IRIN Focus on decline in health of Tajiks

Despite the government's commitment to health care reform, the general health of the Tajik population is deteriorating as a result of economic recession, last year's severe drought and lack of access to essential primary health care. A British NGO, Medical Emergency Relief International, Merlin, told IRIN that many people, particularly in rural communities, were becoming increasingly worried about how they would manage should they fall ill. According to recent surveys, their chances of succumbing to infectious diseases, such as malaria and tuberculosis, have risen sharply over the last few months. Tajikistan inherited the old centralised Soviet health system. The once well-structured network of primary health care facilities has, however, deteriorated since independence in 1991 and the subsequent civil war. At less than US $2 per capita, the limited state budget for the health service barely covers running costs. Highly qualified personnel have left the country in huge numbers, leaving a large vacuum yet to be filled. Those who remain are on extremely low salaries. Medical professionals in Tajikistan can hope to earn only between US $4 and US $8 a month. In many instances, medical personnel simply do not get paid for months, and in the worst cases this prompts the closure of clinics, particularly in rural areas. Where clinics do close down, the cost of accessing health care rises sharply as people must travel to district centres for treatment. Low and intermittently paid salaries lead to unofficial patient charges. According to health experts, the cost of essential medicines is often beyond the means of most Tajik households. As a result, many simply do not seek medical treatment when they fall ill. A survey by Action Against Hunger (ACF) in November last year found that almost 24 percent of households in the capital, Dushanbe, and 35 percent of households in mountainous areas did not seek medical attention for a sick child. According to the UN, there has been an increase in the incidence of disease among Tajiks. The population suffers from chronic as well as infectious diseases, such as tuberculosis (TB), malaria, dysentery, typhoid and sexually transmitted diseases. According to official pre-independence statistics, these diseases appeared to have been largely controlled. Local doctors report that spraying against mosquito larvae was discontinued after independence, resulting in a subsequent rise in malaria cases. Merlin's epidemiologist, Mani Sheik, said Tajikistan had experienced a gradual increase in malaria over the last few years, but a 36 percent rise last year was "concerning". Due to the drought, hot weather arrived early in April in Tajikistan, bringing with it an increase in the mosquito population. When the harvest was lost, many Tajiks began growing rice around their houses, an easy food crop, but involving large areas of stagnant water - the perfect breeding ground for malarial mosquitos. Many people in rural areas were ignorant of basic disease prevention, nor did they understand how malaria is transmitted. Merlin was attempting to develop a surveillance system in parts of Khatlon District to gain a better understanding of the spread of the disease. WHO head Lyubomir Ivanov told IRIN that the problem of malaria was so complicated that it could not be solved in the short term. "It needs at least three years working intensively with the support of donors to control the spread." In parts of Tajikistan adjacent to neighbouring Afghanistan, particularly in Khatlon District, refugees repatriated from Afghanistan are thought to have brought malaria with them. According to Ivanov, TB was also on the rise, with a current incidence of 200 per 100,000 people in the capital, Dushanbe. Compared to other Central Asian countries, the level of TB was relatively low, though discrepancies were often the result of poor record keeping. In a bid to combat the growing problem, WHO was working with an American NGO, Hope, in implementing a pilot programme in Dushanbe to treat patients with modern antibiotics. Ivanov, however, said that the programme needed long-term funding to be successfully carried out beyond the pilot phase. Last year's severe drought has also exacerbated the situation by leading to an increase in brucellosis and anthrax. Pastures have largely dried out, and the soil, contaminated with anthrax spores, is often swallowed by cattle while pulling the sparse vegetation out by the roots. In addition to a rise in the prevalence of infectious diseases, the ACF survey found evidence of stunting among children. Half the children surveyed in the mountainous regions of Tajikistan were stunted for their age, while a quarter were stunted in Tajik cities and suburbs. Four percent of children surveyed also suffered from acute malnutrition. WHO head Lyubomir Ivanov told IRIN that poor nutrition, poor living standards and disease had contributed to stunting. Poor quality drinking water, responsible for intestinal infections and water-borne diseases, was another major concern. The UN claims that about 40 percent of the Tajik population lacks access to safe water, while almost 60 percent of rural populations use unprotected water sources. Most of the country's water pipes are leaking, resulting in contaminated water. In addition, there is a lack of chlorine for water purification, and many public facilities such as school and health posts no longer have running water or adequate sanitation systems. Merlin public health nurse Ginni Burdis said: "The water in the irrigation canals, which people are drinking from, either comes off the fields or from another village up the road. People simply don't take care not to pollute the water. In one village we went to, seven other villages dumped their rubbish in the water. They washed their dishes in it, they put their ashes in it, they put their scrapings from the cow-shed in it, and down it goes to the next village. And there is nothing to prevent that happening, because it is an old system that doesn't work any more." Burdis added: "If you live on the main pipeline, you are probably OK. But in a lot of villages the pipes have broken and there is no money to fix them. If you live high up and the pump is broken there is no money to improve the pumps, so even when you are talking of very basic things like hygiene, the answer is: 'How do you expect us to have good hygiene if you can't do something about the water?'" Burdis said that in some instances agencies had tried to rehabilitate water systems, but often it was impossible to put in wells, because the water was too deep or too saline, so people were forced to drink from irrigation canals. Meanwhile, recently proposed health reforms, if implemented, add a positive aspect to an otherwise gloomy picture. The Somoni Healthcare Reforms set down comprehensive strategies for reforming the health care system up to the year 2010. The reforms focus on decentralising health care, increasing equitable access to health care and prioritising primary health initiatives. Merlin country manager Paul Handley says the reforms are very much in line with the British medical relief organisation's strategy in Tajikistan. In the coming year, it plans to develop programmes that will work in conjunction with the move towards a new system of public health. Currently, Merlin was focusing its attention on a public health promotion campaign targeting high-incidence areas of Khatlon District. Through a coordinated approach, it was helping to educate health workers in communities, as well as children in schools, on better health practices. Ivanov said he was hopeful that the reforms were heading in the right direction. "The key figures will be the family physician and the family nurse. Until now there have been no family physicians in the country. We will also be reforming the hospital system, so there will eventually be a general hospital through to a regional hospital." In the meantime, Merlin's nurse, Burdis, says the conditions affecting people in the villages are definitely declining. "There are rich and poor, and the divide is getting bigger. People are not able to afford the basic commodities which previously they were, they cannot afford foods of higher nutritional value, so they get by on a very bland diet. Many people would say they were better off under the Soviet system."