Turkmenistan, Asghabat (2008) © MSF

Turkmenistan’s
opaque health system
April 2010

I Introduction
The people of Turkmenistan are being failed by their healthcare system, by their government, and by the international
community. The system that is supposed to ensure their healthis instead designed to conceal problems. This is not a case ofindividual practitioners failing to do their jobs but one that is
far more systematic.

Key Findings•

Access to health care for the population of Turkmenistan isrestricted by fear of the social and political consequencesof illness for both health care practitioners and patientsand by stigma.

It is undeniable that communicable diseases such as HIV/
AIDS, tuberculosis (TB) and sexually transmitted infections
are more prevalent than reported figures would suggest. It isequally clear that public health risks are not being effectively
addressed and that prevention mechanisms are not in place.
Misinformation about how to avoid contracting and spreading
disease is rampant. However, rather than encouraging workers
in the health care system to actively counteract this throughit and encouraging people to seek help, serious health careissues are being driven underground. As a consequence, it
is all but impossible to gauge the real state of the health ofpeople in Turkmenistan today.

•

International standards and protocols exist mainly on
paper, and are not routinely or consistently implemented
in the country’s health care system.

•

Failure to acknowledge or address communicable diseases
such as TB, HIV and sexually transmitted infections ismost likely compounding upon and expanding existing
problems. TB, particularly in its multi-drug-resistantform, is perhaps the country’s most serious public healththreat, and poses a high risk of creating a serious crisis in
Turkmenistan.

•

Despite the appearance of greater openness since theaccession to power of former Health Minister Gurbanguly
Berdimuhamedov, real change has not taken place.
Instead, greater engagement with the international
community is serving only to mask the continuation ofold practices, including the manipulation of health data.

•

International organisations risk being complicit in theentrenchment of problems by transmitting government
misinformation as fact and by failing to address openly
and firmly the problems that they are witnessing in thehealth care system.

In December 2009 Médecins Sans Frontières (MSF) took the
difficult decision to close the last of its programmes in Turkmenistan. MSF had been present in the country for more thanten years and had had unique opportunity to witness the challenges facing the health care system. Unlike most of the countries in which MSF works, Turkmenistan’s health crisis is notcharacterized by large-scale outbreaks of infectious disease,malnutrition or violence, nor by a complete absence of healthcare provision. Instead it is through systematic denial andmanipulation; a system of smoke and mirrors reinforced byfear.
The purpose of this report is to shed light on some of the
key issues in Turkmenistan’s health care system and toraise concerns about the role of international actors in the
country. Anonymised examples from MSF’s experience ofworking directly with the country’s health care system illustrate the extent to which the capacity to make real change or
improvement was constrained.1 Instead, international organisations help perpetuate the problems by giving a veneer oflegitimacy to figures and practices that are not only ineffective, but often dangerous.

Examples and testimonies in this report are based on the direct experience of
our expatriate health staff in country.

1

3

II Médecins Sans Frontières in Turkmenistan
MSF worked in Turkmenistan for more than ten years andremained, until its departure in 2009, the sole accredited
international NGO with a permanent presence outside thecapital. The decision to leave was not taken lightly. MSF’s
commitment to the people of Turkmenistan and its convictionthat there is a need for transparent, international support in
the health sector remains unchanged. However, over time theorganisation recognised that rather than obtaining greater
confidence from the government and freedom to provide
assistance, its activities were becoming increasingly restricted.
MSF began its work in Turkmenistan in 1997 providing assistanceto approximately 10,000 Afghan refugees in Tagta-Bazar. In
1999 MSF received accreditation with the Ministry of Foreign
Affairs and signed a memorandum of understanding (MoU)
with the government to begin a pilot DOTS2 programme to treat
TB in the two etraps (districts) of Dashoguz Velayat (region):
Konya-Urgench and Turkmenbashi. By July 2002, a training
centre had been opened in Dashoguz and all medical facilities in Dashoguz Velayat were covered by DOTS programmes,
making Dashoguz the first velayat in Turkmenistan to havesuccessful complete coverage of DOTS. This programme washanded over to the Ministry of Health at the end of 2003.
In 2004, following an assessment of needs in Lebap andMary velayats, MSF began a children’s health care project in
Magdanly in Lebap. Over time the project expanded to include
obstetric/gynaecological care and laboratory support. MSF
also provided extensive formal and informal training andinfrastructure support. This intervention, while successful inachieving improvements in the hospital and surrounding area,
was problematic in many respects. From the beginnings theterms of the agreement were significantly more restrictive than
MSF was accustomed to, including a “hands-off clause” that
did not allow MSF’s international staff to directly treat patients.
Access to patients and data was restricted3 and MSF’s capacity
to implement internationally recognised protocols was limited
by standing orders that were impossible to counter.
In 2008 MSF obtained an initial agreement from the Ministryof Health and Medical Industry (MoHMI) to begin a pilot
programme to treat multi-drug resistant TB in Turkmenabad.
Based on regional trends, data that had been submitted by
the government to the Global Fund to Fight AIDS, TB and
Malaria and an MSF drug sensitivity survey in the country, MSF
determined that TB, especially the drug resistant forms, was2
DOTS is directly observed treatment, short-course, and is the
WHO-recommended strategy for detection and cure of non-resistant forms of
TB.
3
These restrictions increased over time, rather than the reverse. In 2009 MSF
international staff were barred access to the operating theatre, following a
training for MoHMI staff on a standard and internationally recognised surgicalprocedure. Disagreements with regard to the admission of patients fromother etraps resulted in further limitations, including the refusal to allow MSF
Turkmen national staff to access certain wards or to provide treatment and,reportedly, verbal threats.

4

Turkmenistan’s single most serious health issue. However,in May 2009, after nine months of negotiation, the MoHMI
finally rejected the plan, determining that there was no needfor MSF support as all health gaps were to be filled by theend of 2009. This was in spite of repeated requests from the
MoHMI for technical support in their Global Fund applications,along with the knowledge that the Round 9 application thenin progress, if accepted, would not see patients treated until
2012.
Despite ongoing lobbying and negotiation, MSF was unable to
make progress in coming to an agreement about future interventions.
MSF’s conclusion was that its effectiveness had been dramatically reduced and, worse, that the organisation was increasingly complicit in masking problems in the health care systemrather than addressing them.4 Moreover, MSF had noted that
it was not only that the government was limiting its activity
in Turkmenistan but that, over the course of time, the organisation had begun to engage in a form of self-limitation.
Repeated rejections of MSF’s requests for assessments alongwith refusal of permission to intervene in areas of critical need,and concerns for the safety of national staff, all resulted in an
increased tendency to shy away from sensitive issues and torefrain from speaking openly about problems witnessed in thecourse of MSF’s work.
While MSF has taken the decision to leave, internationalorganisations such as the World Health Organisation (WHO)and UNICEF remain. It is MSF’s belief that they too play a role inperpetuating problems in the Turkmen health care system. In
fact, as this paper will illustrate, it is clear that such problems,particularly communicable diseases, are under-reported,and that there is no real visibility regarding their extent orseverity. MSF repeatedly witnessed the tendency of organisations to overlook gaps, to fail to follow-up on government
commitments, and to provide legitimacy to government databy diffusing it internationally without comment or caveat.
It is impossible to know how serious or pervasive Turkmenistan’s health problems really are. It is clear, however, thatpatients are not receiving the treatment to which they areentitled, and that the government of Turkmenistan’s publichealth response is inadequate.

4
Within Magdanly hospital, as some of the examples in this paper will
illustrate, this manifested itself in a tendency to circumvent orders or
systems. While this had the positive effect of ensuring that patients received
treatment who might not have done otherwise, it did not necessarily resultin them receiving the best possible treatment, nor in accurate reporting for
epidemiological purposes. In some cases, for example, when admission to thehospital was refused, MSF found a way to treat on an outpatient basis. While
this resulted in the patient being cured, inpatient treatment would have been
the correct course of action.

III Manipulation and its Repercussions
Since it’s independency in 1991, the Turkmen state has put
a higher priority on the appearance of health and prosperity
than on the substantial reforms necessary to actually improve
the health status of the population. This has had negative
repercussions at every level of the system and has resulted ininadequate treatment of patients and a lack of managementof public health risks. In recent years there was much talk of
health care reform, particularly in the areas of TB and motherand child health,5 as well as more openness and collaboration
with the international community. However in MSF’s experience any changes have been essentially cosmetic.

Creating the Appearance of Prosperity
Turkmenistan rarely warrants mention in the international
media, but when it does there is often comment on thecontrast between the marble and gold façades that gild themost visible parts of the country and the poverty and hardshipthat is suffered by many members of the population, 30
percent of whom live below the poverty line.6 This tendency
is replicated in the health care system, where there has been
large-scale investment in infrastructure – including an eightstory oncology hospital in the capital, Ashgabat, and state-ofthe-art diagnostic centres in regional capitals – but where few
patients have access to such resources, and technology is notmatched with the ability to interpret findings.7
Vital to maintaining an appearance of prosperity is for Turkmenistan is the international representation of itself asa country with its public health situation under control.
Therefore here, too, appearance has been given priority, tothe extent that it is quite impossible to obtain realistic dataon anything from maternal and infant mortality to communicable diseases. For analysts attempting to understand Turkmenistan’s health situation, the lack of reliable data remains
one of the most crucial barriers.8
The most obvious area of obfuscation is in the area of communicable diseases, such as HIV, sexually transmitted infections
and TB, particularly multi-drug resistant TB (MDR-TB). Equallysensitive, however, are infant and maternal mortality rates.
Highlighted in the United Nations’ Millennium Development
Goals (MDGs), these indicators are taken as a barometer not
merely of women and children’s health, but of the health anddevelopment status of the whole society. They have been a

See for example Rechel, Sikorskaya and McKee, “Health in Turkmenistan
after Niyazov”, London School of Hygiene and Tropical Medecine, 2009, http://
www.lshtm.ac.uk/ecohost/projects/turkmenistan%20files/Health%20in%20
Turkmenistan.pdf.
6
Economist Intelligence Unit, www.eiu.com
7
Turkmenistan.ru internet newspaper. Health Oasis in Kopetdag Foothills,
January 28, 2007. http://turkmenistan.ru/?page_id=5&lang_id=en&elem_
id=9247&type=event&sort=date_desc. And Eurasianet.org. Turkmenistan:
Public Health Remains in Critical Condition. January 8, 2010. http://www.
eurasianet.org/departments/insightb/articles/eav010810.shtml.
8
Rechel, Sikorskaya and McKee, 2009, see fn 5, supra.
5

primary focus of health and development actors in lobbying
the Turkmenistan government and have been at the centre ofmany of the country’s recent health reforms. It is notable thatthese are also the only mortality data that the governmentof Turkmenistan has reported to international bodies, despite
their accuracy being highly suspect. Furthermore, emerging
diseases such as avian flu and H1N1 seem not to exist within
Turkmenistan’s borders.
Accessing information from outside of the country has proved
difficult, but closer proximity has not necessarily improvevisibility. Even from within Magdanly Hospital, MSF was
unable to obtain basic data, to such an extent that, in 2005,
the team conducted an informal bedside survey in order tobetter understand and address infant mortality.9 While taking
into account that there are higher number of limitations inusing this method, the results clearly showed a far higher
level of infant mortality than other countries in the region.
Furthermore repeated attempts to conduct basic assessmentsin the area were continuously denied, making it impossible toobtain better visibility on the health situation.

Manipulation of data
MSF’s experience in Turkmenistan overall and in Magdanly inparticular made it clear that the difficulties in obtaining data
were not due to lack of capacity, but rather because of a deliberate obscuring of information. Furthermore, it was not thatfigures were adapted to present a more optimistic view of thesituation, bur rather, that the reality was adapted to ensurethat the statistics would meet pre-determined targets.
While there has been greater availability of data to international organisations and analysts since President Berdimuhamedov came to power, the previous system of quotas foreverything from mortality to communicable diseases has
continued.10 The government puts pressure on health care
workers to meet these quotas, but the necessary resources are
rarely provided to ensure that these targets can be met. For
example, in Magdanly in August 2007, the hospital received
a fax with instructions to start TB DOTS diagnostic services. It
was only with the support of MSF teams, who constructed,
equipped and supplied a laboratory department for the
purpose, that patient services could be offered from March
2008 onward.
In MSF’s experience, health care workers are not encouraged toreduce stigma and barriers to treatment. Rather, at every level,
they are under pressure to actively prevent cases from reaching
the treatment facility in case they might harm the statistics. If
the cases reach the treatment facility staff are under pressure
Over a period of four months, MSF staff asked a series to questions of womenin the maternity ward to obtain a reasonable estimate of retrospective infantmortality.
10
One example is the 2006 Safe Motherhood decree, which demanded a fifty
percent reduction in maternal mortality.
95

to either prevent the patient from staying or from appearing in
the registry books at all. Laboratory technicians are also underpressure to not report ‘too many’ positive results for infections
considered to be sensitive. As a result, laboratory test results
have been manipulated, including the deliberate dilution ofreagents and falsification of results.

[There was a high-level complaint] of the lab reporting
parasites in stool found in patients. Instructions were
given to bring back all these positive reports to the lab,for the lab to re-write all of them as negative. He said
that the lab should never give positive reports on patientsfrom his department because it makes morbidity registers
look bad when the commissioners come to do their ward
visits. January 200711
Patient admitted with vomiting and nausea, no diarrhoea. Stool sample showed massive parasites. Whentreatment was provided to patient, grand-mother said
that she was sure that her grandchild had not produced astool since admission and she therefore does not believe
the result. She collected two more samples during thefollowing days under supervision of MSF-nurse thatwere negative, so first stool was definitely not from thispatient. When looking for a plausible explanation. I learnt
that by “Prikaz” every patient has to give a stool sample
and that MoHMI is in trouble if these are not produced.
As a consequence, stool samples are split or “imported”
into the hospital in case the patient does not have a stool.
Apparently, this happened in this case. July 2007

mortality in children under five years of age has decreased
from 71 to 51 and life expectancy at birth has risen from 62 to
63.12
The tendency of international organisations to report the
government’s health data as fact is dangerous not only for thecountry’s population, but also regionally. For example, countries like Uzbekistan, which provide much more credible data
to the international community (see Figure 1, below), havereceived significant negative attention on the basis of theirreported TB prevalence. By contrast, Turkmenistan has merited
barely a mention.13 As a result, the failure to address publichealth issues is rewarded, while efforts at transparency arepunished.

Figure 114
Communicable Diseases -> Tuberculosis(as of 24 March 2009).
Estimated TB prevalence, all forms(per 100 000 population per year)
Periodicity: Year
Applied Time Period: from 2000 to 2007
2000

MSF repeatedly witnessed and heard of members of staff at
all levels routinely giving and receiving orders to manipulate
STI diagnostic results in order to keep the records within thequotas. This was based not on written instruction but rather
on verbal orders from regional or national superiors:

Turkmenistan

Uzbekistan

130

139

2001

115

148

2002

110

144

2003

103

152

2004

98

149

2005

91

144

2006

85

134

2007

75

140

Screening of a pregnant woman for syphilis. We had two
positive tests in September in maternity and staff received
a phone call with warning not to confirm any more casesof STIs [sexually transmitted infections]. After that phone
call we don’t have any more syphilis cases officiallyconfirmed by the laboratory. September 2008
It is perhaps as much a result of these quota systems as ofany reforms to the health system that Turkmenistan shows, invirtually every category, consistent improvement in its healthstatistics. According to official reports, from 2000 to 2006 infantmortality is reported to have reduced from 59 to 45, while

WHO WHOSIS, accessed March 1, 2010, http://www.who.int/whosis/en/index.
html.
This applies not solely to TB but also to other diseases. WHO HIV/AIDS
epidemiological fact sheets, for example, report that Uzbekistan has increased
from 1,400 reported HIV positive patients in 2001 to 16,000 in 2007, while
Turkmenistan has fewer than 500. www.who.int/hiv/countries/en/
14WHO, Global TB Database, accessed March 6, 2010, http://apps.who.int/
globalatlas/dataQuery/
12

13

11
MSF staff ensured that positive test reports from the department were taken
to MSF expatriate staff so that patients could receive treatment, even if theirofficial laboratory reports were falsified.

6

IV The Impact on Patient Care
Working within Magdanly Hospital and, when access was
possible, in the surrounding health posts and health houses,15
MSF witnessed countless examples of inadequate patient care.
The easiest explanation is to blame the health care workers
directly for poorly applying protocols and being self-interested
and negligent. To do so, however, would simly be overlooking
the way that the system denies the health care workers thetools they need to do their jobs, and encourages poor practicewithin the system.

Refusal of Care
The pressure on health care workers to meet specific targets forhealth indicators often resulted in individuals being deniedcare. MSF was constantly negotiating with hospital staff toallow the admission of critically ill patients, as the hospital
staff feared that a poor outcome or complications would
impact negatively on their statistics, bringing with it severe
repercussions. This was particularly the case for patients whocame from outside the catchment area of the hospital, despite
it being stated on paper that critically ill patients must be
admitted.

2 admissions on behalf of MSF initially refused by the
MOHMI doctors due to poor prognosis. Both survived andthe cooperation in case management of those kids was
excellent after initial doubts and fear. May 2007
Other patients were discharged from hospital early to avoid
having to record a hospital-death.

MSF medical doctor was informed that it was the consensus
of the Turkmen medical doctors to discharge a baby assoon as possible for the following reasons: poor prognosis(as proven by the death of the other twin), the parents
come from another district, and therefore, should thepatient be send home, the patient will surely die but thedeath would not be reflected in the hospital’s statistics.
November 2007
Baby was born at gestational age of 26 weeks. On thesecond day the child had a respiratory arrest requiring
short-term intubation and ventilation. MOHMI staff
subsequently discharged the child in the afternoon andthe baby died at home. June 2008
1 years 5 month old child, severely malnourished. Outpatient department referred case to paediatric ward. Medical
doctor of paediatric ward refused admittance as the child
was a ‘lost cause’ and would probably die anyway. MSF

15
Access to health houses and health posts was sometimes restricted bypoor weather or road conditions, however, access was also constrained bygovernment intervention, as when MSF was denied permission to visit healthhouses for a period of time.

doctor found a solution to treat the child on an outpatientbasis. September 2007
A particularly difficult problem encountered in MSF’s maternaland health programme was on how to define live births. The
Soviet definition of a live birth used previously in Turkmenistan stipulated that infants born before 28 weeks of gestation
weighing less than 1000 grammes or measuring less than 35
centimetres in length were not considered live births unlessthey survived seven days. This method of measurement wasused previously in Turkmenistan, and consequently, many
infants’ deaths went unrecorded. The WHO definition of a live
birth is any infant that shows evidence of life, and this international definition was officially adopted in Turkmenistan on
January 1, 2007.
However, official ministerial expectations of the infantmortality rate did not change. This increased the pressure tohave as few infant deaths as possible. One way to keep infant
deaths low was to not attempt resuscitation after birth, so thatthe case would be classified as a stillbirth rather than a death.
MSF worked closely with the hospital staff to demonstrate thatwith proper care many of these infants could survive and be
successfully discharged from hospital.

Poor quality of care
MSF witnessed many examples of poor medical managementof patients and a lack of understanding of basic principles.
This is not surprising given the inadequacies of the medical
education system. Reforms during Nijasow’s government leadto a loss of the countries medical educators (Russian speaking)and reduced the availability of training materials, scientificpublications and WHO protocols.

4-year-old child came for consultation for “runny ears” for2 years. Delayed speech development, impaired hearing.
Symptoms started 2 years ago, since then smelly discharge
from both ears, perforated ear drums with large defects
on both sides . So far, never received systemic antibiotic
treatment. Previous MoHMI treatment given: Crushed anddiluted Amoxicillin tablets were instilled into the ear every
month for a couple of days. MSF started treatment withoral amoxicillin. Both ears healed nicely, much improved
hearing and no discharge any more. July 2007
A 2-year-old boy was admitted to inpatient department
with severe dehydration caused by vomiting and diarrhoea
since two days, weight loss of 2 kg in 5 days. Weight 12 kg.
Discussion with MoHMI doctors about rehydration therapy.
MoHMI was seriously telling me that 400 ml total fluid
intake per day was enough and the maximum to be givenin this case was 500 ml. Reasons given: Danger of overhydrating, Central Asian children are not used to so much
fluid, children die if they are rehydrated aggressively. I
explained patiently three times the calculation method of7

daily fluid requirements depending on weight, indicating that this child needs at least 1,2 l [maintenance]
fluid intake per day not counting the losses. I explained
how to calculate deficit and how to estimate and monitor
losses, and how to rehydrate properly. He still argued
that this is not feasible for children of this area. I copied
literature for him, brought training materials – he stillargued that WHO protocols do not apply to Central Asian
children and that he as a doctor as well as the patient
would get serious problems if they followed these rules.
Head of therapeutic departments, who came along andwas involved in the discussion, confirmed this opinion
and said, WHO protocols had been proven to not work in
Turkmenistan. MSF managed to explain [to] the mother togive the child at least 1500 ml oral fluids in frequent small
portions. Luckily the vomiting stopped and the patient
recovered within 3 days – mainly due to MSF-nurses’ andthe mother’s effort. August 2007
As far as MSF was able to establish, continuing professional
education to maintain levels of competency and ensure up
to date scientific knowledge is not mandated or facilitated.
In Magdanly hospital, most of the staff were natives of thearea who received medical training in Ashgabat, Turkmenabad or in nearby Uzbek medical colleges many year ago.
Predominantly Soviet-educated with little if any continuing
medical education, they had little or no exposure to up-todate evidence-based on either practice or scientific literature.
This resulted with MSF witnessing many repeated examples ofpoor or dangerous practices.

powerful anti-seizure drug phenobarbital was used for ‘raised
intracranial pressure’, which sometimes amounted simply toa child crying with colic. Phenobarbital was also observed tobe administered routinely to children who had been deliveredby forceps. All of these practices were observed despite thefact that international treatment guidelines have been officially adopted. Even worse, MSF saw cases of misdiagnosis andincorrect treatment.

2-year old child received blood transfusion upon indicationof fever signs, while Hb was 16. MoHMI denies that thetransfusion occurred knowing that MSF would recommend
against the blood transfusion. Three witnesses however
confirmed it took place. November 2006
Over the course of five years, MSF medical teams conducted
formal trainings weekly and bedside training sessions daily
on diagnostics, therapeutic management and care for virtually
all prevalent health conditions among pregnant and lactating
women and in newborns, infants, children and adolescents.
Emphasis was consistently on the concept of evidence-based
medicine and other international standards of patient care.
Despite these efforts, MSF’s success in changing local practiceremained hit and miss. This was largely because there wasno systemic encouragement for staff to implement or follow
international protocols and so opportunities to correct poor
practices were often lost when the use of unsafe practice orabandoned treatment protocols simply went ‘underground’.

A Culture of Fear
MSF Expat was present in all Caesarian sections over 14
days. In none of the sections, sterile operating techniques
were strictly followed. Of most concern is that the chief
nurse is sorting the sterile instruments without sterile
gloves on. This means that all instruments are unsterile
when operation starts. Surgeons are not aware of proper
technique how to put gloves and keeping their hands
sterile. May 2007

MSF observed medical staff in Turkmenistan reduced to delivering sub-standard care through a culture of fear. Frequent
staff reshuffling creates anxiety and uncertainty and staff
become fearful of making any change, no matter how positive
the outcome might be for the patients under their care. This
culture of fear has filtered down from the highest politicallevels.

Pregnant woman with pre-eclampsia; very high bloodpressure in late pregnancy; foetal heartbeat reported as
normal; no blood pressure surveillance carried out, andno labour induction took place; next morning baby inwomb was dead. November 2006
Based on MSF’s direct experience and observations, there
appears to be rampant misdiagnosis of common conditions
and a vast overuse of antibiotics and multiple intravenous
administration of medication for complaints as simple as thecommon cold. There is little understanding of correct fluid
management and children in respiratory distress are given
large boluses of Ringer Lactate. There is persistent use of blood
products without indication, and transfusions are frequently
performed without screening for HIV or Hepatitis C. Casesof blood transfers by syringe from adult relatives directly tochildren without any screening at all were also witnessed. The

8

A medical doctor from Turkmenabad who came to Magdanly
for consultation was later sacked because an official from
Ashgabat determined that he made a “wrong diagnosis”.
Two members of local staff received fines, reportedly for
not reporting this case earlier to the Sanitary Epidemiological Service.16
Although MSF could not independently corroborate them,
reports were received that high maternal mortality rates resultin imprisonment of the doctor in charge, and MSF knew ofnumerous individuals who had been imprisoned in thecourse of their work. It was also reported that the head of the
Narcology Hospital was fired for reporting cases of HIV.

16

MSF Monthly Medical Report, April 2009.

The punitive nature of the system affects the behaviour not
only of health care workers, but also of their patients. In Turkmenistan, as elsewhere, shame and social pressure play animportant role in preventing patients from seeking assistancefor diseases which are stigmatised in society. However, in Turkmenistan MSF found that the official repercussions of having
contracted infectious diseases such as syphilis, HIV and TB
are so severe that patients will resort to extreme measures toavoid having this recorded. For example, if a positive syphilis
result is recorded in a patient’s ‘Sanitary Book’, the result will
be exclusion from many types of employment, including in the
education and health care sectors. Patients are not guaranteed
the right to confidentiality of their medical records, and all
employers have access to the information in the sanitary book.
The consequences therefore can lead patients to avoid seeking
care, or can push them to pay bribes to health care workers inorder to receive testing or treatment without it being documentated.

result was officially documented as negative but verballycommunicated as positive to the Chief Doctor of the ward.
The correct treatment for brucellosis was conducted.
January 2007
It is indicative of the commitment and integrity of many healthcare workers that cases like these exist. The fact that data is‘doctored’ in this way, though, raises serious concerns about
the real prevalence of disease and the state of public healthin Turkmenistan.

Lab diagnosis showed Trichomoniasis, a sexually transmitted disease, and there was a big hunt for the patientas according to Prikaz (official decree) all Trichomoniasis
cases are to be admitted and notified, thus stigmatizing
the disease. The patient went in hiding to avoid registration. October 2008
According to MoHMI lab records, 121 male urethral swabs(for STI) were examined, and all results were negative.
Unfortunately, it was confirmed that the lab neverreceived these samples. The forms were simply completed
and returned to the Venerealogy Department. It has
been suggested that the patients pay for these negative
results.17 April 2009						
To give health care workers their due, on many occasions
efforts were made to ensure that appropriate care was given,
despite significant pressure. In these cases, however, diagnostic records were found to have been creatively altered tomatch expectations.
A 14-year-old boy with complaints of prolonged fever,rash, vomiting, abdominal pain and 7-8x per day blackstool. Initial diagnosis was measles. Child deteriorated,then treated in line with typhoid diagnosis. Records
however say Acute Viral Diarrhoea. December 2006
A case of brucellosis18 was seen in a 4-year-old girl from
Magdanly town who was admitted in the Infectious
Disease ward. A laboratory test was conducted and… asample went to SES, which took three days to process. SES

MSF Monthly mission situation report.
Brucellosis is a serious bacterial infectious disease. In pregnant women, if
not treated, it can result in a miscarriage. In this and cases like it, MSF madeefforts to find the patient through other means in order to ensure adequate
treatment

17

18

9

V Public Health and Epidemiology
Turkmenistan is far from exceptional in its hesitance to reportcases of infectious diseases, and it is known that many countries seek to minimize or underreport. However Turkmenistan arguably goes farther than most, to the extent that in2004, according to the London School of Hygiene and Tropical
Medicine, ‘secret instructions’ were said to have banned
all mention of infectious diseases like TB, measles, cholera,dysentery and hepatitis.19 Moreover, although increasinglyinternational standards and protocols have been introducedby the government, in MSF’s experience, these are rarely
applied or applied consistently. The result is a patchwork of
prevention and treatment practices, unwillingness on the partof health care professionals to diagnose or treat infectious
diseases and of patients to seek assistance, and the manipulation of statistics to avoid the appearance of problems.

Non-implementation of International Standards
and Protocols
The failure to prevent, diagnose and effectively address
public health issues appears to be evident at every levelof the health care system. While the government publicly
endorses evidence-based medical protocols, it fails to ensure
their implementation. The following is a summary of someexamples with which MSF struggled in Magdanly.

•

On paper, TB is taken seriously in Turkmenistan. In
2008 Prikaz #288 was adopted, implementing DOTS in
Ashgabat, and since then further prikazes have been put
in place to facilitate the implementation country-wide.
However, in practice, old prikazes remain in effect, suchas #313, which provides for ‘seasonal treatment’ of TB –a holdover from the Soviet era. After “2M rest,” patients
who complete DOTS treatment (both those who havesputum converted and those who have not) are automatically registered for seasonal treatment – Isoniazid
and Rifampicin – given in the months of March/April and
September/October. Patients are enrolled in this plan for
up to five years. This dangerous practice puts patientsat risk of drug resistance to the two most important TB
drugs, Isoniazid and Rifampicin.

These examples are indicative of the lack of capacity within
the health care system to implement improved practices andprotocols effectively. While some of the blame can be laid onlack of adequate training and inadequate resources invested
in the health care system, there are other factors that militate
against any real health care reform.

Denial and Lack of Response to Pandemics – H1N1
and HIV/AIDS•

Turkmenistan endorsed the Integrated Managementof Childhood Illnesses (IMCI) in 2004. However, neither
under the previous government nor the current one has
this led to the application of evidence-based clinicalpractices in paediatric care. The medical knowledge andunderstanding of health professionals is worryingly low
and harmful practices are still widespread in paediatriccare, made all the more shocking by their consistency.

The government’s response to emerging public health risks is
simply to deny any possibility that they might exist in Turkmenistan. While this does not prevent the implementationof some preventative measures, the follow-up is notably
half-hearted. International organisations have contributed
to this by uncritically reporting health statistics provided by
the Turkmen authorities and failing to press the authorities toimplement and adhere to international standards.

•

The National Safe Motherhood Programme was adopted
in 2007, but despite the involvement of international
agencies in supporting its development and implementation, in MSF’s experience, large gaps still exist. While
pregnant women are theoretically entitled to free antenatal care services, numerous user fees are still in place.
Consultation fees (formal and informal), associated laboratory testing including screening for sexually transmitted
infections, and even the cost of basic ferrous and folicacid supplements remain significant barriers to carefor many women. Family physicians tend to have a low
level of knowledge, and there are frequent instancesof medication being prescribed and administered topregnant women that are contraindicated in pregnancy.
Furthermore, indications for Caesarian sections are poorly
understood, surgical techniques are outdated, andmedical staff are under pressure to keep the number ofC-sections performed low.

This was particularly evident in Turkmenistan’s responseto the advent of H1N1 or ‘swine flu’. On November 4, 2009,
the governmental newspaper Neutral Turkmenistan reported
that there were no cases in Turkmenistan and stressed that
serious measures were being taken to prevent the outbreak ofthe disease, including strict controls on travellers and special
detection equipment at airports.20 The government’s official
position is that there have been no cases in the country, andwithout independent information it is impossible to refute
this. However its advent has revealed real fear in the population about health status and a lack of trust regarding thetransparency of the government. This has surfaced in international articles and blogs, often with very strong allegations ofgovernment cover-ups.21

Rechel and McKee, Human Rights and Health in Turkmenistan, London Schoolof Hygiene and Tropical Medicine, 2005, p. 41.

19

10Perhaps most widely reported was the government’s decision to not permit
Turkmen Muslims to attend the Hajj in 2009.
21
Influenzastan, a five part series. http://www.neweurasia.net/tag/swine-flu/.
See also Washington Post, In Ukraine, H1N1 pandemic sets off panic andpoliticking, November 21, 2009. http://www.washingtonpost.com/wp-dyn/
content/article/2009/11/20/AR2009112004023.html?sid=ST2009112004284
20

The management of H1N1 also serves as an illustration of
the failure of international actors to effectively address
public health issues in Turkmenistan. The government public
education campaign (published in Neutral Turkmenistan)
included recommendations for prevention, including taking
vitamin C and adaptogen drugs or cyclopheron, α-interferon
as a nasal ointment and oxaline ointment. Research done by
MSF indicated that these were protocols used for influenza
during the time of the Soviet Union, but certainly do not correspond with WHO protocols for treatment.22 However, when thiswas discussed with WHO in a meeting on November 13, there
appeared to be no plan to raise this with the authorities.
Moreover, WHO remained silent in the face of government
claims that there were no cases in the country, despite theirknowledge that there was an outbreak of respiratory disease(with flulike symptoms)23 and that no testing was being done –diagnostic tests had not arrived in the country and no laboratory technicians had been trained. As of March 21, 2010, thegovernment of Turkmenistan continued to report the complete
absence of cases of H1N1 in the country, as taken from WHO
external records.24
HIV/AIDS remains the most ‘invisible’ of diseases. The change inleadership did not affect its core message, which is, that there
are no cases of HIV in Turkmenistan. However, now it is now
delivered with the reassurance that, “if there were HIV positive
individuals in Turkmenistan, then they would, of course,
receive treatment according to international standards.”25
A study released in 2008 of blood services in four Central Asian
health systems reported serious problems in the testing anduse of blood products,26 adding that the greatest increases arefound among injecting drug users, a problem that Turkmenistan shares.27 Unlike these countries, however, Turkmenistan
has not reported any new HIV infections in the last three years
and has not performed sentinel surveillance.

By the end of 2006, Turkmen authorities had reported
a cumulative total of just two HIV cases, one of whichdeveloped AIDS and died. Almost no other national data
are available… Unofficial reports indicate a substantial
and unaddressed epidemic in progress.28
22
Patients who have severe or progressive clinical illness should be treatedwith oseltamivir. Treatment should be initiated as soon as possible. See WHO,
Clinical management of human infection with pandemic (H1N1) 2009: revised
guidance, page 6, November 2009.
23
Warden Message US Embassy Ashgabat, Turkmenistan November 3, 2009http://turkmenistan.usembassy.gov/warden_information.html
24
http://www.globalhealthfacts.org/country.jsp?i=110&c=216&cat=4&sn=1
25
Meeting with Mr. Serderov, Minister of Health, May 2009.
26
Blood Services in Central Asian Health Systems: A Clear and Present
Danger of Spreading HIV/AIDS and other Infectious Diseases. Global HIV/AIDS Program, World Bank. May 2008. http://siteresources.worldbank.org/
INTECAREGTOPHEANUT/Resources/cabloodbankstudy.pdf
27World Health Organization, Regional Office for Europe. Turkmenistan– HIV/AIDS Country Profile. http://www.euro.who.int/aids/ctryinfo/
overview/20060118_47.
28
WHO Country information, updated 19 June 2008. http://euro.who.int/aids/
ctryinfo/overview/20060118_47

The impossibility of Turkmenistan having had only two casesof HIV/AIDS, as per their official reports, is widely recognised. Surprisingly, however, this has received relatively little
attention from the international community, and the government’s neglect of the issue is rarely directly addressed. For
every comment on the WHO website such as the above, there
is a bland and reassuring statement from UNICEF such as thefollowing:

Although Turkmenistan is a country with a low level of HIV/AIDS (one case of HIV reported in 2004), the government
recognizes that it must remain vigilant if it is to protect
the country from becoming yet another casualty of thisillness.29
As in the case of H1N1, government efforts to prevent the
spread of HIV are insignificant. For example, in 2005 thegovernment adopted a national programme on HIV, howeverin Magdanly, MSF observed that HIV testing was extremely
difficult to procure. Rapid tests were not available in thehospital laboratory, and although MSF was told that the tests
were being carried out at a laboratory one hour away, teams
rarely saw transport of test samples or records of results being
returned. In addition, although HIV prevention of mother-tochild transmission (PMTCT) training was provided in 2008 and2009, and despite WHO reports that it had been rolled out
throughout the country, resources have not been allocated tohospitals for its implementation. It was only in March 2009that anti-retrovirals (ARV), essential agents in preventing
mother to child transmission and in treating HIV, were added
to the country’s essential drug list. Tellingly, these agentswere not explicitly referred to as treatment indicated for HIV
infection but rather as ‘immunomodulators’.

Management of Blood Products
Most dangerous, however, not only for the spread of HIV but
also for other diseases, is the management of blood products.
National health directives explicitly state that all blood is tobe checked for Hepatitis A, Hepatitis B, Syphilis, Brucellosisand HIV. In practice, however, blood is often taken from relatives directly, without being tested. Although officially identified blood donors are to be tested every three months forpossible infections, MSF observed that this was not systematically done and suspected that results were being falsified or
not recorded. The more vigorous that MSF became in recommending alternative treatments, or at least practicing safe
transfusions, the more frequent were the attempts to hidethem from the organisation’s staff.

29
UNICEF. Turkmenistan – HIV/AIDS country profile. http://www.unicef.org/
turkmenistan/hiv_aids.html

11

A boy came for a consultation because he has been sickfor months, initially with jaundice and all the time tired.
There is no diagnosis known to the parents. He got 9 bloodtransfusions – including one from a “successfully treatedchild”. Upon examination the boy has still jaundice andincreased lab tests for liver functioning showed liver
impairment suggesting suspect Hepatitis. No testing for
Hepatitis was done. November 2008
Even hospital staff members among the donors asked that
their positive status for such infections be hidden.

One doctor is found positive for Hepatitis B and C. He isa known blood donor. The doctor was telling us that they
do not always follow the official transfusion procedure.
That means his blood was not always tested before giving
to a patient. Also concerning is the way of these transfusions: They take with one syringe blood from a donor andtransfer it immediately to the recipient. That procedure isrepeated by using the same syringe for this recipient all
the time. Later we found that this doctor... has no recordof any donor testing at all. March 2006
Throughout its intervention MSF struggled with the issue oftransfusions and the lack of testing for HIV of blood products.
Training was provided and concerns were raised at all levelsin the hospital and in the local Ministry of Health. When thisfailed to make change, the issue was raised at higher levels.
Concerned that its continued involvement would encourage
the belief that blood products were being safely and responsibly managed, MSF finally withdrew its support entirely fromthis process on the grounds of medical ethics.

cites a much higher prevalence of 115 cases per 100,000 people
per year.31
Moreover, the government’s reported cure rate of 84.8 percent for smear positive new cases clashes with their own
reported resistance rates in their recent reapplication to the
Global Fund, Round 9, quoting 20.9 per cent of new smear
positive cases and 33.9 per cent of previously treated cases as
MDR. These figures for drug resistance contrast with what is
officially recorded in the WHO TB Surveillance reports.32 Thesesurveillance reports refer to the drug resistance survey done
by MSF in 2002 which report levels of 3.8 per cent and 18.4
per cent respectively for new and previously treated cases. The
more recent figures submitted to the Global Fund indicate an
extremely high level of drug resistance and demonstrate how
severely the situation has deteriorated in a short period oftime. These results demand urgent response.
MSF currently supports a TB programme in Uzbekistan on theborder with Turkmenistan where approximately 40 per cent of
new sputum positive TB cases are diagnosed as MDR/XDR casesand only 30 per cent are fully susceptible patients.33 At the
moment in Turkmenistan there is no national protocol for thetreatment of MDR-TB and what MSF has witnessed in practice
are ad hoc attempts to prescribe any second-line medications
that are available. Patients who fail treatment are diagnosedas ‘chronic’, and it remains unclear what, if any, services areavailable to them and how infection control is managed. MSF
expects rates of infection in Turkmenistan to be similar to or
worse than those in Uzbekistan.

Indeed, in recent years Turkmenistan has been credited with‘substantial progress’ in TB treatment and has been praised for
publishing some health data including the incidence of TB.30
However, information is still contradictory. Both, Turkmenistan
and the WHO, report consistently declining prevalence rates,
decreasing each year to 75 cases per 100.000 people in 2007,
the last year for which data is available. However in theirapplication to the Global Fund in 2009, the Turkmen MoHMI

TB and MDR-TB is arguably the most urgent public health issue
in Turkmenistan, but the government has been consistently
unwilling or unable to take real steps towards addressing
them. The most recent application to the Global Fund proposes
to enrol the first patient only in year three of the programme,
which means that patients would not start receiving treatment
until 2012 at the earliest. Moreover the contrast between
the amount of money allocated to construction projects in
Ashgabat alone and the lack of national funding committed
to TB treatment gives an indication of how low the issue ranks
on the national agenda. This is evidenced by the fact that,
despite having already been rejected twice for funding by the
Global Fund, the government of Turkmenistan continues toapply for external funding rather than changing the prioritization of its own resources. At the same time, the president
announced in January that in 2010, all together, $23.6 billionof Turkmenistan’s state budget of a reported $75 billion will be
used to fund hundreds of buildings all over the country in thenext two years.34

Rechel and McKee, “The Effects of Dictatorship on Health”, BMC medicine
2007, p. 9. http://www.biomedcentral.com/1741-7015/5/21

It has been assumed that one of the reasons for the failure of Turkmenistan
to receive Global Fund support, unlike other countries in the region, is the lackof transparency in its reporting.
32
WHO, Multidrug and extensively drug-resistant TB (M/XDR-TB), 2010 Global
Report on Surveillance and response.
33
MSF Mycobacteriology Laboratory Nukus, Karkalpakstan, Uzbekistan 2008
34
Turkmenistan News Brief, Issue 3 2010, http://www.eurasianet.org/resource/
turkmenistan/newsarchive/

Tuberculosis
Unlike other diseases, the government of Turkmenistan not
only recognises the presence of TB in the country but also has
substantial programmes and plans for addressing the problem.
This has included ambitious applications to the Global Fundfor funding TB programmes in the country.

31

30

12

VI Conclusion
Over a decade of working in the country, MSF experienced the
Turkmen health care system as critically flawed by a lack oftransparency from the point of delivery to the reporting ofdata. While hospitals, health houses and health posts arewide spread, MSF observed that access to them is restricted bystigma and the fear of the consequences of illness. Increasingly, international protocols and standards are formally
introduced to the country, but in MSF’s experience these arerarely implemented. This has a significant impact on qualityof care.
Indeed, practices witnessed by MSF in the country are likely
to be creating more health problems than they address.
The failure to effectively address or even acknowledge theexistence of communicable diseases such as TB (including
MDR-TB), HIV and sexually transmitted infections is most likely
compounding and expanding existing problems. Furthermore,
the failure to collect and disseminate epidemiological information in a transparent way means that the government andthe international community have no accurate picture of thehealth situation of the population of Turkmenistan. Given
the prevalence of drug-resistant TB in neighbouring countries, MSF fears a looming TB crisis in Turkmenistan. Without
an immediate and significant intervention, this will lead to amajor medical and health crisis in the country and could havebroader regional implications.

Key Recommendations
Among the myriad problems encountered by MSF during its
work in the country, the following issues need most urgently
to be addressed:•

Rapid diagnosis and treatment of drug-resistant TBshould be implemented immediately, with international
experts as direct implementation partners.

•

The failure to test blood products for Hepatitis A, Hepatitis
B, Syphilis, Brucellosis and HIV must be urgently investigated, and national directives implemented without
delay.

•

International organisations must stop reporting data thatis contradictory as fact and should take the responsibilityof actively promoting transparency in the health system.

The change of regime since Berdimuhamedov came to power
has not resulted in improvements to the health care situation in Turkmenistan, and despite the appearance of greater
openness, real change has failed to occur. Rather, a closer
engagement with the international community is serving only
to mask the continuation of old practices, the entrenchmentof corruption in the system and the manipulation of data.
The role of the international community in situations like thisis to insist on transparency and to push for implementationof international standards. This is not happening. Instead, by
remaining silent in the face of government misinformation,international organisations are allowing themselves to becomecomplicit in the problems.

13Impressum
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