My first ever visit to Turkmenistan last week was an eye opener on so many levels. I was there presenting at an international seminar on "Health and diplomacy" that brought together participants from the Ministries of Health and Foreign Affairs from all five Central Asian countries -- Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan -- and Georgia, Belarus and Armenia.
A highlight was giving a lecture and answering many questions from students at the Institute for Humanitarian affairs and Development where the curriculum is now exclusively taught in English. It has been an engaging week -- to a person the warmth and hospitality of the Turkmenistan people has been a constant.
Mysterious and disconcerting Turkmenistan.
Drenched in desert winter sun one moment, covered with snow and blanketed by thick impenetrable fog the next.
The country's desire to modernize and open up is everywhere: in its infrastructure, in the number of its students now learning abroad, in its increasingly contemporary lifestyle; in the construction of the China-Turkey railway and the pipelines that will see the country become a gas exporter to Europe. It is a determined modernization project but at the same time, a cautious one. How could it be otherwise? Turkmenistan has for so long been closed to the outside world, ruled under a cult of personality-driven and authoritarian leadership.
Turkmenistan is one of the fifteen (out of 27 globally) high-burden countries for Multi-Drug Resistant Tuberculosis (MDR TB) in Eastern Europe and Central Asia. The energetic and competently run National TB program operates out of a beautiful white marble-covered building benefiting from the most modern equipment in the Northern outskirts of the city. Thanks to Global Fund grants, the center in the capital, Ashgabat, and centers in each of the five provinces of the country are equipped with GeneExpertTM machines now allowing for rapid diagnosis and detection of resistance in samples sent to these referral centers by primary health care facilities around the country.
According to the official figures, MDR TB represents at least 15% and 34% of newly diagnosed and re-treatment TB cases in Turkmenistan, which is of significant concern. But this may not tell the full story -- these are the available figures but there are considerable gaps -- Data transparency remains a huge issue in Turkmenistan.
An increasing number of patients diagnosed with MDR TB access treatment with the new and standard international regimens but 80% of the funding for this remains dependent on international funding. The financial sustainability of the AIDS and TB responses in middle-income countries is an issue of concern as international funding is withdrawn and the ability of a country like Turkmenistan to respond in the short to medium term remains questionable if its current levels of national health funding (2% of GDP) persist.
As for HIV/AIDS, we are back to the old mysterious Turkmenistan. No single case of HIV infection has been reported in the last fifteen years. And no statistic from the country is to be found in the latest UNAIDS/WHO annual reports. Again, the lack of transparency of data is an issue.
Next to the TB center in Ashgabat is the National Center for Prevention of HIV/AIDS. The center edits booklets, reaches out to schools and institutions, organizes events for December 1st (lots of excitement there last week). Daily it performs around one hundred tests -- the vast majority of which are compulsory: pre-operative, pregnant women, foreigners coming to the country, citizens of Turkmenistan about to leave the country for work and who receive a certificate indicating their HIV negative status (Turkmenistan is a country with restrictions on travel for HIV-positive people).
I felt the uneasiness of the medical staff as I questioned the relevance of these policies and their alignment with human rights. The answer was that -- yes, it is time to revisit them. The question is: will that be politically accepted, as the leadership struggles between balancing tradition and modernity.
Despite the best testing equipment, the preparedness for measuring CD4 cells and viral load and the knowledge of professionals and their dedication, it is clear to me that the country is not prepared for facing HIV/AIDS when, sooner or later it arrives as the country both opens up and becomes more transparent.
Turkmenistan is not ready to respond to HIV/AIDS for least three reasons:
One, a high level of stigma is easily perceptible across the board, from the uneasiness of medical professionals and high-level health officials in referring to "the problem".
Second is the split between the health sphere in the hands of the doctors and specialists, and the community that they serve. The civil society sector is almost non-existent and does not engage in dialogue with the professional health sector, the notable exception being the respected and active national Red Cross and Red Crescent. In meeting with their leadership and staff, I learned more about the non-surprising realities of sex work and drug use than in any of my conversations with health professionals.
The third reason is that there is a feeling of false security in the country inherent in the current repressive law enforcement policies on border control and drug use. These approaches, together with official policies around healthy lifestyle promotion and mass prevention that fail to target or reach the most vulnerable groups of the population will ultimately produce unintended consequences including human rights violations. If it turned out to be the case that an HIV/AIDS epidemic eventuated, one linked to the wave of drug use in the second half of the nineties and/or the growing international trade and travel as the country opens up, Turkmenistan would consequently be poorly prepared to respond.
The health diplomacy challenge here, as in many countries in the region, is to instigate a meaningful and ongoing dialogue between government and health authorities, which builds public confidence in the health system, one based on scientific evidence and the respect for human rights that consciously engages with civil society representatives and the wider community.