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

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.

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