Kyrgyzstan: Tuberculosis Tests Bishkek’s Approach to Public Health

A curious
debate involving individual rights and the limits of state authority is
unfolding in Kyrgyzstan. International donors and local policy makers are
wrestling with the idea of whether Bishkek can compel people with tuberculosis
to receive treatment – even if they don’t seek it.

Tuberculosis
is a highly contagious, airborne bacterial infection that attacks lung tissue
and it has wrought havoc in Kyrgyzstan since the Soviet Union’s collapse two
decades years ago. Containment efforts have grown more problematic of late with
the appearance of multi-drug resistant (MDR) forms of the disease. Currently,
Kyrgyzstan ranks among the top-10 countries worldwide for MDR TB, according to
the World Health Organization.

To
confront the problem, Bishkek wants to build a prison-camp-like facility for
forced treatment in cases where contagious patients refuse medical help. But
privately, international donors, who fund 100 percent of the country’s
anti-tuberculosis drugs, are concerned about the initiative’s civil rights
implications.

TB rates
in Kyrgyzstan are highest in crowded penitentiary facilities, statistics from
the country’s National Tuberculosis Center show. Though the center says
TB-related deaths are on the decline – last year, TB killed 19 inmates, down from
32 the previous year – difficulties diagnosing all cases of TB in prisons, and
the tendency for some prisoners to discontinue treatment once released, means
that some of the least treatable forms of the disease are spreading among the
general population. MDR strains have developed immunity to “frontline” anti-TB
drugs, such as isoniazid and rifampicin.

According
to government statistics, prisons have TB rates up to 10 percent higher than
the population as a whole. But Madina Tokombaeva, director of the Harm
Reduction Network, a collective of foreign-funded non-governmental
organizations that work with vulnerable groups in juvenile detention
facilities, contends that the real figure is greater still. “Working with
prisoners and ex-prisoners for over 10 years we are confronted by the fact that
people who leave jail thinking they don’t have TB turn out to be sufferers,”
Tokombaeva said.

According
to Tokombaeva, only two of the country’s roughly 20 prisons are specially
equipped to treat TB patients. But many former prisoners trying to get medical
care for TB claim they have never spent time in either facility, leading
Tokombaeva to worry that prison doctors simply aren’t diagnosing many
sufferers.

In 1998,
Bishkek passed legislation designed to contain TB. While obliging the
government to provide free treatment, the law made sufferers who repeatedly
refuse healthcare criminally liable. Criticized by rights activists at the
time, the law was reinforced in March 2011 when parliament adopted a resolution
to send patients abstaining from treatment to a TB colony. The facility has yet
to be constructed.

While
civil society groups, including Tokombaeva’s Harm Reduction Network, are
against the idea of forced treatment in principle, Myrzahat Imanaliev, director
of the Center for Information and Epidemiology at the National Tuberculosis
Center, believes the state has a duty to protect the broader population. Thus,
he sees no alternative to the colony concept. Ex-prisoners often don’t seek
medical assistance once they are released, he explains. “Some of these people
have lost all social ties and connections to their families. They get out, they
don’t take care of themselves. … They begin to infect people. Within six
months they are back inside again, and so on,” Imanaliev told EurasiaNet.org.

Imanaliev
acknowledges that the idea of a guarded TB colony for sufferers refusing
treatment makes international aid organizations squeamish, but insists that
such a facility is necessary as a safeguard against the further spread of some
of the most dangerous TB strains. “The patient would go [to the colony], get
better, or die. But they would not infect the population,” he argued.
“What about the rights of other people to have security from infection? We need
to weigh these things.”

A Western
aid official familiar with infectious disease programs in the country said that
“under no circumstances” would the aid community walk away from Kyrgyzstan’s TB
problem. Nevertheless, the source confirmed the government’s stated intention
to build a TB colony posed a dilemma for international development
organizations.

Describing
the idea as “very Soviet,” the source said, speaking on condition of anonymity
to protect his organization, that donors “could not endorse” any facility where
democratic values and the “human right to refuse treatment” were ignored. “This
is problematic. If [donors] can’t endorse [the colony], then they can’t be seen
to fund and equip it,” he said.

by Chris Rickleton

Editor’s
note: Chris
Rickleton is a Bishkek-based journalist.

 http://www.eurasianet.org/node/65402

Originally published by EurasiaNet.org                                 http://www.eurasianet.org