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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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 12^th 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

1. UNDP: Dr. Alexander Kosukhin, Program of Healthy Lifestyles Development Coordinator.
2. Public Opinion Research: Bauazhan Zhusupov, Director.
3. AIDS Center: Dr. Gulsara, Deputy Director, and NGO "ANTINAR" – Sergey Soroko, Director.
4. UNAIDS: Dr. Rudick Adamian, Inter-Country Program Adviser.
5. UNDCP Country Office: Dr. Alma Yesirkegenova, Program Officer.
6. Women’s League of Creative Initiatives – Asiya Khairulina, President, and Olga Kshnyakina, Accountant.
7. Karaganda Oblast Health Department: Dr. Kenzhebaev Nurbai, Deputy Director.
8. Karaganda Oblast AIDS Center.
9. Karaganda Trust Point #2: Ms. Galina, Nurse, and Helen Polefaeva, Psychologist.
10. Karaganda Trust Point #1: Alimova Vera, Nurse, and Dil Vera, Psychologist.
11. City Council of Temirtau.
12. Infectious Disease Hospital, Toxicology Unit: Dr. Mikhailova Svetlane, Director.
13. Psychology/Narcology Hospital: Dr. Apel Alexander, Executive Director, and Fonareva Natalya, Head Nurse of Narcology.
14. Oblast Health Department: Dr. Yermekbaev Kanat, Director.
15. Soros Foundation Kazakhstan: Auezov Murat, Executive Director.
16. GTZ: Karlfried Metzler, Director in Kazakhstan, Tajikistan, Uzbekistan, and Turkmenistan.
17. Teen Challenge Kazakhstan: Douglas Boyle, Executive Director.
18. Soros Volunteer House: Birzhanova Nazilya, Executive Director, and Community Development Center "Accord" – Vinogradova Helena, Director.

1. Valeriya Gurevich, Medical Coordinator, Soros Foundation, Almaty.
2. Baurzhau Zhusupov, Research, Soros Foundation, Almaty.
3. Alexander Kossuchin, HIV/AIDS Focal Point, UNDP, Almaty.
4. Aizhan Shumosheva, WEP of west Kazakhstan, Soros Foundation, Aktobe.
5. Igor Vassilenko, WEP of north Kazakhstan, Soros Foundation, Lostanai.
6. Tsoi Vyacheslav, Secretary of Parliament, City council, Temirtau.
7. Marat Achmetov, Director Medical Department, Ministry of Police, Almaty.
8. Ms. Froin, Health Care Ministry, Almaty.
9. Sholpan Baibolova, Director of NGO, son-in-law of the President of Kazakhstan, Almaty.

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.

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Posted March 1, 2001 © Eurasianet
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