WELCOME TO IWPR'S REPORTING CENTRAL ASIA, No. 541, April 11, 2008
RESILIENT TB STRAINS THRIVE IN KYRGYZSTAN Unsound medication practices are
creating increasingly incurable strains of tuberculosis, in a society
ill-equipped to cope. By Andreas Hedfors in Bishkek
TURKMEN FARM REFORMS FAILING Government needs to launch comprehensive overhaul
of agriculture if production is to be increased. By Annadurdy Khadjiev in Varna
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RESILIENT TB STRAINS THRIVE IN KYRGYZSTAN
Unsound medication practices are creating increasingly incurable strains of
tuberculosis, in a society ill-equipped to cope.
By Andreas Hedfors in Bishkek
If you catch tuberculosis in the Kyrgyz capital Bishkek, the risk is higher
than anywhere else in the world that it is a strain resistant to the best drugs
The main sources of drug-resistant TB strains in the world abbreviated
therapy and insufficient medication have become almost routine practice in
the Kyrgyz healthcare system. The resulting hardier strains of TB become
extremely difficult to treat and spread in the community.
I am pretty much immune to all of the drugs I am taking now, except
Kanamycin, said Mikhail, 38, one of an estimated 1,300 to 3,500 people in
Kyrgyzstan now suffering from drug-resistant or even multi-drug resistant
(known as MDR) tuberculosis.
After ten years of donor engagement, Kyrgyzstan is slowly getting the upper
hand in the battle against the standard tuberculosis virus. These efforts have
stabilised and brought down the annual incidence of new cases from 128 per
100,000 people to 109 over a period of seven years.
But according to the preliminary findings of a World Health Organisation, WHO,
committee, 26 per cent of the new cases recorded in Bishkek in 2007 were
resistant to at least the two most powerful TB drugs Isoniazid and Rifampicin.
This statistic is the worst ever recorded for drug-resistant TB. A recent WHO
report listed Azerbaijan's capital Baku and Moldova as having the highest
incidence of MDR strains, at 22 and 19 per cent, respectively. Several
countries were left out of the study due to lack of reliable data.
What is more, the special drugs needed to treat MDR strains have always been
absent or extremely scarce in Kyrgyzstan, due to the complexity and expense of
In the three-room flat he shares with his parents, Mikhail rummages through a
plastic bag full of vials and pill boxes. He improvises his own treatment, with
drugs he gets from contacts in Kazakhstan and Russia.
The alternative is grim without medication, half of tuberculosis sufferers
will die within two years, experts say, and the chances are even worse for MDR
However, do-it-yourself treatments also risk killing the patient, and can give
the TB virus greater immunity.
Every day, Mikhail takes four tablets of Pyrazinamide, one of five drugs that
are routinely combined in a six-month therapy to treat ordinary TB. He also
takes the antibiotics Kanamycin and Ofloxacin.
These are classed as secondary drugs, used when one or several of the
standard substances are useless. But therapy with these less effective drugs
may take 24, possibly up to 36 months, and it can also set off severe adverse
effects requiring supervision and individual care.
The subsidised world market price for a full standard course of treatment for
drug-resistant strains is presently 4,600 US dollars compared with some 50
dollars for the treatment of ordinary TB.
Certain drugs are inexpensive Ofloxacin costs 600 soms or 15 dollars for a
month-long supply and available without prescription in Kyrgyz pharmacies, to
people such as Mikhail.
To be honest, I have lost confidence in the doctors. If I were to follow their
advice, I would have been long gone. So I improvise a treatment according to
what feels good for me, he said.
But treating TB with too few medicines, or with types that are not effective
against a particular strain, as Mikhail is doing, is precisely what breeds
drug-resistant TB in the first place. The normal bacteria are killed while
those which have accidentally mutated to a resistant form survive, multiply and
become the dominant strain in the patient.
Doing this repeatedly can create further resistance to the point where no drugs
are effective. A laboratory in Germany recently identified the first ever
Kyrgyz case of this kind, defined as XDR.
XDR is increasingly feared in developed countries. While TB is a social disease
which mainly threatens people with ailing immune systems in developing
countries or among risk-groups, XDR TB can be impossible to treat wherever it
CHAOTIC TREATMENT METHODS
It is not just patients who are creating ad hoc treatments and thereby
unwittingly generating MDR strains. Not far from Mikhails home in a southern
suburb of Bishkek, the countrys foremost TB experts have been doing much the
same for years.
Kyrgyzstans National TB Centre consists of a cluster of pink stone buildings
surrounded by a park. Here, Doctor Atyrkul Toktogonova is responsible for
treating the country's MDR TB population.
It was not until November 2005 that she was given the range of medicines she
needed, under a project funded by the Global Fund to Fight AIDS, Tuberculosis
and Malaria, a part-public, part-private body. Even then, it was only a pilot
project covering 100 patients, a number which doctor Toktogonova was able to
stretch to 154.
With nothing left over for the thousands others needing help, she started
treating them with whatever appropriate medicines she could find, hoping they
might be enough for a cure or at least to prolong the patients life.
We are doctors and if a patient looks at us with hope and asks for help, well,
we put in what we can, she said, closing the door to her office.
In the hallway outside, coughing men and women from all over the country were
gathered in hope for treatment.
Outside the pilot project, she was only able to obtain two out of the four or
five substances needed, and even these came in such small quantities that she
could help only a few patients, 313 since 2004, and only for six months,
instead of 24. The patients were encouraged to buy more medicines themselves to
obtain the right combinations of drugs for the full period of treatment.
Sure, we have violated the treatment principles a bit, said Dr Toktogonova.
We know that to get good results, we should put in a minimum of four or five
new substances. But for the sick, life is going by. And we have to save them.
Dr Toktogonova says some of the people she treated by this method are now
cured, but she admits many will have developed further resistance and died.
>From a public health perspective, these budget therapies are a catastrophe.
Dominique Lafontaine, until recently in charge of a Doctors Without Borders,
MSF, team working on the TB epidemic in Kyrgyzstan's prison system,
acknowledges there is an ethical dilemma here, but insists nevertheless that
improvised treatments are wrong.
Don't start any antituberculosis programme, if you are not sure to do a good
programme. You will select those [bacteria] which are resistant to these drugs,
and then you will spread this strain in the community, said Lafontaine.
DOCTORS BREAK THEIR OWN RULES
The dangers were recognised in an order issued by Kyrgyzstans National TB
Programme Director Aftandil Alisherov in May 2006, instructing doctors to
refrain from "chaotic prescription and use of second-line TB drugs in the
treatment of chronically ill TB patients.
Alisherov is aware the treatment at the TB centre is wanting. arding
"We give full treatment to only about 100 people. For some of the rest, we buy
two or three substances from the budget. Those who wish buy other substances,
for their own money
. And they write complaints to the ministry, and we have to
explain that the state lacks the funds," he told IWPR.
Alisherov did not comment on how these practices fit with his own prohibition
of such treatment, but he admitted they might violate the understanding the
centre has with WHO regarding responsible treatment.
IWPR approached his second-in-command, Bakyt Myrzaliev, who said he was unaware
of these "budget" therapies and said they would be unlawful.
"The purchase of second-line substances alongside official supply lines is
forbidden, he said.
Oskon Moldokulov, the WHO representative in Bishkek, said he had heard about
the partial treatments, but that he did not think it involved this many
patients. He promised to take a closer look at the situation and take it into
account when future decisions were being made on WHO support.
Such treatment is an enormous risk. You can create virtually incurable
diseases, he said.
HUMAN ERROR ADDS TO THE RISKS
In April or May, Kyrgyzstan is expecting the first major shipment of
high-quality second-line drugs, enough for some 1,780 MDR TB patients over five
"We are waiting, and the patients are too. As soon as these drugs arrive, we
will be able to convert all insufficient therapies into adequate ones," said Dr
Once these pharmaceuticals start arriving, they will theoretically wipe out the
backlog of MDR TB patients as well as the new 560 cases believed to arise
The challenge will be to ensure that the correct drugs are used properly. In
the first two years of the MDR TB pilot project, only 60 per cent of patients
actually completed the full length of treatment, Dr Toktogonova said.
One problem is the shortage of trained medical staff, as many leave the country
in search of a better wage than the 90 dollars a month an experienced family
doctor can expect to earn in Kyrgyzstan.
There is a brain drain of TB personnel, said Maxim Berdnikov of the
International Committee of the Red Cross in Kyrgyzstan. In Kazakhstan and
Russia, the salaries are five to ten times higher. In some places in the south,
there are no lab technicians left to diagnose the disease, and hospitals are
Another obstacle will be patient motivation. Shamyrza Amankulov, a 52-year old
resident of the Issyk-Kul region, has interrupted and resumed his treatment
more times than doctors can count.
IWPR interviewed him in the MDR ward at the National TB Centre, where he had
been transferred after many months of treatment.
He believes he knows better than the doctors at times. I have left treatments
when I have thought they give me the wrong treatment. Last winter ,they gave me
first-line medication for four months that was completely wrong, he said.
As for others who disrupted their treatment, he explained, Maybe people don't
understand fully that this is a serious disease. Some people say you get better
if you eat dog or badger meat. Amankulov tried such folk-medicine methods
himself but admitted they did not help.
In early April, following this interview, Amankulov again broke off his
Dr Toktogonova has had difficulty in making even the lucky few patients who
were included in the pilot project stay on the treatment.
During the interview, she received a phone call from a 22 year old man who
wanted to come back after stopping his treatment just two months before full
His relatives didn't do anything about it and his district doctor had quit, so
none could find him, she said. His lungs are not yet destroyed. But he must
begin the entire treatment again, and perhaps for 36 months instead of 24.
Toktogonova says TB can return and further resistance can develop when therapy
is halted prematurely.
It always comes back, of course stronger and with resistance to second-line
medicines. Then we have nothing left to treat with, and then the patients die,
She has launched a series of seminars to teach medical staff all over the
country about the dangers of mistreatment.
I am in a state of terror as I watch how our doctors prescribe substances and
create XDR, she says.
The National TB Programme has recognised the danger of poor adherence to
treatment and is scrambling to improve matters in time for the arrival of
To minimise the number of drop-outs, Toktogonova said, treatment has been
reformed into a four-stage model with six months each spent in intensive care,
a rehabilitation home outside the city, an open ward near Lake Issyk-Kul and
finally treatment at home.
"This has already brought the number of therapy violations down from some 24
every month to a mere four," she says, commenting on the reforms impact on the
existing MDR pilot project.
Other measures may include food packages for TB patients and better pay for
doctors. The National TB Programme headed by Alisherov has applied to the
Global Fund to Fight AIDS, Tuberculosis and Malaria for 40 million dollars,
half of it to pay for food packages that would be distributed to patients every
day they show up for their medication, and the rest to go on raising health
If approved, the money will not arrive until the summer of 2009.
Despite all the investment and effort, Alisherov says only rising living
standards in Kyrgyzstan will ultimately decide the battle against the TB
If the economy stays at this level, we won't beat TB. I say this openly. It
will remain where it is now. Perhaps the numbers will go down a little, but it
will remain, Alisherov concludes.
Andreas Hedfors is a freelance journalist in Bishkek.
TURKMEN FARM REFORMS FAILING
Government needs to launch comprehensive overhaul of agriculture if production
is to be increased.
By Annadurdy Khadjiev in Varna
A year after President Gurbanguly Berdymuhammedov came to power, his pledges to
reform agriculture have yet to make much of an impact. If things are really to
change, he needs to stop focusing on grain production and develop a more
diversified and efficient farming sector that is better suited to conditions
and food needs in Turkmenistan.
At a cabinet meeting on March 12, President Berdymuhammedov took agriculture
sector chiefs to task, saying that spring sowing was behind schedule and arable
land was in poor shape, with drainage systems collapsing and high levels of
salt in the soil.
The president told his officials needed to make fundamental changes to the
way food was produced in Turkmenistan.
His damning statements come a year after he announced large-scale reforms of
farming. A strategic programme approved at the end of March by the Halk
Maslahaty the supreme legislative body in Turkmenistan set out steps
towards making better use of the land and the water that irrigates it. Two
other laws approved at the same time were designed to improve the lot of
small-scale private farmers.
Analysts suggest attempts to reform the sector have failed, for the moment at
It is of course early days for Berdymuhammedov, who inherited a failing economy
in which under his predecessor Saparmurat Niazov, who died in Decembe 2007
erratic policy decisions and neglect of the infrastructure led to chronically
poor performance, covered up by officials who routinely misstated production
Seventeen years after independence, Turkmenistan is largely dependent on food
imports. According to local observers, more than half of all the foodstuffs
consumed on the local market have come from other countries. Grain and flour,
together with meat, vegetable oil, fish, rice, and dry milk are purchased from
Kazakstan, Russia, Ukraine and the United Arab Emirates.
Turkmenistan is a largely desert country with only limited access to
irrigation, and much of its arable land is given over to the export cash crop
cotton. Wheat is also an important crop, but not enough is grown to meet local
demand. Last years harvest was put at 1.2 million tons by the official
statistics, or closer to one million according to independent estimates, far
less than annual domestic consumption which a United States Agriculture
Department study dating from 2005 calculated at almost 2.5 million tons.
As well as the scarcity of water, experts say this shortfall is due in part to
the low level of technology available to Turkmen farmers. Yields of about 1.5
tons per hectare compare badly with neighbouring Kazakstan, where productivity
can reach 4.5 tons per hectare, making it the main grain exporter in the
region. Furthermore, the Kazak figure is for wheat for human consumption,
whereas in Turkmenistan 55 to 60 per cent of output goes for animal fodder.
Before Niazov died, he ordered a 300,000 to 400,000 ton production increase
every year, in an effort to reach an ultimate target of four million tons. For
the moment at least, the authorities appear to be pressing ahead with this
strategy of driving up grain production to the point where the country is
self-sufficient, and have set a target of 1.8 million tons this year.
This is unlikely to happen, since none of the underlying conditions have
changed, and the starting point is not based on accurate figures. In 2006,
government inspectors found that farmers were planting less than half of the
planned area with wheat, and some regional governors who were found to be
exaggerating output figures were sacked and arrested. Berdymuhammedov has
declared war on the practice of reporting fictitious output results.
It is worth asking whether Turkmenistan actually needs to grow this much grain.
Since gas and cotton are major revenue earners, the country should be in a
position to buy the grain it needs rather than placing a huge strain on its
limited land resources and poor infrastructure.
It might make more sense to grow enough cereals to cover local demand for
animal feed, and diversify agriculture to produce fresh fruit and vegetables
for the local market, as well as building up the livestock sector, a
traditional strength of this once nomadic nation.
The country could also make tinned foods, wine and other processed items if it
invested in industrial production.
It would not be difficult, with private-sector funding, to build poultry and
fish farms, hothouse plantations and small-scale processing factories all
around the country.
The structure of agriculture must also be addressed new laws are needed to
encourage farmers and food producers, together with better access to loans and
preferential tax rates and import/export tariffs. The procedure for registering
new agricultural firms also needs to be simplified.
Finally, the government must also end the Soviet-style state order which
tells farmer what to grow and fixes artificially low purchase prices.
If all this was done and the sector was managed properly, Turkmenistan would
gradually move to a position where it not only produced much of its own food,
but was also an exporter, thereby recouping the money it has to spend on items
that are better imported, like grain and sugar.
Turkmenistan may never become self-sufficient in food, but then there are very
few countries that are. Russia, for example, buys 45 per cent of the pork it
consumes from Europe, 60 per cent of its poultry from the United States and
almost 40 per cent of its rice from Thailand.
Annadurdy Khadjiev is an economist based in Varna, Bulgaria.
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