SUMMARY OF FACT FINDING MISSION TO KYRGYZSTAN
Maitland J. "Aaron" Peak – Peak Options Consulting
For Soros Foundation – Open Society Institute,
International Harm Reduction Development Program
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Observations and Recommendations

Fact finding mission: Due to a change in people accompanying the mission, Osh was chosen as the second site visit. Unfortunately, the mission coincided with the majority of the UN representatives’ annual home leave. The only meeting that could be scheduled was with UNFPA, which is not working in the HIV or drug use fields.

UN: The UN’s commitment seems as low as in the other two countries. However, the cohesiveness of the collaboration of the UN, international and national NGOs, and the government is conducive for moving forward with innovative programs in Bishkek. The drug using community was more involved and there seemed to be lower levels of prejudice than in the other two countries.

Primary care: It was clear from meetings with the State Commission of Drug Control, the Ministry of Internal Affairs, and the UNDCP Country Office that the harm reduction initiative needs to be expanded to include a wider range of services. They expressed willingness to collaborate with OSI if they included assistance in primary prevention, referral mechanisms, rehabilitation, and reintegration of drug users back into society.

Recommended: The Soros Foundation should consider addressing issues relating to a continuum of care and treatment for potential, current, and former drug users. For example, OSI program volunteers could accompany police when they talk to school children about prevention. The law enforcement community as well as the medical, NGO, and target communities have requested appropriate drug treatment, rehabilitation, and reintegration.

The Soros Foundation should be involved with or be represented at the government’s newly developing representative body to address supply, demand, and harm reduction initiatives and policies. Soros would add an active and credible voice.

UNDCP: The UNDCP regional office will soon fund an assessment of the current state of illicit drug use in Central Asia. There has been difficulty finding an appropriate partner for the initiative in Kyrgyzstan. As a result of this mission, however, UNDCP may collaborate with Sotsium. The assessment will document the accurate and current statistics of drug use in the country, which in turn would increase the funding for UNDCP and the Ministry of Health. UNDCP has contributed the most financial support for HIV and drug use within the whole UN system as well as among the non-UN agencies. UNDCP will implement an overall strategy on demand reduction in the coming year focusing on primary prevention in youth and redefining the drug treatment arena.

The Soros Foundation cannot, and should not, be the primary donor agency to provide a comprehensive approach to harm reduction. The ministries, donor agencies, and NGOs need to cooperate on a three-prong approach to harm reduction, including detoxification, rehabilitation, and reintegration.

Recommended: The Soros Foundation should initiate a working relationship with UNDCP and lend support for the possible involvement of Sotsium in UNDCP’s assessment of drug use in Kyrgyzstan. There should be a seminar on developing rehabilitation and reintegration as part of the drug treatment and harm reduction schemes.

Law enforcement: Across the board there has been agreement that something has to be done about the interference of the law enforcement community with volunteers, clients, and former drug users. The low, below survival rate salaries of the police and low status of drug users encourages the corruption and harassment. The ultimate solution, resolution of the country’s financial crisis, is far in the future. In the meantime some pragmatic steps can be taken to address the issues that affect the OSI programs.

Recommended: Support should be given for orientation seminars for the law enforcement community. The seminars should focus on comprehensive harm reduction strategies and highlight the importance of a continuum of care. This is a VERY sensitive issue and any approach has to be well thought out. Another option is to document all the cases of non-legal conflicts between the clients and law enforcement officers. This may demonstrate that the individuals committing the offenses are few. Some officers may enhance the program through referrals rather than arrests. Advice should be requested from the Soros Foundation’s legal division at the country office so that procedures are correctly undertaken.

Osh: Osh was somewhat different than Bishkek. First, it seemed incestuous, as the deputy director of the Ministry of Internal Affairs seems to be related to the chief of the narcology dispensary, who is also the director of the OSI harm reduction program. The head psychiatrist is married to the director and it is said that relatives are working on the program as volunteers. Second, there was little interaction with drug users in Osh. The approach in Osh seemed more autocratic and leaned towards abstinence-based objectives. The main agenda seemed to be to request support from the Soros Foundation for every aspect and initiative. Third, whereas the Bishkek program was more client driven, in Osh the program was more monetarily driven – spacing out the clients, even turning them away, so that in the end they reached the total number for which they had been funded.

The OSI program felt that there was a need to open a second site in Bishkek. The office lacks all infrastructure required to operate a productive and sustainable program.

Recommended: The Soros Foundation should allocate funds to supply the new Bishkek office with equipment, telephone, and supplies so that this much needed additional site can operate at full capacity.

National AIDS Program: It was unfortunate that more insight was not gathered on the reasons for the reduced support from the various UN agencies to the National AIDS Program, which tended to be very bureaucratic.

Recommended: There were repeated requests for the Soros Foundation’s support of the book "Health and Lifestyle" accompanied by workbooks and training for teachers.

TB: There is a continual interaction between drug users and the Tuberculosis Hospital because drug users are susceptible to TB infection and some enjoy retaining the "invalid" status of having TB.

Recommended: Support should be allocated to produce IEC materials on TB and the consequences of sustained TB infection. More collaborative initiatives should be undertaken by the OSI harm reduction staff and the narcologist, doctors, and nursing staff at the TB hospital to enhance knowledge and foster more interaction between the volunteers and drug users that are also TB patients at the hospital.

Disease studies: The Infectious Disease Hospital has been collaborating with the Center for Disease Control on viral hepatitis studies. CDC informally expressed interest in forming a relationship with the Soros Foundation for studies with drug users on the prevalence of hepatitis B and C.

Recommended: The Soros Foundation should establish a relationship with CDC and discuss collaborations on prevention strategies and developing appropriate IEC materials for drug users. A hospital staff member or narcologist should be a liaison between the OSI program and hospital so that an improved standard of treatment can be provided to the drug users.

Printed materials: The mission stopped at the Center for Information and Enlightenment to gather materials, most of which was technical and unsuitable to the drug using community, on different diseases. The National AIDS Program has an adequate but narrow selection of materials on HIV/AIDS. The OSI program has already started re-developing materials for drug users with their assistance, but it does not have enough.

Recommended: Materials from the Center for Information and Enlightenment should be used as a basis to develop appropriate IEC materials for distribution to drug users. Support should be allocated to develop, field test, produce, and distribute materials on primary health care, hepatitis B and C, vein care, nutrition, overdose management, and TB. Extra copies may need to be produced for distribution to agencies or medical houses in the rayons where drug use is most prevalent.

Supplies: Both the client driven program and the monetary driven program, described above, have their pros and cons, but both lack supplies. Hundreds of drug users have been turned away in Osh due to a lack of supplies and not wanting to over-extend the budget. It is difficult, however, to devise an accurate initial budget. Further, those programs that have offered primary health care have demonstrated that the trust between new clients and staff has been accomplished more rapidly when immediate needs of the drug users have been attended to before HIV has been discussed or syringes distributed.

Recommended: A formal primary health care component should be incorporated into the harm reduction program. It should include basic supplies, such as plasters, gauze, ointments, creams, medical utensils, gloves, disinfectants, rehydration solutions, antibiotics, and overdose medication. There should be quarterly trainings.

Toxicology Unit: Staff at the First Aid Hospital Toxicology Unit feel that the unit is not a high government priority. Only one doctor in Bishkek has credentials in the toxicology field. The main toxicology unit does not even have a computer or Internet so that the doctors can have access to up-to-date information.

Recommended: A computer with Internet access should be supplied to the toxicology unit. A seminar should be developed for all staff so that they can share experiences, briefings on current methodology, and orientation on harm reduction strategies and information. A session should be incorporated into the agenda to train harm reduction staff on patient survival before he or she is transferred to the toxicology unit or hospital. Basic equipment should be procured for the main toxicology unit to assist the survival of drug users and others.

Drug substitution: The chief of the narcology dispensary was open to piloting different approaches in drug user treatment. He was most interested in the drug substitution scheme even though methadone is controversial. The alternative drug burprenorphine has been used in South Asia successfully and is currently a detoxification medication at the dispensary. It has less of a stigma than methadone and might be easier to get approvals.

Recommended: Discussion should take place on a pilot project of burprenorphine drug substitution in the narcology center. Mechanisms should be explored to procure sufficient supplies directly from the manufacturers so that they are a reasonable price. One pharmaceutical company that supplies burprenorphine to harm reduction programs is also a sponsor of the 12^th IHRC in New Delhi.

Peer groups: Bishkek had the best models for AA, NA ALANON, and ALATEEN programs, most of which have been in operation for five years and have met with some success. Some of the individuals associated with the programs have a good amount of sobriety behind them. They extended their experiences to drug users by visiting Osh, but were limited as they had to pay their own way. These individuals would be a great help if they could travel to the sites and talk to drug users as well as local authorities. This would be beneficial for Tajikistan as well as Kyrgyzstan.

Recommended: A small amount of funding should be allocated so that some of the AA, NA ALANON, and ALATEEN members can assist in developing programs as well as interacting with drug users, alcoholics, and families that are interested in joining the programs.

Children: There is a need to address issues concerning children of drug users, alcoholics, and parents that are incarcerated on drug charges. The Children’s Welfare Foundation is dedicated and their work plan is thorough, but they need to secure funding for their activities.

Recommended: The Soros Foundation should assist in setting up meetings and introductions of the Children’s Welfare Foundation to donor agencies. It should also critique the Foundation’s funding proposal so that it is more presentable to the donor community. Its expertise could also be used to explore the possibility of incorporating rehabilitation and reintegration initiatives.

CSWs: Tais Plus is a valuable service to the 25,000 sex workers in Bishkek and the rest of the community. They were pragmatic enough to discontinue their needle exchange component as it was going to undermine their overall efforts. However, they still need harm reduction services.

Recommended: The OSI harm reduction program should include a position – staff or volunteer – to focus on drug users who are CSWs to ensure that this specific population is represented in the OSI program.

GTZ: Collaboration with GTZ is a good idea, even though it is not directly involved in working with the drug using community. New labor laws mean that drug users are included in the ranks of the unemployed. Some of GTZ’s techniques for gaining employment should be duplicated in the OSI harm reduction program to reduce the rate of relapse. GTZ is willing to lend its expertise to the OSI programs for such schemes as a mobile unit for documenting residency, procedures for acquiring official papers and passports, and getting lists of employment opportunities. The "job clubs" would be beneficial to the OSI programs. Other NGOs might wish to be included.

Recommended: Meetings should be scheduled with GTZ and the government to explore collaboration on a sustainable human development component for drug users. If this proves to be a viable working relationship then support from the Soros Foundation should be allocated to the schemes.

Waste: There is no facility at the local hospital in Osh to incinerate syringes or other medical waste that may be contaminated with infectious diseases. MSF/F, the Soros Foundation, and UNDP together could fund and install a medical waste incinerator.

Recommended: The Soros Foundation should move forward on this collaboration for a central medical waste incinerator, as one is urgently needed in the area.

Conclusion: The OSI programs and other initiatives in Bishkek were impressive, especially for the cohesiveness demonstrated among the different entities, from the drug using community to top officials. Bishkek is an example of perseverance to overcome obstacles to the harm reduction movement. With the inclusion of the above-mentioned suggestions and recommendations to the harm reduction movement and a study tour to several Asian countries, Bishkek could be a prime example of a "best practice" approach in the international arena.

References

1. Soros Foundation Kyrgyzstan: Medet Tulegenov, Deputy Executive Director.
2. National Project Manager on HIV/AIDS: Larisa Bashmakova.
3. Narcology center, Dr. Tynchiykbek Asanov, Director.
4. Sotsium: Dr. Batma Abybovna, Director.
5. UNDCP: Temur Aziz Ahmad, Chief Technical Advisor, and Nurlan Kenenbaev, National Project Coordinator.
6. German Technical Cooperation (GTZ): Janyl Kojomuratova, Local Adviser.
7. Tuberculosis Hospital: Dr. Kurmanbik Osuyevich, Director.
8. Infectious Disease Hospital: Dr. Alla Sarkina, Deputy Director.
9. Tais Plus: Group of commercial sex workers meeting.
10. Sotsium: Drug user group meeting.
11. Crime Police Illicit Drugs: Lt. Col. Almaz Garifullin, Director; Licit Drugs: Vira Jurchenco, Director; International Legal Department: Almaz Karabalaev, Director; Dr. Kairat Osmanaliev, Researcher – Law; and Kyrgyzstan University: Stanislav Grionev, Student.
12. First Aid Hospital – Toxicology Unit: Dr. Akylbek Usupbaev, Director of Hospital; Dr. Ibraimov Nurlan, Chief of Toxicology MoH Kyrgyzstan; Dr. S.S. Satiev, Head of Neuro Surgery; and Olga Deshpet, Head of Nursing Department.
13. National AIDS Program: Dr. Boris M. Shapira, Director.
14. UNFPA Country Office: Elmira Suyumbaeve, Coordinator Population and Development; Gulnara Kadyrkulova, Coordinator Reproductive Health.
15. Aitana Children Welfare Foundation: Three Foundation board members, two volunteers, and ten children.
16. Trust Point, October District: Volunteer, lawyer, police, and two IDUs.
17. Parents Against Drugs: Dr. Burchanov Mamaobyr, Director.
18. Ministry of Internal Affairs: Colonel Rasulberdy R. Raimberdiev, Deputy Director.
19. Narcology Dispensary: Dr. Burchanov Mamaobyr, Chief Narcologist for Osh.
20. Osh Oblast Center on AIDS Prevention: Tugelbay M. Mamaev, Chief Doctor.
21. Trust Point Needle Exchange Program: Burkhanova Rano, Psychotherapeutics and Narcologist; Akimbekova Nurilya, Nurse; and six volunteers.
22. Ministry of Health: Deputy Director.
23. Medecins Sans Frontieres/France: Dr. Yves Marchandy, Head of Mission and Medical Coordinator.

1. Elvira Muratalieva, Medical Coordinator, Soros Foundation, Bishkek.
2. Batma Abybovna Estebesova, Director of Sotsium NGO, Bishkek.
3. Tynchiykbek Asanov, Chief Narcologist of Ministry of Health (Pharmacist), Bishkek.
4. Kairat Osmanaliev, Research and Law Department, State Commission on Drug Control (PhD in law), Bishkek.
5. Glinenco Victor, Deputy Health Minister on Epidemiology, Bishkek.
6. Colonel Raslil Raimberdiev, Deputy Director of Internal Affairs, Osh.
7. Burkhanov Mamasobyr, Chief of Narcology Center and Director of Parents Against Drugs, NGO, Osh.

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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