SUMMARY OF FACT FINDING MISSION TO TAJIKISTAN
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 30th to August 9th, 2000, did its work in Dushanbe and Khugan-tube. The majority of the meetings and site visits were held in Dushanbe.

How Illicit Drug Use Affects the Lives of People in Tajikistan

Some officials consider Tajikistan a trans-shipment country for illicit drugs from Afghanistan to Russia and beyond. (Ref. 4) The cultivation of opium and marijuana in Tajikistan is insignificant. Most drug trafficking routes follow the road and railway systems, while a large portion of drugs is flown out of Dushanbe by air. The border between Tajikistan and Afghanistan, more than 1000 kilometers long and including the river Pyanj, is difficult for the drug enforcement agency to monitor, control, and seize drugs. The Drug Control Agency does not have sufficient equipment to respond to the drug traffickers and, since UNDCP funds its salaries and activities, it is concerned about its future sustainability. (Ref. 5)

According to the country’s criminal code, arrests are made for trafficking and personal possession of drugs. No law exists for the use of illicit drugs, since drug users are viewed as sick individuals who need treatment rather than punishment. Earlier this year the government sent doctors and police to rural areas to educate users and potential users about the harms associated with drug use. The limited funds and supply of printed literature – based on the Islamic code and teachings – made it difficult for the campaign to have an impact.

Poverty makes trans-shipping drugs through Tajikistan easy. The malnutrition rate of 6%, one of the highest in the world after Ethiopia, is being aggravated by the drought which, the government estimates, will affect half of Tajikistan’s population. As incomes have diminished from farming and agriculture more people have gone into the drug trade and there has been an influx of new drug users. The cultural norm is for men to marry young even if they cannot find work or support their family. This often leads to fathers looking the other way if a son gets involved in the drug trade as long as it brings money into the family. Further, it is difficult for youth who are educated for a chosen career to find a job, which has degraded their dignity and curtailed their income. (Ref. 2) The unemployment rate in major towns in southern Tajikistan is 60-80%. Thirty percent of the population is dependent on the illicit drug business. (Ref. 8)

Corruption also makes trans-shipping drugs through Tajikistan easy. (Ref. 4) The Drug Control Agency has asked UNDCP to help combat corruption within its ranks. Low salaries in the law enforcement community has led many to supplement their income by taking money from drug users. Other public security sectors, including customs and border control, are also corrupt.

Tajikistan lacks appropriate drug treatment for users. The narcology and psychology centers have been joined for financial reasons but there is a motion to have these separated despite the complicated logistics. During Soviet times drug users were involuntarily treated at hospitals. Now, treatment is voluntary, largely because the government cannot afford mandatory treatment, but users are registered. The narcology dispensaries offer physical detoxification and at present the Dushanbe dispensary has a capacity of one hundred beds. (Refs. 10, 12)

A man named Muzzafar, a patient in the dispensary, was interviewed by the fact finding mission. Muzzafar described the difficulty of finding work or work sufficiently well paying after coming out of treatment. Most "employers" prefer to pay in drugs, not money, and in most cases if drugs are not available then there was no payment at all. Many dispensary patients are afraid to go back to the community due to unemployment or having to re-enter the drug scene. Further, Muzzafar suggested that the Soviet system of working for several months, then having an extended break to get away from the drug environment would be beneficial. He also welcomed vocational training. (Ref. 10)

Heroin is cheaper than vodka, so alcoholism is on the decrease while drug use is on the increase. The attempt by some drug users to detoxify themselves with alcohol has led to more cases of overdose deaths. The Chief of Narcology for Tajikistan initiated a 12-step program in which people have been interested. A recent drive to orient government officials on the use of methadone is controversial.

Illicit Drug Prevalence and Consumption

The drug of choice in Tajikistan is heroin, which is becoming more frequently used, especially by school-age youths, most of whom have tried hard drugs. Records from January 1, 2000, show 2,703 registered drug users, of which 1,695 use heroin, 768 opium, 202 hashish/cannabis, and 128 other drugs. Suspected drug users number 486, which brings the overall total to 3,189. The reality, however, could be 15 to 20 times this total. Newly registered users for 1999 included 1,295 males and 37 females, an accurate representation of the gender ratios in the country. (Refs. 4, 7)

Opium eradication efforts by drug control agencies and governments are encouraging the switch to heroin in all of south, southeast, and east Asia. One kilogram of heroin costs USD $750-800 on the open market; and grams sell for .30 cents. In Dushanbe and other urban areas where it is hard to buy food and heroin is cheaper than vodka, there is an abundance of heroin. In Tursunzade, a quiet city of 32,000, has 7,000 drug users, mostly 14-18 years of age. The perception that users and alcoholics come from "bad" families is changing. (Ref. 7)

The high quality of the heroin in Tajikistan – 12 times more pure than in other countries – means it does not have to be cooked. It is popular to mix it with water and inject. It is also mixed with tobacco and smoked or snorted straight from the packet. Seventy percent of drugs taken are smoked or snorted while 30% prefer injecting. Most users inject in the crux of the arm or the lower part of the leg. Some inject in the neck and groin to avoid detection as an injecting drug user. Those who inject intra-muscularly are more susceptible to abscesses and other infections. Some put the fine powder directly under their eyelids. Injecting is less expensive than smoking. The frequency of injections depends on the length of drug use. Beginners often smoke one hit every two days, while older, addicted users may inject heroin up to five times a day. The average is two to three times a day. (Ref. 7)

The rate of relapse is high. This is partly explained by the fact that specialists in this field moved out of the country after independence and few others have chosen to train for the vocation. While the government acknowledges the need for rehabilitation and psychological services, there is a lack of information on different treatment modalities and the government stance is only detoxification. Most users released from the dispensary return to the same place because it is familiar and also because it is otherwise difficult to find employment.

Muzzafar, who has been to the narcology dispensary 36 times, is a good example. He started smoking drugs in the military in Afghanistan but stopped, got a job, and married when he got out. After he was laid off he started injecting heroin. He would like to stop. Treatment is expensive, however, and many users decide to spend a little on a hit rather than the USD $100 on treatment. Muzzafar recounted the popularity of opium in 1984 and how blood was used to prepare it for injection to avoid getting the shakes. After 1985 new opium from the Caucasian region was mixed with penicillin; sometimes Demerol was added to the mixture to help get rid of the taste of penicillin.

Many injecting drug users do not have money to buy syringes and so they share. Muzzafar says he finds syringes on the street and cleans them with boiled water and use them for one or two weeks. Most IDUs inject in groups of three to four and share needles. They flush between uses not to prevent infectious disease but to avoid mixing blood types that can cause violent shaking. Users with not enough money to buy drugs can sometimes collect four cotton balls used in filtering and make up a satisfactory dose for one hit. Whether users decide to smoke or inject depends on how much money they have; how many drugs are available; and how quickly they want results. (Ref. 10)

Young people, boys and girls, who do not have much money start selling drugs from home for spending cash. Before long the dealers persuade them to try some for free. After they are addicted they share syringes. It is thought that under Soviet rule youth had many activities to occupy them.

To treat people who have overdosed, one should inject them with 15 to 20 mls. of distilled water, massage their heart, give them mouth-to-mouth resuscitation, and protect them from swallowing their tongue with a spoon in the mouth. Most overdose cases are those who have just come out of treatment and go back to the high dosages their bodies are no longer used to that they were using before treatment.

The chief of the psychology/narcology dispensary in the town of Khugan-tube said there are 247 drug addicts and 210 drug users, up from 57 drug users three years ago. Since several regions in the Oblast do not report drug users the actual numbers are higher. The government is planning to open another narcology dispensary in Kulyab before the end of 2000. There are approximately 135,000 drug users in the country; 40-45% inject heroin. Those who still smoke heroin are switching to injecting. (Ref. 12)

The biggest hurdle in Tajikistan is changing the law on methadone and burpernophine, which are currently illegal.

Infectious Diseases Associated with Drug Use

The director of the National AIDS Center did not know the exact prevalence of HIV but acknowledged, in a February 17, 2000, meeting, that drug use was on the rise. (Ref. 1) The first two cases of HIV were in 1991, followed by one each in 1997, 1998, and 1999; four are male, one is female, and two were infected through injecting drugs. The National AIDS Center, that was established in 1991 in Dushanbe, has been chaired by the head of the Committee on Religious Affairs since 1997.

The two UNAIDS funded projects, that see 150 drug users per day per site, do not test for HIV because they do not have funds for the test kits. Tajikistan does have 24 laboratories that could test for HIV, HBV, HCV, and STDs. However the government does not have enough ELISA test kits or NOVASIBIRK kits from Russia for confirmation testing. The National AIDS Center would like to receive two high quality brands for confirmation testing. Earlier in the year an attempt was made to test 200 drug users in prison, but the project failed due to lack of test kits.

The National AIDS Center wants to evaluate the rate of infection among drug users who visit the sites, including the Soros Foundation sites, and drug users in prison. Tests could be done simultaneously for HBV, HCV, syphilis, and gonorrhea. The CDC-Atlanta, which has an office in Dushanbe, could possibly collaborate with the Center to provide test kits for HBV and HCV. (Ref. 6)

In order to establish the two UNAIDS programs, officials from many Ministries had to be educated about the importance of harm reduction. While the UN is committed to reducing HIV they do not seem to have funding for it. Funds will have to come from other international sources. The government is also seeking funding for its HIV prevention program for 2001-2005.

Money is not the only problem. Getting infected with HIV is a criminal offence because it is linked with drug use and culturally inappropriate behavior. Anonymous HIV testing does not exist. Further, according to the UN Resident Representative, the Chief of Gynecology and the Minister of Health control the pharmacies, medications, and outlets and directly benefit from the status quo. (Ref. 8)

Tuberculosis is considered the most prevalent disease among drug users. A lack of medicines last year prompted the government to request support from WHO, with whom it would like to start a new method, "DOTS", for TB prevention nation-wide. Other infectious diseases include malaria, which has increased by 26% in the last year; typhoid; and respiratory infections. Basic supplies are needed for the facilities that treat these diseases. (Ref. 9)

Abscesses are more common among opium users than heroin users. Most self-treat with the leaf of the podorozhnik plant (plantain) or the aloe plant because the hospital is expensive. There is no discrimination in the hospitals, where anyone who can pay is treated. While harm reduction programs do not now provide medical assistance, to avoid possible discrimination or fear of detection, the programs should offer primary health care to their clients. The programs also need a solution for the disposal of used, potentially infectious, syringes.

How Service Providers and International Aid Meet the Needs of the Drug Users

The commitment toward drug users and related infections is low in the international donor community and UN system. Save the Children-US (SCF/US) suggested that the "medical houses" in villages or communities be supported with basic supplies and medical equipment. Soros Foundation should consider integrating harm reduction equipment with the needs of the medical houses. (Ref. 2)

Medecins Sans Frontiers-Holland works in three of the country’s narcology dispensaries, which are connected to the psychology dispensaries, but usually works only with the mentally challenged patients. Since Tajikistan only has five practicing psychologists at present, MSF/H has established and supports community mental health programs. (Ref. 3)

While the Drug Control Agency is primarily involved in supply reduction and defers to the Ministry of Health on matters concerning drug users, it is also interested in demand reduction. In collaboration with the National AIDS Center it is developing a center for rehabilitation which would be UN-supported. It would be beneficial if the Drug Control Agency and Soros Foundation could collaborate in the demand and harm reduction arenas. (Ref. 4)

UNDCP plans to implement a demand reduction program in the last quarter of 2000, including a mass media campaign. This follows its campaigns to strengthen law enforcement and assess drug consumption. Mr. Tmour Aziz, UNDCP’s chief technical adviser for Kyrgystan, will be relocating to Dushanbe. (Ref. 5)

UNDP and UNAIDS are helping with the HIV/AIDS effort through the UN Theme Group. Of the UN co-sponsors, there is no representation from UNESCO or the World Bank in Tajikistan. UNICEF has not contributed or committed to work in the area of HIV/AIDS. The UN funds drug control and health initiatives. The Tajik government cannot sustain this work without UN financial assistance for the next five to ten years.

Two UN supported harm reduction programs that have operated for two years may be closed for lack of funding. The programs provide information and syringe exchange. Ms. Azizova, HIV/AIDS focal point, was concerned that the Soros Foundation was implementing a new program in Dushanbe while the two others that have demonstrated progress in reducing harm among drug users is in need of funding. The programs need USD $62,000 to operate in 2001. (Ref. 8) PAGE 2

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Posted March 1, 2001 © Eurasianet
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