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
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The 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) PAGE 2

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Posted March 1, 2001 © Eurasianet
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