 This is Craig Thomas, your host on Much More on Medicine. And as you may have noticed, I've been gone for a month. So today we're going to change things up a little bit. I'm actually going to be interviewed by Shackley Raffetto, who is the retired Chief Justice of the Second Circuit and a consultant and educator to Mongolia. And we'll let him describe what he does there. And then we're going to talk a little bit about Mongolia. This is, of course, part of Think Tech Hawaii's live stream series. And we're assisted by Ray, our trustee engineer. Thank you, Ray. And just as a brief preamble, I like going on interesting and physically challenging bike trips just because I eat too much the rest of the year, but also because I'm fascinated by different locations, places, and culture. And when I go, I try to learn about them, both from a just geographic and cultural perspective, but also with an eye to what are the impacts on health and what is the general health of the population. And I just came back from Mongolia, which is one of the most fascinating places I've ever been. And in short, I biked from a place called Morone via Lake Kuzgal, and ultimately ended up in the Altai Mountains in the far west of Mongolia, near the Mongolian-Russian border. There's a base camp there, which is about 10,500 feet, and people climbed to the highest mountain in Mongolia, which is considered a sacred place. So why don't you tell us a little bit about yourself, Chief Justice, and your experience in Mongolia? And then we'll take it from there. This is an experiment for both of us, so I'm looking forward to it. Good morning, Craig. It's Chief Judge. Not Chief Justice. Excuse me. You're going to take the Chief Justice, so I call on you. Any case, we've had a chance to speak before today's program, and as you know, I've spent a good deal of time in Mongolia myself. I never got out to the places that you were able to discover. And I thought that, actually, I'm going there in October, I think, as I mentioned. And I was there about a year ago as well. But let's clarify, when we say Mongolia, we mean the Republic of Mongolia, not Inner Mongolia, which is the province of China. Yes. In fact, we should describe a little bit about the Republic of Mongolia, which honestly I knew existed, but that's pretty much all I knew before I went there. So it is a large geographic area, basically its borders are China and Russia. It's actually very near Kazakhstan, which is important because in the far west there is a very substantial Kazakh population. And it was previously part of the Soviet Union. And I believe, Shackly, 1991 is when it exited, and they were happy to leave, but turmoil resulted, and I think that's actually in part the genesis for your involvement. Yes. Well, I should say that Mongolia has a huge country, around the size of Texas, I guess. The population is about three million people. The vast majority of that population lives in Ulaanbaatar, which is the capital city of Mongolia. And more and more people seem to be moving in from the countryside, seeking work. Although a lot of people still live in their traditional nomadic style in the countryside, living in felt tents. Our viewers may be familiar with the Russian term of yurt, but in Mongolia they call it GER, G-E-R, but it's a wooden structure with felt blankets laid over the top of it. And it's very, very effective, even in the severe cold weather that they have in Mongolia, to protect people and allow them to live out into the countryside. And I'm sure you came across many of those during your trip. Let me back up just a second, though. You're affiliated with the Aloha Medical Mission and the Hawaii Emergency Response Physicians Association. Is that correct? Well, it's called HEPA, Hawaii Emergency Physicians Associated, and we staff emergency departments across the state. And yes, I've been involved with the Aloha Medical Mission since the early 90s. And my current focus, in fact, focus for the last 15 years or so, has been a educational, medical, and microcredit project in Bangladesh. So the similarities and contrasts to Mongolia were fascinating, honestly. Yeah, I've been to Dhaka, so I know what you mean. So was your trip purely recreational or recreational slash professional, or what? Well, in fairness, I should call it recreational, or at least, shall we say, mind and body improvement and mind expanding. But I'm always interested in local health issues and sort of elements impacting health in the societies that I visit. And so I definitely looked, I toured a hospital in Ulaanbaatar, and I met with a Seattle physician who works with the Gates Foundation on health care delivery worldwide in low income countries. And he was there evaluating processes in Mongolia. And we'll talk about that in a few minutes, but it was pretty interesting. Just to kind of tag onto what you also said, Ulaanbaatar is an interesting, pretty big city, a million and a half people. The health aspect of it, the good news is, like many parts in the rest of the world, they have devoted a fair amount of resource to public infrastructure. The town square is heavily used. It has concerts. It's supported. Kids are riding their bikes around on it. Doing a much better job, I think, than we do of that sort of thing. There is a pretty big gap between the people with good jobs, often in government or mining, and the people looking for work who live in Soviet-era high-rises around the periphery of town and then in gurus outside of that. And those are generally people who came in from the country. So one of the health issues in Ulaanbaatar, like much of the rest of the world, is the need for constructive meaningful work and a living wage. And that seemed to me the big health challenge in Ulaanbaatar. Also, I'm told, and I have every reason to believe it, in the winter the air pollution is pretty impressive, which led to an interesting thing. Ulaanbaatar has more prehaces per total vehicular count than any place I've ever been, which is an effort by the government to support efficient, clean vehicles. So that's Ulaanbaatar. The rest, and we're going to spend a fair amount of time talking about it, the health advantages and disadvantages and challenges of nomadic culture, which is, in essence, the entire rest of the country. Yeah, just one thing I wanted to add. Mongolia was never actually part of the Soviet Union. It was one of their buffer states, but they were dominated, of course, by the Russians. And it's more of a Russian culture than it is anything close to a Chinese culture, for that reason. As you may have noticed, they drink a lot of vodka and... Well, speaking, sorry about that, speaking of health issues, the older folks who were educated in Russia, my friend who's a law professor there now, received a legal education in the former Soviet Union. The younger people, of course, don't have that same connection with Russia, but they are in between those two huge countries. And so they have to contend and manage those relationships, which they do pretty effectively, actually. Yeah, they're in an interesting situation because they have no maritime border or port. So unless it comes by air, stuff has to come from Russia or China. And yes, I experienced the same thing you did. The sort of professionals who were older than, let's say, mid-40s generally received their advanced training in Russia. The ones younger went to other places. It seemed to me more often in South Korea than anywhere else, which is sort of an interesting connection. In the background, I'll just describe this slide as we switch to the next one. This is a very typical river valley near Lake Kuskal, which is an enormous freshwater lake. Freezes over in the wintertime and people drive trucks on it right now. It's a sort of recreational, but also, of course, grazing and local nomadic location. The little white dots in the distance are gurres. And although you can't see it, there are shepherds. And I think this had cows and goats. But typically, you see cows, goats, sheep, and then smaller herds of horses. And in the drier areas, mostly the North Gobi Desert, camels. Ray, if we could switch to the next slide, here we are. Here's a picture of a gurre. And that is my bicycle, which carried me about 1,100 miles. And the often twisty, bumpy, and confusing roads of Mongolia. I discovered early on that none of my maps were right, which was an interesting challenge. These gurres are belt insulated, canvas covered, and they're surprisingly cozy. They have a stove in the middle that can burn dung, coal, or wood. And they're pretty snug. They're also a key feature of nomadic living. It's communal. Extended families live together. People are independent, or interdependent, I should say. And I think this is one of the great health assets, which is humans are well adapted to helping each other and being interdependent. And societies that do that are, I think, have an intrinsic, healthy advantage from cultures which isolate people. And you were welcomed by the locals when you biked around? You know, people were great. I think they thought I was insane because there aren't many bicyclists, wrong distance bicyclists in Mongolia. Bicycles are pretty common, and kids love riding them. They rode mine, even though they were tiny and the bike is big. But they went to tremendous effort to make sure I went the right place. To the extent, since very little English is spoken in the countryside, calling up an English speaker, putting me on the phone with them and making sure I knew where I should go next. And given the map issue, that was important. We're going to take a break now, but after the break, we're going to paint a picture of life and health in Mongolia. I'm going to the game, and it's going to be great. Early arrive and for a little tailgate. I usually drink, but won't be drinking today because I'm the designated driver, and that's OK. It's nice to be the guy that keeps his friends in line, keeps them from drinking too much so we can have a great time. A little responsibility can go a long way because it's all about having fun on game day. I'm the guy you want to be. I'm the guy saving money. I'm the guy with the H2O, and I'm the guy that says let's go. Welcome back. This is Craig Thomas, returning with much more medicine, and we are going to continue our discussion of Mongolia. So we need to switch a couple of slides through to the past agir, and we'll talk a little more. So, Shackley, what are your thoughts? Well, a question we were discussing during the break, which the viewers may be interested in, is you actually rode your bike in excess of 1,100 miles over some pretty challenging terrain, and I was wondering if you'd had any particular mechanical problems. Do you recommend that method of travel in Mongolia? Or at some point, would you rather have a horse in the saddle? Well, given my competence on horses, I don't think we want to go there. For me, biking is great. You go faster than you can on foot, so you can see a lot more, but you're still going plenty slow enough that you interact with people. You have a very close connection with the environment. You have a good idea of what the hills are like. The biggest challenge, honestly, was figuring out where to go, because I had two different GPS maps, neither of which was accurate, and a paper map, which disagreed with both of them. And the interesting thing about Mongolia is it's mostly pasture. So if somebody says, you know, I'm going to try this way this time, they drive off. We could do the same. A bicycle can go almost anywhere in Mongolia, track or not. But the trouble is, in the end, you need to end up in the right place, and that was challenging. But people were really nice, and it worked out. The other big challenge is the roads are rough. And stream crossings, especially if there's a little flash flood, is a real problem. And so then everybody kind of huddles up on the side of the little flash flood, trying to figure out, can you cross it, and if so, where. So we generally let a Soviet era jeep or something like that go first. And they made it worth a try. It all worked out. The bikes did well. The trip did well. And maybe we can slide through a couple slides and give a picture of kind of what it was like. How far west did you get? I got it almost as far west as you can possibly go. The ended up in the Altai Mountains at the base camp for the highest mountain in Mongolia, which is a sacred site. In fact, the Mongolian president has visited there. And sort of as a religious pilgrimage. And many people from Ulaanbaatar come out there. And it's honestly not an easy thing to do. You have to drive on very rough tracks for two or three days. They have to navigate also. And in the end, hike up to this about 10,500 foot area. The mountains are huge. They're about 14,000 feet. They have big glaciers. And it's a destination for climbers from all over the world. And it's about three kilometers from the Mongolian-Russian border. So it's in a restricted area. You have to get a special permit. The interesting thing about health in Mongolia is outside of Ulaanbaatar, life is challenging, as I said, it requires communal cooperation and hard work. In the summertime, people take their herds up quite high, up to about 10,000 feet. They didn't quite get to base camp. They have to herd them up every morning, herd them back at night, make sure they get water. It's pick up the dung to burn, dry it, et cetera. It's real work. But didn't see anybody fat outside of Ulaanbaatar. And I didn't see much smoking or drinking outside of Ulaanbaatar. Go ahead. The diet of the folks way out in the countryside like that is pretty much meat-based, right? I don't know if pretty much is a fair characterization. I would say 99 plus percent. That's not quite right. There are a few vegetables. But no, farming in general is not much of a deal in Mongolia. And yes, it's absolutely meat-based. And I was sort of chuckling because I got invited to a feast. And the feast was basically pretty much everything inside a sheep from tongue to the other end, all sort of steamed and boiled together. And then they hand you a knife, and then you reach in and grab something, whack off a piece, and eat it. And it was fascinating. And a good example also of a communal experience. So yes, it's a meat-based diet. But I think it's also a testimonial to if you are active and receive sufficient calories and some diversity of diet, you're fine. And these people, diet was not their issue. People seemed well-nourished. They were not heavy. And outside of Ulaanbaatar, there did not seem to be a huge impact of alcohol, though it worries me. And in Ulaanbaatar, it was clearly a factor. And although people smoke, I think that the income limitation prevents it so far from being the impact it is in much of the higher-income world. Did you drink any Iraq? How are they good? Iraq? Yes. So it's a very good marriage smell. Well, yes, once. The people are really generous. They want to try what you have, and they want you to try what they have. So a couple of young guys on a motorcycle really wanted me to try it. I'm not a drinker, but in addition, it would definitely be an acquired taste. But it's popular there. Did they put on a traditional Mongolian barbecue for you? I did do that, and that was also pretty wonderful. But truthfully, the collection around the big pot of sheep insides was more fascinating. But the really nice thing is people share their living space, their stuff, and very clearly the right thing to do is for us to share also. And when I say yes, I rode alone for a couple of weeks, then a guy who is an engineer from Seattle and works on vaccine issues in the low-income world joined me, and we then rode the last piece together. So it was a combination of a nice solo trip where I interacted a lot with local people and then shared experience with a friend, where we still interacted locally, but also were a little bit more of a traveling unit. I read someplace that the high level of meat can meet fat in the diet helps the Mongolians who need high caloric intake, especially during the severe winter months. I don't know if there's any medical sense to that. Well, they share a diet that that element of their diet is similar to that of the native people of the far north. And what you need is caloric density, because yes, as it gets colder, you need calories. So I think that's true. And I was there in July. I thought the climate was honestly, other than the thunderstorms, was pretty delicious. But it's hard to picture what it's like at 30 below in January. And short daylight, too. You're pretty far north. You're north of 50 degrees north most of the time. And the days have to be short. The work is still there. They have to take the animals out and graze them. It must be stubble by that time. There's certainly some snow around. So yeah, they need calories. Did you try any blood sausage? Didn't have blood sausage. But in the aforementioned, sheep entered's feast was a large pool of steamed blood. So that's like the sausage without the casing. It's interesting. American hunters bleed the animal after they kill it. But in Mongolia, they save the blood. They use everything in my experience. They have to. Life is honestly, even in July, pretty tough there. Having said that, though, people were extremely welcoming and friendly and always had time to share, even though there was usually a language thing, it reminded me of the fact that clearly our ancestors lived in a more communal manner than we do now. And honestly, I think that to the extent we can increase our interpersonal connections and interdependencies, we would be healthier. I think that's one of the lessons of Mongolia. During the break, I asked you if you had come across any of the burial mounds that we had learned about those by watching documentaries of burial mounds that the Russians have found in that general area and the Chinese and the far west that they some date back to the Silk Road. And they found all kinds of really interesting things. Did you see any evidence of anything like that? We did. And what we'll do is, in the background, Ray is going to start moving us through pictures just to give people a sort of an overview of what it's like. And while he's doing that, so Ray, let's go to the one after the gur and the bicycle. There are a number of different kinds of, I guess we'll call them, archeologic phenomena. So in the background now, you'll see a picture of a big brown river. This is normally a small brown river. But in July, which is the wet season, there are these tremendous rainstorms. And you can see it's flooding. So a big current, big flood. And we didn't have to cross this river. But you can see how that would be impassable. So we saw both burial mounds. We saw some, there are some vertical stones that look like small monoliths. And there are stone circles. And all of these apparently are related to burial practices. I think in part it depended what your role was. Next slide, please, Ray. So this is a shot of the aforementioned impending thunderstorms. We're about to ride into the middle of that. This is a very typical road. And you can see there's sort of the main strand. But off to the left, there are a bunch more. And the challenge always was, one of those strands sort of veered off somewhere, did it matter? Because 90 times out of 100, it didn't. They rejoined. And the other five or 10 times, it mattered a lot. And you either needed to be on it or not. This was a good part of our daily quandary. Next slide, please. This is up. That's near base camp. This is a Bactrian camel. They have two humped camels in Mongolia. They use them to carry heavy things. And in the background is a glacial moraine and a glacier. The Gobi Desert is a big part of Mongolia. And when I biked to there, all I saw were herds of camel. They were pretty wild, but I would guess they belonged to somebody. But for an entire day, I saw no humans, except on the road itself. Next slide. Well, I asked you previously a line about whether you'd come across the Mongolian people eating marmot and whether or not that is. I remember when I was there, there were cautions about eating marmots during certain times of the year because they said that the fleas on the marmots carried the bubonic plague. I'd never heard of an outbreak of it, but could you tell us anything about that? Sure. So the Mongolian people eat marmot, interestingly, in the far west, the Kazakh people, the dependent who have immigrated from Kazakhstan, do not. So we saw lots of more marmot when we got into the far west than we saw before that. I actually stayed out in the middle of nowhere in a gur where there was a marmot that had been dressed and was hanging sort of aging inside the gur. I did hear that about bubonic plague. I do not believe there was an outbreak when I was there. And I heard that the way they hunt them, which is to try to get them to alert so they stand up and whistle, is a way of selecting the healthy ones because the sick ones don't stand up and whistle so they don't get shot. Of course, they're probably going to die anyway. Ray, let's kind of slide on on the remaining pictures. So we're about to close. This is actually the highest mountain in the Altai mountains. You can see the base camp and the glaciers. And people from all over the world come in climate. It's also considered a sacred site. And honestly, you can see why. Next slide, Ray. Did you see evidence of the resurgence of Buddhism in Mongolia while you were there? So there is a Buddhist stupa. That's what we do call it, Nepal at least, that overlooks base camp from a bit of a distance and the mountain. And it's considered the most sacred site in Mongolia. So the last slide is a picture of a statue. It's about 10 feet tall. It's powerful. It's called oppression. And it's the first abstract art in Mongolia. And it's a picture of the populace's impression of what life was like as a Soviet satellite. And I'm sure that it's why you're there. And so I guess the thought I'd like to leave people with is that a country that was challenged as a Soviet satellite has, with the help of people like you, developed a new democracy and a legal system which has really changed things. Now their challenge is, how do you accommodate a nomadic culture, along with a urban industrial mining culture? And honestly, it's a challenge of the world. So I would encourage anyone who can to go there and experience for themselves. Is that just about running out of time? Or do you have any? How are we doing? I think we're nearly done. I'll say one other thing. There's a project to put right now. They're reforming their criminal justice code. It's based on the civil law system that was probably the highest form of it, or purest form of it. It's from Germany. And it was picked up by the Soviets and the Mongolians adopted it as well. But they're reforming it now. And they've actually included an adversarial character into their system, much like the common law system has. And so they're always looking outside and seeing what they can learn to improve their legal system and move on from the old Soviet period. Well, thanks for helping them do that. And thank you for joining us. Again, this is much more on medicine. Shakli Rafetto and I, thank you both. And Ray, thanks for your help.