BMJ No 7120 Volume 315
Education and debate Saturday 29 November 1997
Tajikistan: no pay, no care
Hans Veeken"If I tell you all the problems, you will get scared and run away." The chief psychiatrist of the government can still joke, although the situation in Tajikistan gives no reason to do so. "But, if you insist: we lack specialists. They just ran away when we became independent in 1992 after the breakdown of the Soviet empire. Some of them studied in Russia; most were Russian anyway. Well, given the salaries in our country, a mere 2800 Tajik roubles a month [$3] for a psychiatrist, you cannot blame them. In psychiatry you cannot earn extra money - you will find little corruption; who can make a psychotic pay? Then, there is no transport in the country; we have no drugs. There is a lack of training and we have no contact with other countries. Since the civil war started, everything has gone downhill. Dr Gulmayov, the grand old man of Tajik psychiatry, was killed last year. Who can replace him?" The chief psychiatrist is aware of the problems, eager to get training, and realistic in his expectations. "Give us time," he tells me.
| Summary points |
| Tajikistan's psychiatric services lack specialist staff: many left when the country became independent after the breakdown of the Soviet Union. Since then the civil war has disrupted society and health services have no drugs, equipment, or transport |
| The therapies used seem odd to Western eyes and are based on outdated Russian textbooks |
| Though clean, psychiatric hospitals are run down, with few supplies, and without heating in winter |
| Since the start of the civil war some psychiatric hospitals have seen half their patients die each year during their admission |
Electrosleep therapy
It is best not to hurry in Tajikistan. Our planned trip the next day is cancelled because of security problems. At night we hear tanks rolling in the streets. The government is after Mahmout, a temporary dissident, an army colonel of 34 years, who attacked Dushanbe the day before my arrival. We reschedule and visit a day care centre for people with mental disorders.
The place is old, and the doctor guides us carefully along the corridor, as if through a minefield: there are gaping holes hidden under the carpets. But it is spotlessly clean and friendly. A few patients are lying in bed. "I just gave them haloperidol," he says and walks on. I notice that the ampoules they have been given expired in 1995. "The family will come to collect them at the end of the day," he says. It remains a mystery whether the patients come every day. We pass some equipment that resembles an old radio. "What is this?" I ask curiously. "Electrophoresis" is the answer. He explains to me about anodes and cathodes, currents that flow between the two, drugs that are sucked into the skin right on the spot where the problem is, and finally about how it relaxes patients. "Shall I demonstrate it?" he asks and grabs my arm. I decline politely.
Behind a screen I notice another instrument. "And this?" I ask. He pushes the screen aside and to my surprise there is a man wired to it, fast asleep. The wire is connected to spectacles that cover half his face. "This is electrosleep therapy," he says casually. I feel the ground moving (which later turns out to be related to the floor). "How does it work?" I ask, visibly surprised. "Two electrodes are positioned on the mastoid and the eyes, a minimal current between the two will stimulate sleep. Within five minutes he is fast asleep. A session lasts half an hour depending on the individual patient. We use it for neurosis, hypertension, all sorts of complaints. The patients feel relaxed afterwards. Usually around ten treatments are enough." To convince me he pulls a book from the shelf: Electrosleep, published in Russia, 1959. "Did you try it yourself?" I ask. "No, no, luckily it is not necessary," and we walk on.
Tajikistan is a mountainous country in central Asia, with 6 million inhabitants. Its healthcare system depends on foreign aid. The country has been crippled by a continuing civil war and by the collapse of the Soviet Union, which used to supply essential goods. Its healthcare problems are a rigid system, poor centralised planning, a focus on quantitative indicators (number of doctors, number of beds), specialist rather than primary care, and total funding by the state. Reforms are planned but are slow to get off the ground.
The children's home
The children's home is equally old and spotless. "Most
children suffer from oligophrenia, perinatal syndromes, spasticity, but
we have also abandoned children," the director explains. The term
oligophrenia, I find out, is loosely used to describe any sort of
learning disability. The home is well furnished. "How do you get all
the materials?" I ask. "Begging, Sir" is the answer: "I write
to embassies, invite them and they donate a t By car we travel to a large psychiatric institution; some military
checkpoints have to be passed. It seems that Mahmout, the commander who
rebelled against the government, has surrendered. Temporarily peace has
been restored, at least in town. The rest of the country is not yet
safe.
The psychiatric institute used to have 700 beds. The buildings are
spread out over a spacious compound. The director has no problem
identifying what the needs are. "There is no food for the patients;
the heating doesn't work. But that is only a problem during three
months. The laundry is worse: we have no washing machines. We ran out
of drugs, the personnel ran away. And," he hesitates, "the patients
die: last year 176 deaths." I can hardly believe the figures and
insist on seeing the registration book. The book is handed over. I have
difficulty calculating the death rate as the number of admissions is
unclear. It seems they have an average of 300 patients, each admitted
for about six months. In any case it is a humanitarian emergency.
"How does this compare to before the war?" I ask. He laughs,
"Before the war we had no deaths in this institution, death was a
rarity which we took with great grievance. But what can we do?"
We walk around and pass a ward for patients who have been admitted
after being convicted for crimes. We are not allowed to go in. I'm
told that some criminals try to get admitted on purpose to escape
prison. The buildings are all decrepit, windows have no glass, toilets
have no tiles, mattresses are old or absent completely. Yet the place
is still rather clean. The summer sunshine hides a lot, and the
patients quietly linger in the court yard. The quietness may be the
effect of the haloperidol. What will it be like in winter? Everybody
inside, few blankets, no shoes, no heating.
We find a taxi to take us to Isfara, a town far out in the north east
of the country. The driver is not enthusiastic. "Why do you want to
go there? It is only for mad people," he warns us. On one side we see
Uzbekistan, a desert-like area, yet on the other side is a dram-
atic backdrop of the snow capped mountains in Kyrgyzstan. The
director tells us the same story. "Last year half of the patients
died; if aid is further delayed we had better close the place. This has
been going on for four years. I can predict that half the patients who
are admitted now will die this winter." I hardly dare to ask: "What
is the total budget that is available for the place?" He sighs at my
ignorance. "There is no budget." He mentions his salary as an
example and asks what a doctor earns in Holland. I make up a figure,
too embarrassed to tell the truth.
It is doubtful whether the place can be renovated at all. Is it worth
the effort? Isn't it wiser to find another building in a better
location? These questions run through my mind. But aid has to be
organised and quickly, before this winter. If not, half of the patients
will die.
It is difficult to take decisions based on a visit of a week. The main
problems are, however, clear and need rapid action. It will take
decades for psychiatric care to catch up with Western standards. In the
short term the number of beds will need to be reduced, and the
diagnostic system, as well as treatment, needs updating. The training
curriculum in psychiatry will need to be revised. Outside contacts at a
high ministerial level are necessary to support the reform. Luckily
several places show that the positive attitude of the health
professionals will make cooperation possible.
Médecins Sans Frontières,
email: hans_veeken@amsterdam.msj
Half of the patients die in winter
PO Box 10014,
1001 EA Amsterdam,
Netherlands
Hans
Veeken, public health
consultant
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