April 25, 2002
International Doctors Battle Drying Sea in Uzbek Epidemic
as appeared on Eurasianet
by Elena Dubrovskaya, a freelance journalist specializing in Central Asian affairs
The United Nations Development Program (UNDP) closed its mission this spring in the Karauzyak District of the semi-autonomous republic of Karakalpakstan amid an increase in tuberculosis cases. According to independent sources, 100,000 people in Karakalpakstan—which is located in northwestern Uzbekistan—have become infected with tuberculosis over the past three years; the Republican Anti-Tuberculosis Dispensary reports that 560 people died from the disease during 2001. Some observers say that official figures are underreported, as many tuberculosis bacilli victims, particularly in rural areas, do not seek treatment.
Nukus, Karakalpakstan's capital, has become the base for a dramatic surge in this disease. According to international physicians' group Doctors Without Borders/Médicins Sans Frontières (MSF), the rates in this region are twice as high as those in Uzbekistan—and Uzbekistan's TB rates are among the highest in the former Soviet Union. People suffering from tuberculosis in Nukus significantly outnumber those living in Kungrad and Muinak Districts and cities in the nearby Khorezm region of Uzbekistan. But relatively rural areas can seem more overwhelmed by the disease. In the Karakalpakstan districts of Muinak and Kungrad, for instance, entire families have become infected. "My husband died of tuberculosis several years ago," says Mrs. Bazargul Kaljanova. "My two daughters shortly after fell ill. When my elder daughter's husband found out, he left her. The younger one had to quit school. We live in extreme poverty. Sometimes you will not find a single breadcrumb in our house."
The widespread poverty seems to bear on the region's high TB rates. According to MSF's experts, after the collapse of the Soviet Union, Uzbekistan's and Karakalpakstan's healthcare systems have declined in quality. Conditions in the local hospitals and other medical institutions may often even contribute to the spread of the disease. For example, hospital crowding often breeds repeated infection and cross infection. Poor lighting and ventilation provide a fertile ground in which tuberculosis bacilli can thrive. Unsanitary hospital food and inadequate bathing facilities can also make patients with the disease less responsive to treatment. Doug Kittle, a Canadian doctor who served with MSF in Uzbekistan, told the Toronto Star that a TB patient's average age in Uzbekistan is 27. Nearly 30 percent of those suffering from tuberculosis are children; many of them cannot go to school because of the disease.
Geographically, doctors have spread out their efforts to fight the disease. Uzbekistan contains 20 anti-tuberculosis dispensaries, five specialized kindergartens, a specialized boarding school (in Turtkul) and a children's sanatorium (in Nukus). But virtually all, particularly those for children, are in need of funds for repairs and medications. MSF has started distributing drugs and training to local doctors; it hopes to hand the reins for anti-TB programs to the government in "the next few years." For now, local physicians readily admit they lack access to necessary equipment and medicines, particularly in rural areas.
But TB does not simply spread in rural districts. As convicts leave prison, they transmit the TB germs to the general population; in January, over 460 former convicts registered at the Republic Anti-Tuberculosis Dispensary. Though Uzbekistan maintains prison hospitals, witnesses say the hospitals do not work well. "Lethal outcomes of this disease are rather common," says Abdulla Zakirov, who was released from prison this year. "In the prison, no one cared about my disease and only now that I am released do I have an opportunity to receive medical treatment. My disease is at the stage next to the last."
Even if the government improved prison health care or immunized children, though, a broader public health crisis will keep pushing up TB rates. The desertification of the Aral Sea has made drought conditions normal in Karakalpakstan over the past few years, causing huge losses for local farmers. [For more information see the EurasiaNet Environment archive]. Many farmers have not received salaries for years, and prioritize putting food on the table over procuring medicine or teaching their children to protect themselves from the disease.
The drought may also increase the amount of dirty dry fruit and sunflower seeds in the market, as well as general unsanitary conditions in public places. Families may also buy untested or spoiled meat and milk products, which make them more vulnerable to bacteria. Finally, ignorance may make the disease spread faster and farther. "Unfortunately, after becoming infected people for a long time do not know they have tuberculosis and continue to be treated at home, infecting relatives and neighbors," says MSF assistant program coordinator Kamal Khamidov. "Or [they] turn to the local healers."
Working alongside the Ministry of Health, organizations such as MSF, the International Committee of the Red Cross and the German Development Bank are trying to enhance local healthcare workers' skills. "Today the mission of MSF is not only confined to medical treatment," says Khamidov. "Another direction is training the medical staff and educating the population." According to the chief physician of the Republican Anti-Tuberculosis Dispensary, Daribay Doshetov, a World Health Organization program called the Directly Observed Training Short Course, or DOTS, now treats thousands of people in eight northern areas of the republic and will soon debut in five more. In 2003, three more districts in the areas adjacent to the southern part of the Aral Sea should receive DOTS instruction.
This training will only go so far. TB rates in Karakalpakstan have reached 300 per 100,000 people, evidence of an epidemic. Local authorities say they will need financial help to treat patients, distribute medicine, and promote good public health. Uzbekistan receives humanitarian aid from numerous sources, including the German Development Bank. Local residents and officials anxiously await this aid's conversion into medicine and care.