Since April 2006, I have traveled 3 times to the Central Asian Republic of Tajikistan to work with migrants on the risk of HIV/AIDS. According to the United States Agency for International Development, Central Asia has the fastest growth rate of HIV/ AIDS in the world. The International Center on Catastrophes at the University of Illinois at Chicago is collaborating with Dr Mahbat Bahromov of the Ministry of Health and Dr Azam Mizroev of the Tajik Republic AIDS Center.
During these visits, I spoke with male migrants and their wives and asked them about work, families, their concerns regarding HIV/AIDS, and how they saw their lives. I also met with sex workers, health workers, nongovernmental organization (NGO) staff, and public health officials. Tajikistan received money from the Global Fund to fight AIDS, tuberculosis, and malaria (www.theglobalfund.org)and set up "Trust Points" for sex workers, drug abusers, and migrants where they could receive HIV testing and counseling on risk reduction. There was a sense of pride that something was being done to slow the epidemic.
When the health professionals learned I was a psychiatrist, the response was invariably, "Psychiatry in Tajikistan is not a prestigious field." In 1 week, more than a dozen persons repeated this sentence.
I already knew that psychiatry in Tajikistan was in trouble, ever since the former head of psychiatry, Dr Minkhosh Gulyamov, was murdered in 1997 during the civil war. Last year, someone mentioned the name of a psychiatrist at an NGO who works with injection drug abusers. This made me wonder: In a country of so few psychiatrists, why was he not practicing psychiatry?
The reason is that psychiatry in Tajikistan is in collapse. Besides the decline of psychiatry, Tajikistan also faces enormous economic, social, and political problems, including extreme poverty, drug trafficking, the legacy of war and risk of terrorism, and the collapse of the Soviet-sponsored infrastructure. Tajikistan is dependent on other countries and governmental and nongovernmental organizations for support and development. To date, few to none have made psychiatry a priority; as a consequence, psychiatrists in Tajikistan simply fight for survival.
Today, the leading figure in psychiatry in Tajikistan is Dr Nigina Sharapova, who is the daughter of Dr Gulyamov. On my first visit we met in her office at the Ministry of Health. She told me that during the Soviet reign, many of the psychiatrists in Tajikistan were Russian, and any psychiatrist with contacts abroad left long ago. Because psychiatrists cannot make enough money through their practice, some sell goods in the bazaar or go to Moscow and work in construction.
Presently, there are about 40 psychiatrists in Tajikistan. Some regions have just a few, and some have none. There are 2 large psychiatric hospitals for inpatients, but there are no pediatric psychiatrists and there is no emergency psychiatry. "For other specialties there is a dissertation committee. Not for psychiatry," said one psychiatrist. In the medical school, no psychiatrist can advance to the level of professor, and there is no functioning organization to advocate for the profession.
I learned that psychiatrists in Tajikistan are paid $10 a month. Unlike other medical specialties, psychiatrists' patients are mostly poor; they cannot afford to pay under the table for services. One psychiatrist said, "Poor and disabled people can't give money to their doctors."
I met 2 other psychiatrists who were not working in psychiatry per se but instead had an NGO that was internationally funded to work with drug users. One was the psychiatrist mentioned previously. The psychiatrists told me they had tried many different initiatives over the years, but none received enough financial support to last.
I spent time with a young psychiatrist who recently completed her residency. She loves psychiatry but could not get an acceptable position, so she worked at the AIDS center. We did some interviews together and she asked very good questions and knew how to listen. She would be a good psychiatrist.
I visited an outpatient center for "neurotics." Off a pleasant garden courtyard, there was a compound with a few small rooms. Several young male patients lay on beds waiting for their sessions—either psychotherapy or acupuncture. The staff complained that the physiotherapy machines no longer worked. Four patients were scheduled that day, but often there were no patients. The head psychiatrist said, "Patients don't come to us so often. We serve them, but when we prescribe medicine they cannot buy it because they don't have money for that." On his desk was a Russian translation of a Kaplan and Sadock book. He likes this book and wants others. These psychiatrists realize that their knowledge is not up-to-date. They know that the system in which they were trained is not in step with Western psychiatry. I asked why there are so few patients. The head psychiatrist replied, "The Islamic world doesn't so much like psychiatry."
Dr Sharapova said, "I don't know how to solve these problems." I asked her some basic questions: What is the estimated number of persons with mental illness? What is the number of mental health contacts? What is the mental health budget? Dr Sharapova told me that there were about 40,000 registered mentally ill persons and 1580 psychiatric beds in Tajikistan. She did not know the mental health budget because it is administered by local governments that do not report to the Ministry of Health. Because psychiatrists do not have basic information about the population and the system, they are in a weak position for improving psychiatry.
Too late for change?
Walking out of her office brought back memories of nearly 10 years ago when I was contacted by an international governmental agency that was involved in peace negotiations in Tajikistan. They asked what could be done about mental health for the demobilized soldiers after the civil war. Something could be done, but it had to be based on an assessment of the state of psychiatry in Tajikistan. We offered to work with them on reforming psychiatry in Tajikistan. Unfortunately, we never got to go. I asked myself if the picture would be any different had we gotten involved back then. I believe it would because the central issue we would have worked on, as we have done successfully in Kosovo, Croatia, and Bosnia-Herzegovina, was developing psychiatric leadership.
For there to be hope, psychiatric leaders must be able to learn to advocate for patients and for the provision of adequate treatments. Psychiatry in Tajikistan lost its leader, and no one else has had the support, structures, or will to rise up and fight for psychiatry. Without strong leadership in a poor country in transition, psychiatry will fail.
To make matters worse, psychiatry in Tajikistan has received little to no international support. Some NGOs conducted trauma trainings, and some helped to write mental health laws. There is a limit, however, to what mental health trainings and laws can accomplish when the system is incomplete, inadequately supported, and has weak leadership.
In a society practically without psychiatry, what happens to the seriously mentally ill? Some may live alone, some are cared for by their families, some are tied up in back rooms, and some are in prison. I was not actively looking for that suffering but found evidence of it. Persons with severe mental illness live on the street. Sex workers said that their sexual initiation was rape by soldiers during the civil war. "This happened to most of us," they said. Ex-soldiers spoke of combat trauma and expressed symptoms of posttraumatic stress disorder. Young men and women were made refugees by the war and had their education completely disrupted. Wives and husbands saw each other once a year, if they were lucky, because of the economic collapse that forced them into migrant work. There are tremendous problems with alcohol and drug abuse. Too many people take few or no precautions against contracting HIV/AIDS.
Neither Tajikistan nor international authorities appear to act as if they believe that the collapse of psychiatry bears any relationship to the social instability of Tajikistan. Psychiatric services are still organized in accordance with "old Soviet medicine," without orientation to families, communities, or public health. It is hard to imagine Tajikistan getting a handle on rampant drug and alcohol use, the HIV/AIDS epidemic, or even the war on terrorism without having a functional psychiatry system to address individual and social mental health issues. Tajikistan needs psychiatry to help address the suffering and behavioral problems of individuals and families and to help promote social stability, not by mixing psychiatry with politics as was done in Soviet times, but through community psychiatry that aims to help individuals with men- tal health issues and their families and communities through psychosocial interventions.
What is needed?
How can Tajikistan accomplish this? The most promising path to a position of hope is for psychiatrists in the country to establish long-term collaborative partnerships with psychiatric institutions and with leaders from countries with well-established, humane psychiatric practices and institutions.
Perhaps the model for successful collaborations can be found in the field of HIV/AIDS. I applaud the efforts under way in Tajikistan regarding HIV/ AIDS prevention. There is legitimate hope that Tajikistan can slow the coming epidemic. When outsiders bring resources and expertise, the government and local professionals are open to cooperation. It may never be possible to mount the type of response to psychiatric problems that there is to HIV/ AIDS in Tajikistan. There will likely never be that kind of money made available. But that does not mean that there cannot be some initiative. At present, the country in the best position to jump start this process is the United States.
What the United States can do
Since September 11, 2001, the US government has increased its activities in Tajikistan. The United States is concerned about Tajikistan as a potential failed state that may be a haven for terrorism and drug trafficking. Therefore, the United States has built the largest embassy in Central Asia in Tajikistan to help stabilize it and to use as a base for extending US influence in the region. The United States is providing funding to reform primary care services, maternal and child health, and HIV infection and tuberculosis prevention. The United States also supports conflict prevention activities that are intended to curb extremism in vulnerable areas.
These activities are all beneficial, but it seems that the United States, like other countries, forgot about psychiatry in Tajikistan. Without a functioning psychiatric system, it is hard to imagine the United States accomplishing its goals of promoting social stability in Tajikistan.
The United States is one of the countries that is in the best position to rescue psychiatry in Tajikistan. With modest costs, the United States could support partnership with US-based psychiatrists and psychiatric organizations and make strategic capital investments. The aim would be to boost psychiatric services and to develop the local leadership that would keep psychiatry afloat in the future. By rescuing a collapsed psychiatry system, the United States will be furthering its own ambitions and most important, it will restore hope for the people of Tajikistan.