Central Asia: Ailing Public Health Systems Limit Effective Harm Reduction Efforts

The continued failure to build comprehensive public health infrastructures is severely hampering efforts to address growing drug use and HIV/AIDS crises in Central Asia. Open Society Institute consultant and public health policy analyst Richard Elovich examines some of the reasons for this failure and provides ideas for more effective drug and HIV/AIDS policies in the region.

By Richard Elovich

Central Asia is heading toward a major public health crisis. Yet governments in the region are unprepared for problems that could soon devastate the lives of tens of thousands of citizens and derail political and economic development.

The looming drug use and HIV/AIDS epidemics in the region could overwhelm public health infrastructures that have deteriorated or been neglected in the wake of the breakup of the Soviet Union. These systems are struggling just to provide minimal services for the public at large. An estimated 80 percent of the region’s HIV cases can be traced to injecting drug use. And Afghanistan continues to flood Central Asian neighbors like Tajikistan and Uzbekistan with high-grade heroin. Drug use and the spread of HIV, first among drug users, then among the larger public, are not likely to go away any time soon.

Letting “heroic” individual volunteers, mostly former or active drug users or their relatives, deal with the problem is not a substitute for a collective, systematic public health response.

Harm reduction measures—including needle exchange, methadone substitution therapy, and comprehensive social support services—can provide Central Asia with critical tools for effectively reducing the transmission of HIV and other blood-borne diseases among drug users. But harm reduction programs cannot be implemented in a vacuum, without support from and integration with viable public health and social service structures.

Increased emphasis on epidemiology, the social context of health problems, and transparency are crucial to any efforts by Central Asian countries to improve their public health responses to drug use and HIV/AIDS.

Medical and narcological personnel must be allowed to step back from their growing caseloads of patients and discern the patterns of exposure and health problems across the population. This analysis can then help them deploy resources to prevent the spread of diseases and to engage people earlier in treatment and targeted harm reduction. Epidemiology is invaluable to public health structures because it clarifies causes and effects and promotes responses that are timely, feasible, cost-effective, and consistent with social values.

Epidemiology independent of state interests is critical. For example, Eric Klinenberg’s book, Heat Wave: A Social Autopsy of Disaster in Chicago, about deaths in Chicago during a 1996 heat wave, challenged government and media accounts of “natural” heat-related fatalities. Klinenberg used social epidemiology to show that the disproportionate number of fatalities among elderly black residents was far from natural and more due to social isolation, changes in housing policy, lack of access to safe public spaces, and the privatization of social services. This critique, in turn, was a call for public policy change.

HIV and SARS have demonstrated that there are serious health repercussions if governments are unable to analyze and study data about epidemics, or if they produce accounts about how they are responding that are not transparent and open to scrutiny and discussion.

The Chinese government, for instance, has been roundly criticized for failing to disclose in-depth and accurate information about its HIV epidemic, a policy that has limited its ability to adopt HIV prevention and treatment standards that have proven effective elsewhere. The government’s similarly secretive response to SARS in 2003 was also blamed for allowing the epidemic to spiral out of control for a time; China’s health minister and the Beijing mayor were later fired due to the outcry.

In Central Asia, accurate data and discussion on heroin use or HIV prevalence is severely lacking. For example, in Uzbekistan and Tajikistan, the only consistently available measure is “registered addicts”—drug users who have been arrested or admitted to a hospital and subjected to compulsory detoxification. However, government officials, narcologists, and independent observers generally agree that these registered users comprise as few as 10 percent of the total number of heroin users in each country. Similarly, little to no data exists in either country distinguishing occasional heroin users from drug-dependent individuals. There is little transparency about how Central Asian governments use tax revenue for public health, since there are few independent “budget watch” organizations to monitor and hold governments accountable. Corruption is often endemic and revenues that could be used for public health are frequently reserved for the military or questionable macroeconomic projects.

In Uzbekistan, international funding on health dwarfs government funding. However, international funding is often time-limited because donors seek to have a large impact on a specific problem in a short time. Not many donors have been involved in long-term projects such as developing an educated and reasonably paid health sector workforce and service-delivery infrastructure that would increase local capacity to respond to emerging health problems.

Effective responses to the drug use and HIV epidemics rely heavily on a commitment to community health with well-designed harm reduction services that are integrated within neighborhoods and among local populations. Community health experts also recognize that prevention is just one plank in a comprehensive HIV policy. In countries where HIV is concentrated among the impoverished, prevention programs have been most effective when they are coupled with treatment efforts. In Brazil, for example, experience has shown that if people who are infected receive ongoing health services and feel cared for, they are far more likely to care for others and be involved in efforts to disseminate prevention and treatment information in their communities and beyond.

In an economy of scarcity and joblessness, harm reduction programs in Central Asia are sometimes staffed by people who are interested primarily in having jobs and focus more on filling ledgers with questionable needle counts than on engaging drug users in meaningful education and mobilization. Too many officials and citizens in Central Asia allow stigma, stereotypes, and indifference to ignore calls from drug users, their families, and people living with HIV/AIDS for comprehensive public health policies. Letting “heroic” individual volunteers, mostly former or active drug users or their relatives, deal with the problem is not a substitute for a collective, systematic public health response.

By continuing to turn their backs on the problem and not prioritizing the revitalization of their ailing public health systems, citizens and officials in Central Asia are missing a rapidly closing window of opportunity to address public health problems that may soon overwhelm them.

Originally appeared in OPEB SOCIETY: Soros Foundation Network News, Spring/Summer 2004