Turkmenistan: Public Health Remains in Critical Condition

Since coming to power over three years ago, Turkmen leader Gurbanguly Berdymukhamedov has presided over the openings of gleaming medical facilities in Ashgabat, but his administration is doing little to improve the quality of the health-care system for the bulk of the Central Asian nation's population. Underscoring Turkmenistan's health-care woes is the recent decision of Doctors Without Borders to shut down its operations in the country.

Turkmenistan's health-care infrastructure fell into a state of disrepair during the tenure of deceased dictator Saparmarat Niyazov. [For background see the Eurasia Insight archive].

Upon gaining power in late 2006, Berdymukhamedov, a dentist by training, pledged to make radical improvements to the health-care system. But so far, change has been largely superficial. [For background see the Eurasia Insight archive].

Symbolizing the Turkmen government's preference for style over substance is Ashgabat's new Cancer Center, a vast structure of white marble, blue glass and gold trim, with a row of fountains leading up to the entrance. Inside, the palatial foyer is dominated by a portrait of Berdymukhamedov, who inaugurated the hospital in July by reportedly performing surgery to remove a tumor from behind a patient's ear. Officials have trumpeted the facility as proof of the country's progressive and successful health-care policy.

"The capital of Ashgabat has turned into one of the world's major medical centers with international standards of treatment," Deputy Health Minister Leila Shamuradova in a speech during an investment forum, held in mid-October in Ashgabat. An English-language power-point presentation featured dozens of shiny new facilities across the country, including centers for cardiology, oncology, nephrology, ophthalmology, dermatology and sexually transmitted diseases. Following the forum, conference, Shamuradova was elevated to acting health minister.

The problem is that the overwhelming majority of the population will never get near such facilities, local and international observers say. Doctors quietly admit that access to the newer facilities is only possible with the payment of substantial bribes, despite the fact that the services are officially free.

Far more troubling to international observers is the government's lack of interest in reversing the damage done by Niyazov's malign neglect. During the last years of Niyazov's rule, instruction for medical professionals was reduced from five years to just two, with one subsequent year of unsupervised training. In addition, many hospitals outside the capital were closed, and some were forced to use army conscripts to do the work of nurses. The drastic changes left Turkmen citizens increasingly vulnerable to epidemics. [For background see the Eurasia Insight archive].

Berdymukhamedov served as Niyazov's health minister, and presided over the dismantling of the health-care system. But upon his elevation to the top spot he annulled some of his predecessor's harsher measures. Even so, Berdymukhamedov's administration continues to prioritize political control over public health.

In mid-December, Doctors Without Borders (MSF) announced that it was ceasing operations in the country, explaining that it could not secure government consent to implement a program to treat sufferers of drug-resistant tuberculosis. MSF representatives say one in five people in Turkmenistan suffering from tuberculosis have a drug-resistant form of the disease, adding that the Turkmen government lacks the capacity to quickly address the situation on its own. MSF also was operating programs that aimed to improve the quality of pediatric and reproductive health services.

Long before MSF felt forced to abandon Turkmenistan, foreign organizations faced lots of obstacles. International public health specialists have long complained about a paucity of reliable Turkmen data on public health. "We are engaged in Turkmenistan with the Ministry of Health, but our engagement is relatively modest," said Roger Robinson, the country manager for Kyrgyzstan and Turkmenistan at the World Bank, in a carefully worded presentation given at October investment forum.

The Turkmen political system's reliance on fear appears to be a major obstacle to cooperation with international organizations: Turkmen officials are simply afraid of doing or saying anything that might imperil their positions. For example, Shamuradova, clearly shaken by the presence of journalists at the October forum, refused even to confirm her name after her presentation. Asked for verification of hospital closures under Niyazov, she insisted that "nothing was closed, it was simply reformed."

Reinforcing the notion that Turkmen leaders are unwilling to come to grips with public health problems, authorities in Ashgabat vigorously deny that the spread of HIV is a serious issue in the country, even though circumstantial evidence suggests the opposite.

Turkmenistan lies in a region where most countries admit a growing HIV problem. While there are no accurate statistics on drug use in the country, its long border with Afghanistan leads many to suspect that drugs do find their way in, and foreigners in the country report seeing the evidence of heroin use - discarded needles and syringes - in provincial towns and in the capital itself.

Additionally, prostitution is widespread and highly visible. In other Central Asian countries, drugs and sex work have been the catalysts for rapid growth in the spread of the HIV virus among the general population. But when approached after the conference and asked about HIV in the country, Shamuradova - whose portfolio includes epidemiology - denied that the country has a problem.

"As part of the respected president's new program in health, we have opened an HIV prevention center," Shamuradova said. "However, to our great happiness, not a single case of HIV has been reported anywhere in the country."