Afghanistan and Central Asia

Providing for education is a big part of a sustained aid: providing teachers, doctors, and nurses, with the tools and means to bring knowledge and self-help to Afghanistan’s citizens and to the nation as a whole.  Frequently with aid we think of supplies.  Yet knowledge is something that cannot be taken away, from the mentoring of a surgeon in an Afghanistan city to counseling mothers in a small town. 

Salaries:
The UK’s Department for International Development (DFID) will expend funds to pay teacher’s salaries as well as those of doctors and nurses in the state.  The total funding of 55 million pounds will be part of the UK’s already-stated 500 million pound commitment over three years.

Medical Assistance:
Captain Everdean reports via CENTCOM that a Provisional Reconstruction Team  delivered pediatric medical care in a remote province of Zabul, where they saw 200 people and mentored local nurses in health care.  A couple of weeks ago, another team took the donkey-track to a remote village in Panjshir Province, bringing food, toys and medicine.

The International Society of the Red Crescent/Red Cross (ICRC) has been working with Mirwais Hospital for the past eleven years.  In a recent interview, the head of the Afghanistan effort discusses why they have expanded their aid from surgical support to renewing hospital infrastructure.

Legal Assistance:
450 of Afghanistan’s judges are to receive copies of Afghan law books, and the first 37 judges received their copies on August 25th, in Parwan province.

Just an update.

I found this while looking for news for the Central Asia Beat of last week, but it was well worth returning to:  accounts of torture in Naryn by the police.  The International Helsinki Federation for Human Rights works to raise awareness of human rights violations in Central Asia, improve local human rights defenders personal security and their access to policy-making, and interact between local and international communities.  And indeed August 13th looks like a day of decision: two police officers were acquitted of torture, perhaps wrongly.  One new investigation was formally started on torture charges.  And one more prisoner died.

According to the International Helsinki Federation and the Kyrgyzstani human rights center Kylym Shamy, several arrests by Naryn’s GOVD (a department of the Ministry of Interior) have ended in prisoner deaths.  This is pretty much verbatim from the IHF/Kylym Shamy Press Release:

Alykbek Sakeev, a 48 year old man, was arrested by two officers of GOVD, Chyngyz Kerimkulov and Taalajbek Chypaev, on suspicion of cattle theft on 20 November 2006. After several hours, he was delivered to the emergency room of the casualty hospital in Naryn where he died without regaining consciousness.

According to Sakeev’s relatives and doctors he had five broken ribs on each side, skull trauma, a bruise on the head, and many other traumas. . . .  the GOVD officers that Sakeev simply fell down from the bench several times.

On 25 November 2006, a criminal case was initiated against the two law enforcement officers for torture under articles 305 and 305-1, but in three days they were released after signing a statement that they would not leave the state. In February 2007, Sakeev’s relatives withdrew their appeal after receiving 200,000 Soms from the GOVD officers, and the Naryn city prosecutor’s office tried to close the case.

Under pressure from human rights defenders, the case was reinitiated. On 13 August 2007, the two police officers were acquitted.

It certainly looks as if justice fell off the bench several times, and it also looks like human rights defenders are at some risk:

Several days before the court decision, human rights defender Aziza Abdurasulova, who monitored the trial, was attacked in the court hall by unknown women.

The investigation of Bektemir Akunov’s death began August 13: 

Also on 13 August, the court started the trial to determine the cause of death of Bektemir Akunov, who reportedly hanged himself by his own shirt in the pre-detention cell in GOVD department of the Naryn city on 14 April 2007. The unsettled circumstances surrounding his death have attracted public attention in Kyrgyzstan after an independent commission headed by Aziza Abdurasulova had concluded that Akunov did not commit suicide.

 And another prisoner died.

On the same day of 13 August 2007, Kurmanbek Kalmatov, a 55-year old man, died after he was beaten by the senior investigator of the Naryn city.

Ms. Abdurasulova also reports seeing 14-and 15 year old youths with slash marks on their hands who reported also being kicked while wearing gas masks–in order to get them to confess to a crime they did not commit.

The Kyrgyz Committee for Human Rights is also keeping track of these cases, but it looks like the Kyrgyzstan national government will have to get involved in order to make sure that justice is done and that a policy of torture is no longer pursued in Naryn, or indeed, anywhere else in Kyrgyzstan. 

This video is from Worldvision, and documents the actual living conditions of homeless children in Mongolia.  Film conveys a lot: but like almost all art, it does not convey touch, smell, taste; this video does its best to include at least a verbal document of those miseries of children’s street life.  Along the way, it is also an essay on public health issues.

I checked, and according to CharityNavigator, Worldvision and Save the Children are two highly-rated charities for seeing to children’s needs across the world.  Worldvision is a non-denominational Christian charity based in Washington State and around the world.

Cassie over at the FPA Children’s blog is doing a wonderful job of bringing children’s issues forward: everything from child soldiers to child weddings to the quality of toys.  Go check out what she’s up to: it’s the stuff of real family values.

Further Reading:
Charity Navigator
Child Sponsorship Charities at American Institute of Philanthropy’s Charity Watch site

According to a new release I received from the World Bank (Why, yes of course, the World Bank corresponds with me often) there is some great news from Tajikistan:  New Rural Health Centers that are up and running.

These indicators show what the World Bank can do, in partnership with a willing state:

Health Data At-A-Glance

Infant Mortality Rate:
down to 59.1 from 75.2 per 1000 from 2000 to 2005 (start earlier date)
Under-5 Mortality Rate:
down to 71.4 from 93.3 per 1000 from 2000 to 2005
Source: World Development Indicators 2007

The program that has been implemented in the Danghara and Varzob districts began in 2000: the  trains medical care workers to give treatment using a more accessible family medicine model rather than a hospital care model.  This allows health care consumers to go to a family practice, where they can have all of their symptoms treated, instead of waiting in line to see one specialist and then another.   The new model of health care also reaches out to disadvantaged populations, and also provides a facility for continuing education for medical personnel.  Clinicians are beginning to track the health care they give to others in order to measure their performance and describe further needs.

  The 2000 program was successful, and was renewed in 2005 to meet medical needs in 41 other districts of Tajikistan.  It is part of the 2005-2015 push in Tajikistan to remodel and renew health care in this underserved state: the “Strategy on Health Care Financing Reform”. 

So far, according to the World Bank:

1. Four physicians and 178 nurses retrained with family medicine model.  Right now, 36 physicians and 81 nurses are currently in training
2. Twenty-six rural health centers built (1 by CARE International):
An additional 74 rural health centers will be rebuilt, and 32 rehabilitated.

Primary Health Care Services and Outreach (jointly with SIDA):
1. Community Mobilization: 20 Village Development Committees established and  trained on different health and management/social mobilization topics.
2. Health Education and Outreach Activities: 8000 brochures and 129 videotapes on different health topics distributed.

Now isn’t this just the best?   You can read about this also in Russian on the World Bank Web site.

Kyrgyzstan has recently reported that nine out of the eleven cases of HIV in the Osh district are children who contracted the virus during regular medical treatment.  Yesterday, President Bakiev ordered an investigation of this horrifying situation.

The pain of this to individuals and their families is enormous and so unnecessary.  The suffering from this radiates outward to society as a whole.  Speaking at an Open Society Institute Conference, Els Klinkert said:

The effects of the epidemic become more and more apparent. HIV/AIDS affects entire families and households in the most direct way. The families of AIDS victims are faced with high medical expenses, funeral costs and loss of human resources. But AIDS not only strikes at household level, the epidemic will also negatively effect the workplace, schools and national economic development. The epidemic will form an additional burden on the public health and other services sector, education, agricultural and economic sector.

Not again
In Kazakhstan, a similar discovery of negligence in terms of child medical care leading to HIV infection first began to be uncovered in May, 2006.  Subsequent investigation found that 118 children were HIV-infected during medical treatment in any of three hospitals in the Shymkent area.  Ten of those children have already died.  New cases are also being discovered.

A little over a year later, many facts came forward, and all of them are ugly.  Contaminated blood was used for transfusions on some children, and then the equipment (needles, etc) used for these transfusions were not sterilized properly, and then re-used on other children.  For this reason, many health-care practitioners are at fault.  But the main fault appears to be in the purchasing departments of those hospitals, i.e., the administration.

The contaminated blood in Shymkent was part of an illegal blood trade, where un-certified blood is collected (most likely from street addicts or other poor persons) and sold to hospitals at a lower price than blood collected and certified under HIV-prevention guidelines.  Hospital administrators could purchase this cheaper blood and pocket the difference in price.   What this is: not criminal negligence, but murder, and conspiracy to commit murder.  It is the same as if someone knowingly allows a bomb to sit in the middle of a populous building, knowing that it will go off and kill a large number of people.

In the trials, sentences for health-care clinicians ranged from 9 months to three years.  But the administrators responsible for the purchase of bad blood, or for administering clinic safety, or for providing proper sterilization equipment, received suspended sentences:

Marpiya Butabaeva, chairwoman of Ghibrat (Wisdom), the Shymkent-based Center for the Protection of the Mother and Children’s Rights, told RFE/RL’s Kazakh Service: “The bosses at the top got lenient sentences, while those who were under them got tougher sentences…. There is nothing new in this, it has happened before and it is happening now again. Of course it’s unfair.”

The sentences are not the end of the story in Shymkent. As Altynbekova said, new HIV/AIDS cases among the children of Shymkent are discovered every month.

After news of the first cases broke last year, President Nursultan Nazarbaev ordered an overhaul of the health-care system and better checks on the quality of blood in the country’s blood banks.

Such moves as Mr. Nazarbaev made to ensure blood safety are not recorded here, (more…)

Yesterday, C. J. Chivers wrote in the International Herald Tribune that Turkmenistan’s heroin addiction rate is phenomenally high: but how high, no one knows for sure.  Under the Turkmenbashi, medical care was decimated, census and other facts not gathered, and crime prevention agencies turned increasingly to profit.

In this article, Chivers ties the increasing pall that heroin places over the country to other issues: human trafficking and prostitution; the rise of HIV/AIDS; connections with Taliban-fostered drug trafficking; institutional corruption; and the draconian prison system that has characterized Turkmenistan since before its independence, and which itself can help spread the virus.

In 2005, IWPR reported that Turkmenistan was “in denial” over its HIV incidence.  They also linked the spread of disease to prostitution, poverty, and drug abuse.  This denial is nowhere more evident than at the UNICEF site for Turkmenistan, which indicates that Turkmenistan reported only one HIV case in 2004.  Such reporting means that agencies such as UNAIDS have their hands tied and cannot offer much support.

Hopefully, Turkmenistan will start to admit officially what we know unofficially: but this will take time.  According to Abdulgamid at neweurasia.net, Turkmenistan’s officials are attending conferences on HIV for the first time ever, but are still in a state of absolute denial–at least verbally.  Chivers’ article also mentions a USAID program that Turkmenistan agreed to allow this past March, aimed at combatting HIV.  It will include education on the harms of drug use.

Other related USAID programs include medical training assistance for tuberculosis, as this disease finds HIV+ persons very susceptible; blood safety; and  HIV/hepatitis lab quality assurance.

The more that Turkmenistan can own up to, the more help they can receive.  We all know that things are bad; we all know we have the same problems; and we all know that Mr. Berdymuhamedov is trying to start fresh on many programs.  Asking for assistance would be a sign of strength-not an indicator of weakness.

 1. On Saturday, a bomb exploded close to Tajikistan’s highest court in Dushanbe.  No person was hurt, and the bomb only damaged windows.  It could have been so much worse.  The city’s chief prosecutor, Kurbanali Mukhammetov, said that the motive for the bombing was not clear, but he suspects IMU activity.  However, it might also have to do with the increased organized crime from Afghanistan’s drug trade.  It might also be an anniversary: last year, on June 16, three explosions rocked Dushanbe.

2. In 2002, the UNDP made a  conservative estimate that 100 tonnes of heroin per year transited Tajikistan.  The internal drug market was estimated to be worth USD 120-200 million annually.   In 2003, Russian forces pulled away from Tajikistan’s borders.  A ten-year agreement between Russia and Tajikistan, started in 1993, ended and were not renewed.  Heroin labs were set up in Northern Afghanistan, and transit routes included the Moscovy and Panj river sites, as well as Badakshan mountain crossings during the summer months.   Last week, Vadim over at neweurasianet reported that the Panj river bridge has been rehabilitated, which increases the likelihood of drug traffick through this area just as it does for any other Afghanistan-Tajik trade.  Unfortunately for the most part, that Is the trade available, and it brings new reasons for crime, conflict, and social despair–especially in the absence of good border control.

Last year, CSM reported that Afghanistan’s drug trade, already ubiquitous, was becoming far more organized in its approaches, which included routes through Tajikistan.

3.  Last of all, BBC has an article of the large number of cluster bombs still extant from the 1992-1996 Tajik war.  Like mines, these explosives are still dangerous a decade after war has stopped.  Unlike mines, however, the sub-bomblets scatter upon impact, making it far harder to ascertain where they may be found.  As long as they are extant, however, children and agricultural workers will continue to be injured when they come in contact with these devices.

What conclusion can one derive from these reports of volatile substances in Tajikistan?  First, the key to Tajikistan’s stability is inextricably tied to Afghanistan’s drug trade being better controlled.  Better border control can be a barrier, but both countries need a more varied economy in order to bring the opium trade down.  Once these economies pick up, then funding de-mining and de-cluster bomb initiatives will become part of social services.

However, Tajikistan can’t wait as long as would be convenient for the rest of us.  It’s time for friendly states and international organizations to provide Tajikistan with some help.

Further Reading:
Tajikistan bust on June 14: 100 kilos of heroin 

Here is a short, 1.5 minute video, produced by UNICEF, that illustrates the conduct of polio immunization in Afghanistan.  I alluded to this immunization drive in a previous post.   

The details such as the chalk markers are very interesting procedural points that you rarely get in news articles or scholarly papers–the details, right?

The second 3-minute video starts out with a bit of heart-warming introduction, and then also gives the details.  It also underscores the limits and opportunities to deliver public health as a partnership between Afghanistan’s capable citizens and those of the U.S. military personnel involved–and consider themselves stakeholders as well.

Now these are just great: and they don’t stop us from seeing the need for more of the same.  Hope you enjoy.

Kyrgyzstan’s schools will now teach the Epic of Manas as a required component of the curriculum.   IWPR did not say whether this was to go to grade school, secondary school, or university (or all of the above). 

Like Homer’s epics, the Epic of Manas is part of an oral tradition; unlike Homer, his work is still sung today and various artists sing its excerpts in various form.  It has some similarities to the Mongol histories; and it is also claimed by Uighur historians in Xinjiang.

In 2005, the Turkish scholar Elmira Köçümkulkïzï translated large excerpts of the Epic of Manas to English.  On the Epic of Manas Web site, an article by this scholar is featured, as well as links to excerpts of the poem–and–links to performances of it.

This work is copyrighted, but here is an excerpt (lines 6550 - 6599) from an excerpt of the epic:  (lines 6378 - 7276).  To set the scene: boorish, ambitious warrior Kochku starts boasting before he raids the horses of the noble Kyrgyz: 

Among those horses
Stallions and chargers were mixed.
Kochku and Tagïlïk,
Leading their seven hundred warriors
Raided the horses all together,
They cut off the tether ropes, made an uproar,
Thus testing the forty families,
They carried out their khan’s order
By devastating Bay Jakïp.
Suffering from the Kalmyks,
 
Women and children were distraught,
“We really face captivity,” said
Noble Baltay and bay Jakïp:
Losing hope for their noble souls, they said,
“We suffered from Kochku.
If we resist them,
Not one of us will be spared,” they said,
“Let the Kïtay take our livestock,
And add them to their treasure,” they said.
Only Allah is just,
 
May our noble souls survive!” they said.
The wicked Kochku began the killing,
He didn’t spare any souls
Of the forty Kyrgyz families, the noble people.
From the palace of Esenkhan
He had come on a special mission
To the Kyrgyz,
To inflict great trouble
On Jakïp,
And take away his countless livestock
 
By plundering them quickly.
They destroyed their yurts,
Made their young women and girls weep,
And plundering, stampeded
All the grazing mares.
While that was going on,
The twelve-years-old brave Manas,
Riding his horse Toruchaar
Donning his weapons and everything,
Wearing an unsheathed sword at his waist,
 
Like a dark rain-cloud,
His wrath showing on his face,
Without a moment’s pause,
And risking his life and limb,
Without a second glance,
With no thought for his soul, he said:
“While I still have my strong head,
How can I give up my stallions?
These Kalmyks have gone too far,
I will exchange blows with them.

Thus the first noble deed of Manas–he kills Kolchuk. 

We’re indebted to Elmira Köçümkulkïzï for a wonderful translation and an excellent introduction.  I look forward to seeing this work in English–one of those Penguin classics editions, or similar!  However, I’m glad I don’t have to take the test.

Check also the UNESCO site for downloads.

Photos: Freenet.biskhkek.su; Dick McCray, 1998 

Through twenty-six years of war and repression, Afghanistan has lost its ability to meet its public health needs.  The efforts to rebuild health care systems continues, with mixed results.  

This was illustrated for me yesterday, when I read Asne Seierstad’s The Bookseller of Kabul. Though Seierstad’s book focused upon family relations, disease just kept cropping up over and over again as a barrier to progress, a root cause of desperate acts–in short, a contributor to a poor environment for reconstruction.   One story in particular in Seierstad’s work had a father who stole from his employer in order to feed his family: two daughters had polio, and medical treatment was out of the question.  He ended up in prison, which is a great place to pick up tuberculosis, and an impossible place to try to feed your already starving family.

In industrialized societies, we frequently get our immunizations and vitamins as a matter of course; we don’t have to know these diseases in the way that Afghanistan’s citizens do.  Therefore, I’ll discuss the diseases and eradication efforts  in alphabetical order:  

Leishmaniasis:
Cutaneous leishmaniasis reached epidemic proportions in Afghanistan and was targeted by the UN’s World Health Organization (WHO) in 2004.  In 2004, and estimated 200,000 people were infected, 67,500 of whom resided in Kabul.  A protozoan infection [Thanks, Ms. Clark: see comments below] from Phlebotomus sergenti, a sandfly, infest the skin, making ”active lesions”, primarily on the face and hands.  Later, the scars remain, and can be as much as one inch wide.  The flies are active from April to October, which gives them plenty of opportunities to cause this parasitic disease.

As in malaria, the insect vector itself is not strong; it has increased its habitat by living in the cracks of walls.  Therefore, it is most likely to affect those who are house-bound in regions with poor or decaying construction–this would include women, children, and the aged all over Northern Afghanistan.  A Belgian grant of Euro 200,000 in 2004 enabled a program to combine drug treatment and the purchase of anti-insect bed nets.  This was to be the beginning of a national eradication programme.  So far I have not found any information after 2004 on this programme.  Since the disease is not life-threatening, it does not have the priority of other public health efforts.  However, the disease does affect the quality of life, particularly for women, as there is a social stigma attached to the scars.

Polio
Polio has been endemic in Afghanistan, and programs to eradicate it started in 2002.  The disease is caused by the poliomyelitis virus and first enters the body by mouth, multiplies in the intestine, and causes paralysis, sometimes total paralysis in five hours.  The conditions favorable to it are primarily poor sanitation.   Vaccination efforts continued, and in 2005, only 9 new cases were reported.

In 2006, however, 29 additional cases were reported.  The disease especially affects the Southern regions of Afghanistan, where fighting had been most concentrated; which also hampered health care efforts.  The combined 2006 efforts of Afghanistan’s Ministry of Health, the WHO and UNICEF planned to immunize 5 to 7 million children in 3 days, in all 34 provinces of Afghanistan.  Previous to that effort, immunization was estimated at a 66%.  It was thought that this new effort would halt indigenous polio transmission in Afghanistan.  The three-day push was repeated five times in 2006.  The effort was funded by the World Bank, USAID, Rotary International, the State of Japan, and the UK’s DFID.  The children were also given Vitamin A, which is considered a major aid in battling children’s diseases.  This year, Taliban activity and edicts against accessing medical aid has halted polio immunizations in Uruzgan province.

Rickets
Vitamin D is essential to bone growth, the movement of Calcium and other minerals through the bloodstream.  Children born with vitamin D deficiencies are prone to “soft bones” and bone deformation from rickets.  One primary way humans manufacture Vitamin D is through exposure to sunlight.  Therefore, most of Afghanistan’s women, enjoined to stay indoors or go outside clad in a burka are especially at risk.  This becomes more acute in homes that do not have walled backyards, so that the women may get no exposure to sunlight at all, and their infants are especially prone to the disease.

Tetanus
Tetanus is an extremely painful bacterial disease: its painsful symptoms are caused by a nerve poison produced by the bacteria Clostridium tetani.  Its onset usually comes from untreated wounds of all sorts, but particularly puncture wounds.  Last month, 300,000 mothers and children were immunized against tetanus and measles in Kabul, along with efforts in other parts of Afghanistan.  Not all of those eligible for vaccination chose to accept the invitation for treatement, but anywhere from 50% to 70% of mothers were treated in all regions, and 55% to 70% of children were vaccinated.   Measles is a highly contagious viral disease, causing very high fever, cough, and conjunctivitis.  It’s high contagion makes epidemic fast able to outstrip hospital resources in states all over the world. 

Tuberculosis
In 2003, IRIN news reported that Afghanistan had one of the highest TB rates in the world: and estimated 70,000 cases annually–of which only 15% were treated.   Of TB-related deaths, 65% were women.  The symptoms of TB usually include cough, fever, and wasting away, but it is a very complex disease.  The culprit is primarily poverty and malnutrition. 

There are a lot of subtexts here, including the present and future conditions of Afghanistan’s women and children; the urgent need for reconstruction and the rebuilding of education systems; the future social costs of  today’s disease; and the ability of Afghanistan’s people to move forward economically.  For the moment, I want to focus on another aspect: many are interested in reviving public health systems in Afghanistan–and to their great number, many more need to be added.

A real friend is one who takes his hand in a time of distress and helplessness.     –Afghanistan proverb

 Further Reading:
The Bookseller of Kabul by Asne Seierstad is available (See Worth Reading page-Afghanistan).  A portion of book proceeds go to Afghanistan’s reconstruction.

See also the WHO Web site for Topic Information and Country Information; UNICEF Country Information portal page
Rotary International’s Polio Plus Program worldwide

Photos: Doctors without Borders; IRIN