SUMMARY OF
FACT FINDING MISSION TO KAZAKHSTAN
by Maitland J. "Aaron" Peak – Peak Options Consulting
For Soros Foundation – Open Society Institute, International Harm Reduction Development Program
click here to return to the Eurasia Policy Forum homepageThe fact finding mission, which ran from July 26-30 and August 19-29, 2000, did its work in Almaty and Karaganda / Temirtau. The majority of the meetings and site visits were held in Almaty and Karaganda.
How Illicit Drug Use Affects the Lives of People in Kazakhstan
The president and ministries of Health, Internal Affairs, and Drug Control Agency, have taken new initiatives this year to fight the drug problem, especially trafficking. (Ref. 7) Temirtau City Council has also started a revision of the criminal code (specifically Article 259) to ensure that the law enforcement community focuses on supply reduction rather than arresting drug users. (Ref. 11) The government has no political stance and no set policy on harm reduction. While the government understands that HIV is on the rise, they have no funding to support programs. All drug use and HIV initiatives must for the time being be supported by the international donor community. Since independence, Kazakhstan has received foreign aid for technical assistance, materials, and medicines while domestic support has dropped off.
Although no clear lines are drawn between upper, middle, and lower classes, people consider former political prisoners to be heroes. Opposition leaders who were imprisoned during transition are now leading businessmen and authorities. The population is accustomed to people’s use of alcohol and illicit drugs to relieve pain and suffering and as a mechanism for coping. (Ref. 2)
Harm reduction is addressed by only two groups: UNAIDS and its co-sponsors, who work from the top down; and the Soros Foundation, which works from the bottom up. The Kazakhstan Society Against Drugs, started by the president’s son-in-law, has strong political support and is the leading NGO in the country. No NGO, however, has been established to reduce drug-related harm.
The Ministry of Health provides detoxification treatment, but very little rehabilitation. Few drug users are able to afford the high cost (USD $300) of detoxification treatment, however residents of Almaty are given a reduced rate. (Ref. 1) Under Soviet leadership, tight control was used over the educational, health, and social aspects of people’s behavior. This approach, exacerbated by the government’s combination of the psychology and narcology units, has waned in the urban areas but still persists in the rural areas. (Ref. 2) The narcology dispensaries are under the Ministry of Health, but closely monitored by the Ministry of Interior. There are encouraging plans to divide the psychology and narcology units. Legislation responding to the problems of increasing addiction and the decreasing age of drug users must be passed. The main goal should be fighting drug trafficking and receiving practical assistance from the external donor community. There needs to be a better understanding of public health and security to help eliminate negative attitudes toward drug users. (Ref. 13)
Young drug users and children of drug users have the most difficulty coping. Children of arrested parents either go to a relative’s home or to the children’s distribution center. (Ref. 10) The drug treatment clinic Teen Challenge Kazakhstan tries to help children by creating a drug-free environment with absolutely no police involvement. The facility is maximum security, not to keep the "students" in, but to keep out drug dealers and the police who try to arrest students. The facility is uniquely known in the country for its confidentiality and lack of corruption.
By contrast, the police will take drug users or former drug users to the narcology dispensary to be tested for drugs. The police and the dispensary staff collude and tell users that they must pay USD $50 for a negative drug test or they will have drugs planted on them by the police and be arrested. Police have to meet a monthly quota of drug-related arrests, which was easier to do under Soviet rule. (Refs. 17, 2)
Prison officers and other personnel deny there is HIV in the prisons and oppose the introduction of needle exchange or condoms. Inmates are regularly tested for HIV but not for Hepatitis B or C. (Ref. 1) Two-thirds of the 80,000-90,000 prisoners are incarcerated for drug-related crimes. Every day 20-30 people are arrested for drug-related crimes, including possession of drugs. The police sometimes plant additional drugs on people to ensure an arrest. The government wastes precious funds on imprisoning drug users who will then have a criminal record, be introduced to other criminals, and increase the risk of HIV from sharing hard-to-come-by needles. (Ref. 3)
There are about 4,000 overdose patients and qualified toxicologists in only four towns. The toxicology units are fairly up to date in their training and are in contact with each other and colleagues in Central Asia and Moscow. However, antidotes for opioid overdoses, such as Narcaphine or Naloxson in ampoules, is needed to reduce the mortality rate. (Ref. 12)
After appropriate drug treatment, the second most important issue is employment for drug users. The German Technical Cooperation Agency’s (GTZ’s) attempt at "job clubs" were unsuccessful and the government is uninterested and without funds to do anything. Kyrgyzstan is more advanced in labor marketing and humanitarian efforts than Kazakhstan, and Tajikistan is the least advanced of the three, so it has received one GTZ agricultural project. (Ref. 16)
Illicit Drug Prevalence and Consumption
UNDCP reported the government’s statement that there were 37,000 drug users in 1999. The exact number is unknown but many believe the unofficial number to be around 200,000.
Trafficking of illicit drugs, primarily heroin, originates in Afghanistan and goes through Tajikistan into Kazakhstan. The drug of choice in the north is opium and heroin in the south and the Chui Valley has an abundance of cannabis. (Refs. 1, 2) The European market is bringing in ecstasy, a trendy drug used by middle to upper class youth. Some people claim that all families in Kazakhstan are directly or indirectly involved in drug abuse. In this Oblast every year 600-700 new drug users are added to the already registered 4,000. Users are young, from 18-25 years old, and 70-75% relapse after treatment. (Ref. 13)
Many users are switching from smoking to injecting, in part because it is illegal to posses, but not use, drugs. Many share their injecting equipment, which is cheap and available, and blood is used to prepare the drugs, in spite of the risk of HIV/AIDS. At least 30% of users know nothing about HIV/AIDS and how to prevent it. A recent rapid situation assessment found that 30% of the estimated commercial sex workers are using illicit drugs. (Ref. 1)
Ecstasy, LSD, and ephedrine are becoming popular among upwardly mobile youth in urban areas but are not as prevalent as heroin or opium. Pharmaceutical plants in Kazakhstan and neighboring countries are contributing to the rise of chemical-based drugs while plant-based drugs decrease. Youth are also inhaling "Tolol," a toxic chemical similar to glue sniffing but more dangerous. A children’s rehabilitation center is desperately needed to address the growing problem of street children. The center should offer a safe environment for medical treatment as well as psychological support and an opportunity for reintegration into the family. The Karaganda Oblast supports the center which will open once funding is located. (Ref. 11)
Women are getting more involved in trafficking as a means of survival and as a consequence are using more drugs. (Ref. 5) The Karaganda Oblast, where there are an estimated 15,000 drug users, has seen a dramatic increase in drug use in the last five years. The majority inject opium while 15% have switched to heroin. Government officials are aware of and not trying to hide the problem of drug use and increase in HIV infection. (Ref. 7)
Drug users with health concerns such as abscesses and wounds are uncomfortable going to the hospital for treatment since they will be reported to the narcology dispensary upon release. Many choose not to go into treatment because they do not see the magnitude of the dangers of drug use. (Ref. 8) The facilities to treat overdosed patients are inadequate. In Karaganda City one unit has 25 beds to treat 2,000 patients annually. Alcohol poisoning has decreased from 50% to 40% while poisoning by psychotropic drugs and increased from 1% to 15%. Mortality rates have increased significantly. Most deaths are not due to immediate overdose but to kidney failure and other complications. Once out of a coma, users are transferred to the narcology dispensary, where they receive psychological counseling. Some patients stay for drug treatment, but many leave since it is not required. When parents do not know that their child is using drugs and have to come to the hospital, they are often quite shocked and need help to understand addiction and drug use. Information on overdose procedures that can be understood by many should be available. (Ref. 12)
Co-dependency, or the role family members play in the continuation of drug use, is a large problem that needs to be examined. Many families see the drug using member of their family sell off more and more of the house in order to buy drugs. Teen Challenge Kazakhstan has a recovery program for the families of drug users and does not allow family members on the facility premises unless they have gone through the recovery program themselves. The center also cooperates with other units – House of Hope for men, House of Mercy for women and children, and The Ark for detoxification. No programs accept current drug users, except Exodus, a work program based on labor therapy. (Ref. 17)
Infectious Diseases Associated with Drug Use
According to official data, there are 1,045 reported HIV cases in Kazakhstan, 85% of whom were infected by sharing contaminated drug injecting syringes. Karaganda Oblast has 919 HIV infected persons. Here, drug users make up 93%, and 79% of those are between the ages of 15 and 30 years. Twenty-seven cases of AIDS have been diagnosed, of which 16% are female. Ninety percent of HIV infected individuals and 85% of all drug users in the Oblast are infected with Hepatitis C.
The president decreed that at-risk groups, such as blood donors, sexual or drug using partners, IDUs, CSWs, MSMs, STD patients, people who travel abroad for more than three months, and blood recipients, would have compulsory HIV testing. A few other categories, such as at-risk pregnant women and orphans, are tested. Anyone who wants an HIV test can obtain one anonymously. (Ref. 8)
The cost of treating the illnesses associated with HIV/AIDS is USD $8,000-10,000 for each patient and more than the government can afford. (Ref. 7) To be eligible for treatment, an HIV infected person must not use drugs. AIDS patients may use the hospice in the Oncology Department of the Karaganda Oblast hospital. Soros Foundation is interested in training family members and medical personnel working with HIV in hospice care. The Soros Foundation turned down a proposal submitted in May, 2000, and so other donors are being sought. This Oblast and its AIDS Center, the first in the country to experience AIDS-related deaths, does need help. (Ref. 8) The cost of treating the 150 HIV patients who have been identified for treatment is approximately USD $208,300. Additionally, some of the patients need drug treatment.
Many drug users are former prisoners who caught tuberculosis in prison and frequently request treatment for it from the Trust Points. Many would like to stop their drug use but do not because of long-term use or lack of treatment opportunities. Methadone is a treatment some have tried and would like to see offered by the Trust Points. (Ref. 10)
In Temirtau, where there is a higher rate of HIV infection than elsewhere, tests must be sent to Almaty. Karaganda Oblast, therefore, needs laboratory equipment and western blot capabilities so that test results are not delayed. (Ref. 11)
From time to time the AIDS Center reviews the files of the toxicology unit in order to monitor the number of HIV infected individuals serviced by the unit. HIV tests are also done by the Teen Challenge Kazakhstan center. None of the 3,000 tests on new students has turned up an HIV infected person. If students become ill or have a medical problem, they are taken to a private doctor, Dr. Marty Basset.
How Service Providers and International Aid Meet the Needs of the Drug Users
It should be said at the outset, perhaps, that harm reduction is difficult in a country in which drug users still remember that under Soviet leadership their names were taken by health professionals and given to public security officials to record. Many drug users and commercial sex workers, therefore, are unwilling to go to government medical services. (Ref. 1)
Harm reduction programs in the region reach about 5% of drug users. UNAIDS strives to provide a comprehensive approach to harm reduction, from prevention of drug use to prevention of HIV and STDs, but with a top down approach. The UN has worked on changing attitudes in the government about drug users, commercial sex workers, and men who have sex with men, but the constant change in top officials makes progress difficult. UNAIDS is encouraging the Ministry of Interior to support drug substitution therapy, which the Ministry will support provided that it deceases the crime rate. A project covering 18 prisons includes needle exchange and distribution of condoms and IEC materials. The UN hopes that by decreasing funding to the NGO community that the government will initiate HIV programs. UNAIDS does not feel Country Program Advisers are needed in all five Central Asian countries and that UNDP can assist with a focal person for HIV/AIDS.
Extensive preparations, including staff training and a strategy to contact drug users, was undertaken before the UNAIDS supported harm reduction program was initiated in March, 2000. The trust points are located in the outpatient department of the AIDS Center and in three polyclinics. After several methods failed to get drug users to come to the sites it was determined that the only way to get clients to the trust points is to offer methadone substitution. (Ref. 3) Overall, UNAIDS supports four trust site programs, the government supports three, and the Soros Foundation supports five.
The international nongovernmental organizations have been slow to get involved in the country because HIV prevalence is low and official statistics of illicit drug use are also low. GTZ, however, has just expressed a commitment to being more involved in the region. (Ref. 4)
The Ministry of Health does not consider harm reduction, first introduced by the UN, as its own initiative. Of its 1999 USD $21 million budget, USD $3 million was designated for HIV prevention and was used primarily for HIV testing. The Ministry is focusing its funds on cancer and frankly views drug substitution as promoting drug use. The UNDP HIV/AIDS Focal Point said what is needed is a pilot substitution therapy project; dissemination of IEC materials as prevention among non-drug users; and orientation workshops on harm reduction for public health and public security. (Ref. 1)
UNDCP has been a lead sponsor of HIV prevention, contributing USD $175,000 to the country. The regional office is finalizing a document about its demand reduction project for the Central Asian countries that focuses on drug treatment. Problems with the drug treatment situation include the lack of up-to-date information on treatment modalities for narcologists and the difficulty of passing legislation for sustainable treatment. UNDCP is currently funding a primary prevention initiative that will devise curriculum materials for secondary schools throughout the country. In the future, UNDCP would like to take the lead in the operational aspects of the programs it has funded. (Ref. 5)
If agencies have a good working relationship with top authorities and the law enforcement community for harm reduction projects, then drug users will be less often harassed and the projects will run more successfully. Needle exchanges have difficulty operating because a user can be arrested for possession of a syringe. One possibility is to introduce identification cards such as are used in the OSI funded programs in Kustanai.
Harm reduction is not a priority for the government. It appears to believe it would be wasting money and so is more concerned with the health of socially acceptable non-drug users. The Ministry of Health’s budget is only sufficient for hospitals and supplies. Through the government’s AIDS Center, USD $1-2 million is spent largely on HIV testing. New ideas, strategies, and programs are much more acceptable to the government and local leaders if there is secured funding attached to the project. (Ref. 2) The Ministry of Health provides free treatment only to TB patients and the chronically mentally ill. In spite of the increase in drug use, it has made no effort to build on the existing drug treatment centers or establish independent rehabilitation centers. (Ref. 2)
GTZ’s work in the region does not include issues of drug abuse or HIV. Its two projects in Kazakhstan include a business incubation for small and medium sized businesses in Chemkent and a collaborative effort with the Soros Foundation concerning the taxation of imported medicines and licensing of import companies. "Foundation of Tax Structure Formation Organization" is located in Almaty. (Ref. 16)
The Karaganda Oblast and city administration have established a coordination council whose aim is to inform the government on the number of HIV infections and pay attention to the finances of the HIV centers.
Drug abuse and harm reduction programs should be multi-sectorial, including involvement of the Ministries of Internal Affairs, Education, and the Department of Information. This will help broaden needle exchange and separate the narcology dispensaries from the psychiatric hospitals.
Temirtau has six trust points that provide services, information, and syringes. Karaganda has two such trust points plus an NGO called Mother to Child for mothers of drug users. Former drug users are active in the Oblast, talking to current users in discos, schools, and parks about HIV. As a result of compulsory high school orientations, drug use has not increased in the schools in the last two years.
The Oblast Health Department would like to request from the Soros Foundation an adviser to streamline the work that is taking place, working on more effective drug treatment and prevention messages, for which mass media can be used. The Oblast needs harm reduction and treatment training as well as a mobile trust point for needle exchange and primary prevention as it is a vast area. It would like to open, with the help of the expertise of international agencies, a "Republican Center" for fighting drug abuse. Funding for such programs should be merged into the local budget. (Refs. 7, 14)
The toxicology unit in the Infectious Disease Hospital of this Oblast needs a new gas liquid chromographer in order to determine the cause of a patient’s overdose, specifically whether the coma is from alcohol alone or mixed with other poisoning. (Ref. 12)
The Scientific Center at the Psychology and Narcology Hospital has been working on studying a range of narcology problems from biochemical to psychological. (Ref. 13)
From the beginning of the year to the time of the mission, Trust Point #1 in Karaganda had served 560 drug users and Trust Point #2 had served 231. Their budgets, however, only cover 75 clients. A least 15-16 more trust points and a mobile unit are estimated to be needed. Many drug users were skeptical of the trust points initially, but now they often come for syringes, cotton, condoms, alcohol, and information. The trust points have psychologists for counseling of users and their families. HIV testing is anonymous and encouraged at the sites. About 60% of the drug users, who are often in poor health, get their information on HIV and drug injecting harms from the two sites and distribute it to other drug users.
One problem with the trust points is that primary health care is continually requested but there is no funding for it. Some hospitals will not admit drug users without difficulty. Another problem is the absence of proper documents among drug users, which are necessary for admittance to hospitals or medical facilities. Many drug users are homeless and dirty. Ideally, the trust point should offer showers, clothes washing, and even a place to lie down.
The youngest client at the trust point was 13 years old; male and female clients are split evenly. (Refs. 9, 10)
The city of Temirtau has a critical drug use and HIV problem. Its City Council requested support from Soros Foundation for its HIV programs and would like a plan of action and time frame from Soros in New York to continue their pilot programs, which are nearing their completion dates. In fighting against drug use and the macro business of drug trafficking, the Council coordinates the work of the police, education, health, prosecution office, and NGO sectors. Since it is a transshipment point, drugs are sold easily and, unofficially, it is understood that there is corruption. In this context of drug use, serious problems with trafficking, and roadblocks by the Ministry of Finance to re-allocate project funding, the Council is in great need of funding by the international donor community.
Observations and Recommendations
The mission to Kazakhstan included more of an emphasis on the political and financial situations than programmatic processes, which were emphasized in the other two countries. The size of the country and the time allotted meant that the full scope of HIV and drug use was not grasped. The author would have liked to visit innovative programs around the country that were described to him in the Soros Volunteer House.
The UN: The impression from the UNAIDS Regional Adviser and the UNDP HIV/AIDS Focal Point person is that they are more interested in drug use prevention than HIV prevention. The Regional Advisor clarified the reasons for the reduction of support to the NGO community. The Focal Point person suggested that methadone, which would take time to realize, would be a good advancement.
The lack of understanding and cooperation between the UN and NGOs is demonstrated by communication conflicts and the absence of any program development guidance of the UNAIDS trust points. Conflict also appeared between the government and the UN since it seems that needle exchange would not exist at all had the UN not requested and funded it. Overall, there is a lack of coordination between all entities working in the field. The Soros Foundation director recommended that leadership in this effort should be collaborative. UNDCP is a good – and willing – candidate for collaboration as they are getting more involved in a drug treatment strategy that will affect the trust points. The relationship between the Soros Foundation and UNAIDS is improving and it has been clarified that UNAIDS will oversee redefining policy and the Soros Foundation will take care of initiating HIV programs. (Ref. 4)
GTZ: GTZ initiatives have shown promise and could be beneficial to the sustainable development of the harm reduction programs. GTZ initiatives, however, have worked better in places like Kyrgyzstan where they had more support and participation by the government. GTZ is committed to the prevention and care of tuberculosis patients. The Soros Foundation should develop IEC materials on TB since many drug users are afflicted with it. These materials could also be used in GTZ program areas with drug use but no OSI representation.
Recommended: Meetings should be arranged with UNDCP and GTZ to explore collaborative initiatives such as job clubs, income generation components to harm reduction programs, and integration of harm reduction with drug treatment and sustainable development to improve the quality of life for drug users. Regular meetings should assemble the donor community and the government for discussions and strategy planning to expand the harm reduction program.
Public Opinion Research: The organization, which has good historical and current information, may be able to take the lead in developing and implementing a Central Asian Harm Reduction Network.
Recommended: Electronic and material subscriptions should be requested from networks, including Eastern European Harm Reduction Network, the Asian Harm Reduction Network, and the International Harm Reduction Association. Funding should be directed to the 12th International Conference on the Reduction of Drug related Harm in New Delhi, India, April, 2001, and abstracts should be submitted for oral presentation.
Prisons: The potential for the spread of HIV and other infectious diseases is high in prison, especially since the majority of drug users also have a prison record. Numerous accounts cast doubt on the legitimacy of every drug-related arrest. Information in this sensitive area is difficult to get.
Recommended: Information should be gathered on all prison initiatives and the preliminary development of harm reduction strategies.
Overdose: Overdosing is rapidly increasing while hospital resources remain the same or are non-existent. Staff training is not need, but the medications Narcaphine and/or Naloxson are, as well as a gas liquid chromographer.
Recommended: Support should be given for a trial program of Narcaphine and/or Naloxson or similar medication to establish the impact on mortality rates in this hospital.
Co-dependency: Teen Challenge Kazakhstan, whose form of drug treatment may not be appropriate country-wide since there is no medication for withdrawal and it is expensive, is progressive in its focus on co-dependency of family members of drug users. This is an area hardly explored and yet relevant to Central Asia.
Recommended: Co-dependency material should be explored and included in IEC materials for the programs. Teen Challenge Kazakhstan could be invited to a harm reduction meeting for OSI staff to present information on co-dependency and vocational training.
Karaganda and Temirtau: These site visits were somewhat frustrating because meetings were held with high level authorities only. In spite of requests, the mission could not meet with drug users or volunteers. The director of the Temirtau AIDS Center said it was not necessary to meet with drug users or volunteers since the City Council knew what was best for them. Harm reduction here is top-down, even autocratic. The staff at the trust points were committed, however. With Soros Foundation support and input from the drug using community, the projects could be expanded to include a hospice program and primary health care with basic medical supplies. Further, a mobile unit with all the components of a fixed site would help deal with the estimated 1,000 drug users who live in the areas around Karaganda and Temirtau. Equipment is needed in Karaganda for HIV tests. The director of the Oblast Health Department requested the Soros Foundation provide an expert for long-term technical assistance in harm reduction.
Recommended: The request for an expert should be considered since it might prove beneficial in providing comprehensive harm reduction initiatives and help ensure that the target community is involved. A hospice program should be explored, piloted, and, if successful, replicated in other areas and the Central Asian countries.
References
- UNDP: Dr. Alexander Kosukhin, Program of Healthy Lifestyles Development Coordinator.
- Public Opinion Research: Bauazhan Zhusupov, Director.
- AIDS Center: Dr. Gulsara, Deputy Director, and NGO "ANTINAR" – Sergey Soroko, Director.
- UNAIDS: Dr. Rudick Adamian, Inter-Country Program Adviser.
- UNDCP Country Office: Dr. Alma Yesirkegenova, Program Officer.
- Women’s League of Creative Initiatives – Asiya Khairulina, President, and Olga Kshnyakina, Accountant.
- Karaganda Oblast Health Department: Dr. Kenzhebaev Nurbai, Deputy Director.
- Karaganda Oblast AIDS Center.
- Karaganda Trust Point #2: Ms. Galina, Nurse, and Helen Polefaeva, Psychologist.
- Karaganda Trust Point #1: Alimova Vera, Nurse, and Dil Vera, Psychologist.
- City Council of Temirtau.
- Infectious Disease Hospital, Toxicology Unit: Dr. Mikhailova Svetlane, Director.
- Psychology/Narcology Hospital: Dr. Apel Alexander, Executive Director, and Fonareva Natalya, Head Nurse of Narcology.
- Oblast Health Department: Dr. Yermekbaev Kanat, Director.
- Soros Foundation Kazakhstan: Auezov Murat, Executive Director.
- GTZ: Karlfried Metzler, Director in Kazakhstan, Tajikistan, Uzbekistan, and Turkmenistan.
- Teen Challenge Kazakhstan: Douglas Boyle, Executive Director.
- Soros Volunteer House: Birzhanova Nazilya, Executive Director, and Community Development Center "Accord" – Vinogradova Helena, Director.
Study Tour Participant List for Key Individuals from Kazakhstan
Note: While the Open Society Institute funded this mission, it did not have any input or verify the contents or findings of the mission. The author is solely responsible for the accuracy of this report.