was the focal point of my trip.  There are more than 1500 people treated with disease modifying therapies for MS in Kazakhstan, and the medications are provided free of out of pocket charge if they are the platform agents: glatiramer acetate (Copaxone) and specific interferons (Rebif, Betaseron).  Other disease modifying medications however were not readily available and this led to difficult treatment decision making. In some cases, immunosuppressive therapy escalation seemed most appropriate – especially in patients who had treatment failures on the platform agents. However these medications were difficult to attain due to the high cost of the drugs.  In some cases, off label use of Rituximab or Mycophenolate Mofetil – present on the medication formulary for other conditions – were considered. Some patients had received bone marrow transplants in Russia, a procedure that is not common in North America for this condition. Since aquaporin-4 antibody is not available in Kazakhstan, the epidemiology and impact of neuromyelitis optica versus MS remain difficult to disaggregate beyond clinical criteria and send-out laboratory testing. The impact of Vitamin D and its latitudinal gradient remain unexplored in the region.

My experiences, although brief and initial in the region, inspired several new research ideas and collaborations. I am extremely indebted to the neurologists including pediatric and adult teams, medical students, and postgraduate trainees I met. I also had the privilege of meeting members of the University leadership, Hospital administration, Ministry of Health, and other partnering hospitals in Astana. Some clinical cases remain riddles whereas others are now linked to new testing and diagnoses and deeper understanding.  A professional highlight was watching the graduation of new medical specialists in Kazakhstan. In this event, I saw the microcosm of my entire experience working in Kazakhstan: a blending of old traditions with new ambitions, imbued with enthusiasm, knowledge, and confidence for the exciting future ahead.

For more information, please see highlights of the Global Neurology Research Group website.