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Human rights and health
in Turkmenistan
Bernd Rechel and
Martin McKee
European Centre on Health of Societies in Transition
London School of Hygiene & Tropical Medicine
Human rights and
health in
Turkmenistan
Bernd Rechel and
Martin McKee
European Centre on Health of Societies in Transition
London School of Hygiene & Tropical Medicine
April 2005
Acknowledgements
This study was funded by the Open Society Institute (OSI), New York, although the
findings and conclusions presented here are entirely those of the authors. Bernd
Rechel’s grant was managed within the framework of the United Kingdom
Department for International Development’s Health System Development
Knowledge Programme, which also supports Martin McKee’s work in countries in
transition.
We would like to thank Roxana Bonnell, Erika Dailey, Sue Simon and Danielle
Tuller from OSI for their constant support in implementing this project.
The authors would like to express their gratitude to Yuri Loshmanov for his help in
sourcing relevant documents and translating Russian language sources into
English; to Jesus Maria Garcia Calleja, WHO, and Batyr Berdyklychev, WHO
Regional Office for Europe, for providing helpful information and commenting on
an earlier draft of this report; to Timothy Heleniak, UNICEF Innocenti Research
Centre, for information on the TransMonnee database; to Nicola Lord for
administrative support; to Francine Raveney for managing the publication
process; and to Sarah Moncrieff for design and production.
The authors are especially grateful to all those individuals with first hand
experience of the situation in Turkmenistan who have been willing to share their
experience with us, including those who have felt necessary to remain
anonymous.
Front cover:
“Halk, Watan, Türkmenbasy”
People, Nation, Turkmenbashi
Photo:
Galen Frysinger
Contents
Executive summary 1
1 Introduction 3
2 Human rights 5
Dictatorship 6
State nation-building and personality cult 7
Idiosyncrasies of the Niyazov regime 7
Isolation and total censorship 8
Suppression of civil society 9
Religious intolerance 9
Suppression of minorities 0
Imprisonment, torture and politically motivated beatings 11
Demolition of private homes 12
3 Economic and social situation 13
The economy 13
Agriculture 17
Child labour 18
Education 18
Primary and secondary education 18
Higher education 19
4 Health and health care 21
Health care system 21
Health “reform” 22
Life expectancy 26
Child health 28
Infant and under-five mortality 29
Immunisation 31
Nutrition 34
Women’s health 34
Domestic violence 35
Sex work 35
Reproductive health 35
Maternal mortality 37
Mental health 38
Human rights and health in Turkmenistan
Drug use 38
Tobacco 40
Alcohol 41
Communicable diseases 41
Ban on diagnosing infectious diseases 41
Plague outbreak in 2004 42
HIV/AIDS 43
Tuberculosis 44
Sexually transmitted diseases 44
Hepatitis 45
Malaria 45
Environment 45
Public health 47
Iodine deficiency 48
5 The reaction from the international community 49
6 Recommendations 53
To the government of Turkmenistan 53
To the United Nations 54
To the European Union 54
To the government of the United Kingdom 55
To the government of the Russian Federation 55
To the government of the United States 55
To all international actors and donors 56
Appendices 57
Map of Turkmenistan 57
Abbreviations 57
Useful websites 59
Bibliography 60
1
Turkmenistan, located in Central Asia and comprising a population of about five
million people, is one of the most repressive countries in the world, standing out
among the post-Soviet states for its violations of human rights. While all of the
post-Soviet countries of Central Asia have become more authoritarian in the last
15 years, Turkmenistan is the most extreme case. The country’s President
Saparmurat Niyazov has established a ruthless dictatorship that recalls many of
the excesses of the Stalinist era. While the regime’s violations of human rights
have been noted by international organisations and condemned by the United
Nations (UN), the Organisation for Security and Cooperation in Europe (OSCE)
and the European Parliament, little has been documented about the impact of the
dictatorship on the health of the country’s population, although there are many
signs that the country faces a serious health crisis.
Lack of human rights has direct and indirect effects on health. Some human rights
violations have obvious health implications, such as the imprisonment, torture and
beatings of perceived opponents of the regime, the suppression or deportation of
religious and ethnic minorities, the incarceration of part of the population in
unsanitary and overcrowded penal colonies, or the demolition of private homes
to make way for grandiose presidential projects. The impoverishment of the
population, while the leadership is amassing great private fortunes, is a feature
typical of dictatorships that also has consequences for health, affecting access to
the essentials for life, such as nutrition, and to basic health services.
Impoverishment and despair also lead to increasing sex work, domestic violence
and drug use. The suppression of civil society, the growing isolation of the
country and the general climate of fear, repression and corruption contribute to
deteriorating population health.
Another result of an absence of democracy and protection of human rights is the
recent demolition of the health care system. Although the Soviet health system had
a number of inherent flaws, it provided comprehensive medical care free at the
point of delivery. Since the independence of Turkmenistan in 1991, the health
care system continued to be almost entirely financed and managed by the state.
Funding for health care, however, has been declining and in March 2004,
15 000 health workers were reportedly dismissed and replaced by untrained
military conscripts. In February 2005, President Niyazov ordered the closure of
all hospitals outside the capital Ashgabat, undermining access to health care
services even further.
Executive summary
2
Human rights and health in Turkmenistan
Although the actual scale of the current health crisis is not being reported by the
government to WHO, estimated life expectancy in Turkmenistan, at 62.7 years at
birth in 2002, is the lowest in any country in Europe and Central Asia and more
than 16 years lower than the average of the 15 countries constituting the
European Union before May 2004. Infant mortality is thought to be very high,
estimated at 76 per 1000 live births in 2002, while immunisation coverage
declined in 2003.
An outbreak of plague was reported in the summer of 2004, although this was
denied by the government, which has banned the official diagnosis of certain
communicable diseases, raising the prospect of major outbreaks going unreport-
ed, with grave consequences for the population of Turkmenistan and potential
international ramifications. The government denies that there is any problem with
HIV/AIDS in the country and does not publish credible data about the incidence
of HIV/AIDS in Turkmenistan. Drug use, in particular heroin, has become very
common, with some observers suggesting that the government is either complicit
in the trafficking of drugs or is turning a blind eye to the drugs crisis. In the wake
of this increased drug use, sex work and suicides are reported to have risen
markedly.
As in the Soviet period, psychiatry is being abused for political purposes, with
perceived opponents of the regime being confined to psychiatric institutions. In
another return to Soviet-era policies, the government of Turkmenistan has failed to
address a series of major environmental problems. While a large part of the
population does not have access to safe drinking water, scarce resources are
being wasted in the construction of artificial lakes and rivers, which are likely to
compound existing problems of desertification and salinisation.
The international community has so far been unable to respond adequately to the
health crisis in Turkmenistan. While UN organisations, including UNICEF, UNDP,
UNFPA and WHO, have maintained their country presence, with some apparent
successes in the areas of reproductive health, immunisation and salt iodisation,
their actions have been limited by the Turkmen Government, which has been
resistant to foreign involvement in areas perceived to be sensitive. More profound
interventions for improving the health of the people in Turkmenistan have yet to be
undertaken. These will require the recognition of the scale of the current health
crisis, both domestically and internationally, a sustainable allocation of state
resources to the health sector, and, ultimately, the democratisation of the country.
The rich gas and oil reserves of Turkmenistan, combined with its strategic
geographical position, however, have so far worked as impediments to interna-
tional pressure for improving the country’s human rights record.
3
Introduction
This report aims to trace the impact of the dictatorship in Turkmenistan on the
health of the country’s population and to document what is known about popula-
tion health and health care provision, covering events up to mid-February 2005.
Recent research has shown a surprisingly close association between the extent of
political freedom and several measures of population health, after adjusting for
economic factors (Franco et al. 2004), although the precise nature of the impact
of dictatorship on health is difficult to quantify, as health is influenced by a large
number of factors, including socioeconomic situation, housing, nutrition, drinking
water, lifestyle and access to health services.
The almost total censorship that exists in Turkmenistan and the failure to report
valid data to many UN organisations mean that there is only limited information
available on the situation in the country. International press coverage is therefore
based on partial information and it is sometimes impossible to verify. We have
aimed to overcome these inherent restrictions by using complementary research
methods, in order to gain information from as many sources as possible, giving
details of these sources wherever possible.
A comprehensive search of documents available on the internet was undertaken
between September and November 2004, using the search engines Google and
Google Scholar, and drawing in particular on a number of relevant websites,
which are given at the end of this report. In addition, relevant medical literature
was sourced using the search facility Pubmed/Medline and searching the libraries
at WHO Geneva and the London School of Hygiene & Tropical Medicine. We
have also consulted the databases of various UN organisations, including WHO,
World Bank, UNDP and UNICEF. The documentary analysis was complemented
by semi-structured telephone interviews and correspondence with individuals who
have first hand experience of Turkmenistan, including Turkmen nationals and
citizens from other countries. We have also been in contact with various foreign
embassies in Turkmenistan and a number of UN organisations.
Chapter 2 briefly outlines the human rights situation in Turkmenistan, flagging up
where human rights violations have clear implications for the health of the people
living in the country. Chapter 3 describes the socioeconomic situation, as it also
has direct consequences for population health. Chapter 4 documents what is
currently known about health and health care provision. Chapter 5 reports the
reaction of the international community to the crisis in health and human rights in
Turkmenistan, while Chapter 6 sets out a series of policy recommendations.
5
Dictatorship
The European Parliament noted in a resolution on 23 October 2003 that
Turkmenistan had “one of the worst totalitarian systems in the world” (European
Parliament 2003). In December 2003, the United Nations General Assembly
expressed its “grave concern” about the country’s human rights record (UN
2003a). The country has been described by Human Rights Watch as “one of the
most repressive countries in the world” (Human Rights Watch 2004).
All regimes in Central Asia became more authoritarian in the last 15 years (IWPR
2004o; Lerch 2003). However, Turkmenistan provides the worst example of post-
Soviet development. A Stalinesque President runs the country with an iron fist.
Turkmenistan is a one-party state, dominated since 1985 by Saparmurat Niyazov,
who has established a dictatorship without comparison in Central Asia and
“arguably […] the most dictatorial regime among the former Soviet republics”
(Freedom House 2004). Since 1991, when the country became independent
following the collapse of the Soviet Union, a series of fraudulent elections and
referenda have been held, with alleged participation rates of more than 99% of
the population (IHF 2004). The “Democratic Party of Turkmenistan”, which is a
reincarnation of the former Communist Party of Turkmenistan and the only party
now allowed to exist in the country, won all 50 seats of the National Assembly
(Milli Majlis
) in the parliamentary elections in December 1994 and December
1999. Niyazov, who made a seamless transition from First Secretary of the
Communist Party of Turkmenistan to lead the Democratic Party, is both Head of
State and Head of Government. He was made President for life in 1999.
Turkmenistan is a “corrupt, Orwellian police state” (Righter 2004). There are no
opposition parties or independent trade unions. The Ministry of Justice has
become the “Ministry of Adalat”, meaning “fairness and justice” (ICNL 2003).
The repressive state machinery includes the Ministry of National Security (MNS),
formerly the National Security Committee (KNB), the successor of the KGB. By
1993, the Ministry for National Security “had stifled almost all traces of domestic
opposition” (IHF 2004).
Political and civil rights have been violated continuously in the country. Amnesty
International noted that the human rights situation in Turkmenistan has been
“appalling for years” (Amnesty International 2003). The human rights situation
worsened further after 25 November 2002, following an assassination attempt on
Human rights
6
Human rights and health in Turkmenistan
President Niyazov. Shots fired at the presidential motorcade were deemed a set-
up by many observers, as they provided a pretext for a crackdown on real and
perceived opponents of the government, although there seems little doubt that an
attempted coup did indeed take place. The assassination attempt was followed by
a “purge reminiscent of the Stalinist years” (Kakbaev 2003), with many arbitrary
arrests and torture. Show trials were staged and broadcast on national TV. The
country has apparently plunged into “neo-Stalinist torpor” (Ovezberdiyev 2004).
In February 2003, the “Betrayers of the Motherland” law was adopted, charac-
terising any opposition to the government as an act of treason (US Department of
State 2004). The law permits life imprisonment of anyone “attempting to sow
doubt among people about the internal and foreign policies conducted by the first
and permanent President of Turkmenistan, the Great Saparmurat” (IHF 2004). In
August 2003, constitutional amendments were adopted making the People’s
Council (
Halk Maslakhaty
, previously the supreme representative body) the
highest authority in the country, abolishing the nominal division between the
legislative, executive and judicial branches of government (IHF 2004).
State nation-building and personality cult
As in other newly independent states of the former Soviet Union, the regime in
Turkmenistan has pursued an active process of state nation-building. President
Niyazov is one of the many communist leaders of the former Soviet bloc who has
effortlessly turned into a champion of nationalism. The promotion of Turkmen
nationalism, the “movement for national revival”, has become the President’s cen-
tral aim, with himself at its centre (Templeton 2004). In 1993 the National
Assembly granted him the title Turkmenbashi, or Head of the Turkmen (a term
borrowed from Kemal Ataturk, the modernising leader of Turkey after the First
World War). His actions, in part, reflect the importance placed on creating a
unified Turkmen identity that would overcome the powerful tribal enmities that had
long dominated Turkmen politics and erase the effects of decades of colonial rule,
initially by Russia and then the Soviet Union, with its policy of “ethnic integration”.
Niyazov claims that the country has now reached its “Golden Age”. Every
morning at factories and schools the citizens are required to sing the national
anthem, referring to the country as “the great creation of Turkmenbashi”
(Templeton 2004). State-sponsored opera, philharmonic, ballet and circus were
closed in 2001, as they were considered “un-Turkmen” (Human Rights Watch
2004; US Department of State 2004).
Niyazov has surrounded himself with a personality cult that has reached
“grotesque proportions” (IHF 2004). He has been described as the “most bizarre
and egotistical leader west of North Korea” (McElroy 2004) and his cult of
personality “akin to that of Soviet leader Joseph Stalin or North Korea’s Kim Jong
Il” (Terzieff 2004). Indeed, Niyazov himself has even compared the cult that
surrounds him to that of Stalin, although qualifying it: “Stalin achieved his person-
7
Human rights
ality cult through repressive measures whereas I achieved my popularity without
conflicts” (Hiro 1994). The sole purpose of the media seems to be to praise the
President; portraits of him are omnipresent, and in Ashgabat a golden statue of
“Turkmenbashi” has been erected, rotating 360 degrees every 24 hours, so that
his face always catches the sun (McElroy 2004). In 2001, the Ruhnama, “Book
of the Soul”, was published, allegedly written by Niyazov himself. The book
contains “400 pages of folksy mumbo-jumbo purportedly ‘inspired by Allah’ that
make Mao Zedong’s Little Red Book look almost lucid” (Righter 2004). The
Ruhnama has become a core element of Niyazov’s personality cult (Amnesty
International 2003). Its study has become compulsory at schools and universities
and a copy of it has to be placed in every mosque. Knowledge of the Ruhnama
is an entry requirement for university students and a certification requirement for
teachers, doctors, and other professionals (Human Rights Watch 2003). The
second volume of the Ruhnama was published in September 2004 (ICG 2004).
Idiosyncrasies of the Niyazov regime
Under President Niyazov, Turkmenistan has acquired notoriety for a series of
bizarre policies. “The Turkmen have a proverb: ‘There is a limit to wisdom; but
there is no limit to folly.’ He exemplifies its truth to them, daily” (Righter 2004). In
August 2002, the President changed the names of days of the week and months
of the year. Monday has been renamed Main Day, Tuesday Young Day,
Wednesday Favourable Day, Thursday Blessed Day, Saturday Spirituality Day,
and Sunday Rest Day (Friday is still Friday) (Kelly 2004). January is now called
“Turkmenbashi”, April “Gurbansoltan edzhe” after Niyazov’s mother, and
September “Ruhnama” (Amnesty International 2003). Some commentators have
linked these actions, as well as his identification as “Father of all Turkmens”, to his
childhood, as his father died when he was an infant and his mother and two
brothers were killed in an earthquake when he was aged eight (Hiro 1994).
Isolation and total censorship
The government completely controls the media, censors all newspapers and
access to the internet (US Department of State 2004). News of Georgia’s “Rose
Revolution” in 2004, for example, was not reported in the official media
(Templeton 2004). The OSCE Representative on Freedom of the Media, Freimut
Duve, said in April 2002 that the country lacks any freedom of expression, “a
situation unseen in the OSCE region since the establishment of this Organisation”
(OSCE 2002) in 1995. The only internet provider in 2003 was state-owned and
strictly controlled (IHF 2004). According to the Annual Worldwide Press Freedom
Index, created by Reporters Without Borders, in October 2004, Turkmenistan
ranked among the four worst violators of press freedoms, in company with North
Korea, Cuba and Burma (Reporters Without Borders 2004).
Under the authoritarian rule of the increasingly paranoid Niyazov, the country has
become more and more isolated (Pannier 2004). Restricted freedom of movement
8
Human rights and health in Turkmenistan
in the country makes Turkmen citizens foreigners in their own country as permits
are required to move between different parts of the country. The whole country
“has come to resemble a restricted zone” (Atamanov 2003b). On 1 March 2003,
the Turkmen authorities reinstated a Soviet-era policy on exit visas for travelling out
of the country, which had been abolished in January 2002 (Novruzov 2003a).
After pressure from Washington, which threatened to impose trade sanctions
under the Jackson-Vanik amendment, which can be used against countries violat-
ing their citizens’ freedom to emigrate, the exit visa regime was abolished soon
after, on 8 January 2004 (Muradov 2004b; RFE/RL 2004). However, the govern-
ment retains a “black list” of people not permitted to leave and in practice travel
restrictions persist (Human Rights Watch 2004; Templeton 2004). Foreigners who
manage to enter the country are placed under state surveillance and many
Turkmen try to leave the country illegally (Novruzov 2004c).
Turkmenistan’s almost total isolation has led to a serious lack of information about
the health situation in the country. Since 2000, the government has refused to
report any health data to WHO, setting it apart from all other countries in Europe
and Central Asia.
Health professionals and the general population have no access to information
related to health and health care in Turkmenistan or other countries, or to interna-
tional medical literature. Lack of access to health-related literature or the internet
means that the population has very limited access to information about prevention
or treatment. The almost complete dominance of the Turkmen language, in which
very few medical works are published, contributes to the isolation of the country,
although in practice many are unable to speak Turkmen and use Russian instead.
There is a shortage of training materials and medical knowledge is outdated. In
addition, many health professionals are not allowed to take part in international
conferences.
Suppression of civil society
Civil society activists have faced persecution and imprisonment and the govern-
ment massively interferes in the work of NGOs. NGOs supporting democracy and
human rights are not allowed to operate openly in Turkmenistan. The situation
worsened with the new Law on Public Associations of 21 October 2003, institut-
ing total control over the funding, activities and property of NGOs and outlawing
any NGOs that were not registered with the government (IHF 2004). The activity
of unregistered NGOs was decriminalised by amendments to the Criminal Code
on 2 November 2004, but some NGOs suspect that this change is merely intend-
ed to deflect international criticism (Dailey 2004). Activity by NGOs has not yet
returned to previous levels of activity or visibility.
The suppression of civil society has a direct impact on the health of the popula-
tion, as those NGOs that have started to work in the health sector in recent years
can no longer operate openly. HIV/AIDS prevention projects supported by UNDP,
9
Human rights
USAID and the Open Society Institute have become more limited, contributing to
apparent increases in infections. The current political climate is also conducive to
a continuation of deeply entrenched gender discrimination which has been linked
to low female life expectancy.
Religious intolerance
Turkmenistan has been described as “one of the world’s most restrictive countries
in terms of freedom of religion” (IHF 2004). Religious freedom has been severely
curtailed in 1996, when amendments to the Law on Religion required a threshold
of 500 adult Turkmen citizens for the registration of religious communities (IHF
2004). In early 1997, re-registration was made compulsory and only two groups,
the Russian Orthodox Church and Sunni Muslims, obtained registration, while all
other religions became illegal (Amnesty International 2003; Amnesty International
2004a). Members of minority faiths have been harshly persecuted, with immedi-
ate consequences for their health and well-being, suffering torture or ill-treatment
from law enforcement officials (Amnesty International 2003; Human Rights Watch
2004). The Russian Orthodox Church and the Sunni Muslim community are also
under strict state control (Amnesty International 2003). Mosques are required to
keep copies of the Ruhnama (US Department of State 2004). The former chief
mufti was reportedly sentenced to 22 years of prison for his refusal to use the
Ruhnama in religious services (Human Rights Watch 2004).
A new restrictive law “On Freedom of Conscience and Religious Organisations”
was adopted on 21 October 2003 (IHF 2004). Amnesty International and seven
other NGOs urged the US State Department in a letter of 26 May 2004 to desig-
nate Turkmenistan a “country of particular concern” under the US International
Religious Freedom Act (Amnesty International 2004a). Presumably to avoid this
designation, several religious minority congregations were registered in the first
half of 2004, in what has been described as a “pattern of mollification” (IRIN
2004c), also including pre-term releases of prisoners of conscience. In its
International Religious Freedom Report for 2004, released in September 2004,
the US State Department failed to designate the state a “country of particular
concern”, although this had been recommended earlier by the United States
Commission on Religious Freedom (IRIN 2004c).
Suppression of minorities
In August 2003, the President declared the country to be multiethnic, but claimed
that Turkmen comprised 95% of the population, whereas the most recent data indi-
cated that approximately 77% are Turkmen, with 9% Uzbeks and 7% Russian (US
Department of State 2004). During the years 1991–1995, about 43 500 people
left the country, the majority of whom were ethnic Russians (WHO 2000a).
According to official data, 326 288 persons emigrated in the period 1989–
2003, while 164 571 immigrated, resulting in a net emigration of 161 717
(UNICEF 2004d). In 2003, the number of people emigrating was 16 096,
10
Human rights and health in Turkmenistan
considerably higher than in previous years (UNICEF 2004d), consistent with the
increased level of repression in the country.
In its resolution of 23 October 2003, the European Parliament noted that in
Turkmenistan “ethnic minorities face large-scale discrimination” (European
Parliament 2003). The UN Human Rights Committee also expressed its concern
about the discrimination against ethnic Russian, Uzbek and other minorities in the
fields of education and employment (UN 2003b; UN 2004c). The suppression of
minorities has obvious implications for the health of members of minority groups,
but it also affects the majority population, for example when health professionals
lose their positions because they belong to minorities.
The Niyazov regime has adopted an aggressive policy to promote ethnic homo-
geneity. People from ethnic minorities have been treated as second class citizens.
Minority ethnic and cultural centres have been closed, instruction in other
languages sharply limited and from 2005 onwards education was planned to be
conducted in Turkmen only (Human Rights Watch 2004). Members of national
minorities are not being permitted to obtain positions within financial and military
organisations, in the judicial system, or police and security agencies (IHF 2004).
Universities have been encouraged to reject applicants with non-Turkmen
surnames (ICG 2004; Novruzov 2003b). A disproportionate number of ethnic
Russians have been dismissed from government jobs, including teachers and
medical doctors (ICG 2004; IHF 2004; Turkmenistan Project 2004).
The government has closed most remaining Russian-language schools and
reduced classes taught in Russian (US Department of State 2004). State schools
now reportedly conduct all teaching in the Turkmen language (IWPR 2004d),
and, while it was reported that in early 2004 there existed only one Russian-
language school, under the patronage of the Russian embassy (ICG 2004; IHF
2004; IWPR 2004d), in practice more Russian-language schools seem to exist. In
addition, all but one Russian-language newspapers have been banned
(Turkmenistan Project 2004) and the last Russian radio station closed in July 2004
(ICG 2004).
On 10 April 2003 Vladimir Putin and Saparmurat Niyazov signed a protocol ter-
minating the 1993 bilateral agreement on dual citizenship (RFE/RL 2004), mak-
ing way for an energy and security arrangement that granted Moscow access to
Turkmen gas (Dubnov 2003). The annulment has had worrying implications for
Turkmen opposition figures in Russia, as well as for Russian citizens living in
Turkmenistan (Dubnov 2003). On 22 April 2003, the Turkmen Government issued
a unilateral decree giving Russian-Turkmen dual citizens two months to choose
between Russian and Turkmen citizenship, prompting thousands of ethnic Russians
to leave (Ataeva 2003; IHF 2004; US Department of State 2004). The “revoca-
tion of dual citizenship represented the culmination of the discriminatory policies
of the last decade” (IHF 2004).
11
Human rights
Government policies have also been directed against ethnic Uzbeks, the country’s
largest minority. In November 2002 the President issued a decree for the forcible
resettlement of residents in Dashoguz, Lebap and Ahal velayats (regions) to an
uninhabitable desert area in the northwest of the country, affecting primarily eth-
nic Uzbeks (Human Rights Watch 2004; IWPR 2004l; US Department of State
2004). Uzbeks have also been affected by the demarcation of the border
between Turkmenistan and Uzbekistan, a frontier that was not clearly defined in
the Soviet period. Some 18 000 hectares from Uzbekistan were integrated into
the Dashoguz province of northern Turkmenistan in 2004. Many of the ethnic
Uzbeks of this area have since moved to Uzbekistan (IWPR 2004l).
Imprisonment, torture and politically motivated beatings
The impact of dictatorship on health is obvious in the imprisonment and torture of
members of the population. According to data from the Turkmen Statistical Office,
the number of prisoners declined from 67 143 in 1989 to 7611 in 1990 and was
8723 in 2002 (UNICEF 2004d). The actual number of prisoners in Turkmenistan,
however, is unknown. A report by Radio Free Europe/Radio Liberty suggested
that, in 2004, the country might have about 24 500 prisoners (IRIN 2004g). The
International Helsinki Federation estimated the number of prisoners, at 36 000, to
be even higher (IHF 2004), while an unknown number of people have been sent
to labour camps (IWPR 2004k).
Annual amnesties of prisoners have taken place since 1999, although they are
seen by international observers as “mere window dressing to disguise an other-
wise abysmal human rights record” (IRIN 2004g). The amnesties do not cover
political prisoners or prisoners of conscience, but only people convicted for minor
offences or drug abuse, making room for newly convicted prisoners (IRIN 2004g),
as prisons rapidly fill again (IHF 2004). Under the December 2001 amnesty, for
example, about 9000 of the country’s estimated 18 500 prisoners were released.
By summer 2002, the prison population was estimated to have again reached
17 000 (Human Rights Watch 2003).
International observers have not been given access to prisoners, in spite of
demands that this should happen by the UN Human Rights Committee and the
OSCE. Prisons are overcrowded, unsanitary and lack medical care, and prison-
ers with illnesses have been refused medical treatment, contributing to several
reported deaths (IHF 2004; US Department of State 2004). Food is poor and
infectious diseases such as tuberculosis are reported to be widespread (IHF 2004;
US Department of State 2004). High rates of arrest and frequent amnesties are
likely to contribute to the spread of infectious diseases, in particular tuberculosis,
among the general population (IRIN 2004b). Although concrete data on the
prevalence of infectious diseases in the prison sector are lacking, it can be
assumed on the basis of information from other parts of the former Soviet Union
that prisoners are also at an increased risk of contracting HIV/AIDS, due to the
12
Human rights and health in Turkmenistan
sharing of needles, male-to-male sex and the high prevalence of sexually transmit-
ted diseases (UNDP 2004b). The lack of harm reduction measures in
Turkmenistan, such as sterile injecting equipment and condoms, and the inadequa-
cy of diagnosis and treatment increase the risk of a spread of HIV/AIDS in the
prisons and consequently among the whole population.
Furthermore, prisoners are subject to torture, routine beatings, food deprivation
and overcrowding, again often leading to death (IRIN 2004b). In Gyzlgaya
prison, prisoners were forced to work under hazardous and unhealthy conditions
in a kaolin mine (US Department of State 2004). In the strict regime colony in
Bayram-Ali, 4200 people live in a building designed for 600. One to two people
are reported to die every day during winter and three to four in the summer (IHF
2004).
In Turkmenistan, torture has become more the rule than the exception (IHF 2004).
It is systematic (Human Rights Watch 2004) and has been extended to relatives
of real or perceived enemies (Amnesty International 2003; US Department of
State 2004). Family members and friends of those accused of the assassination
attempt in 25 November 2002 have faced detention, intimidation, threats, evic-
tion of property, as well as torture (IHF 2004). Some detainees have reportedly
been tortured by playing tapes of their relatives being beaten after they were
arrested (McElroy 2004).
There have also been politically motivated beatings and incarceration in psychi-
atric facilities to silence perceived dissidents. In February 2004, for example,
Gurbandurdy Durdykuliev was placed in a psychiatric institution after asking for
permission to hold a peaceful demonstration against the policy of President
Niyazov (Amnesty International 2004b; Eurasianet 2004d).
Demolition of private homes
The President “lavishes fortunes on razing and rebuilding Ashgabat” (Righter
2004). Ashgabat has been transformed from a desert village into what the
President claims to be a world-class capital (O'Donnell 2004b). Large numbers of
private homes are routinely bulldozed without notice or adequate compensation
(Human Rights Watch 2003; US Department of State 2004). As housing conditions
have a direct impact on health and well-being, these measures not only violate
basic human rights but also negatively affect the health of the people affected.
An entire village on the outskirts of Ashgabat was demolished in 2003 to improve
the view from the main highway out of the capital of a new showpiece mosque,
leaving hundreds of families homeless. They were given 24 hours’ notice to leave
their houses. The mosque will be the largest in the region, costing an estimated
US$ 100 million (IWPR 2004c). In February 2004, hundreds of families were
made homeless when their houses in Ashgabat were destroyed to make place for
a Disneyland-style amusement park (Biramov and Novruzov 2004).
13
The economy
The economy of Turkmenistan is based on the production of raw materials:
mainly oil, gas and cotton. Turkmenistan has one of the largest gas reserves in the
world and large reserves of oil. It is also one of the top ten cotton producers in
the world (WHO 2000a). During the Soviet period, Turkmenistan received a
substantial subsidy from Moscow, accounting for 10% of GDP in 1990 (Kaser and
Mehrotra 1996). However this did not come close to compensating for the very
low price paid for its natural gas (Hiro 1994). As it gained control over its
natural resources on independence, the country was potentially rich. However,
Turkmenistan had to rely on Russian pipelines to export its gas to Western markets
and the Russian Federation shut these pipelines in 1994. Payment defaults by gas
importers in the former Soviet Union led to a further decline in both gas exports
and GDP (Mamedkuliev et al. 2000). Official statistics suggest a recent growth in
GDP per capita although it remains far below the average for the countries of the
World Bank’s Europe and Central Asia region (Figure 1). However, as with all
Economic and social
situation
0
500
1 000
1 500
2 000
2 500
3 000
1991 1993 1995 1997 1999 2001 2003
US$
Europe & Central Asia average Turkmenistan
Figure 1 GDP per capita (constant 1995 US$)
Source: World Bank
14
Human rights and health in Turkmenistan
recent data from Turkmenistan, these figures must be treated with considerable
caution.
The country is currently reported to have amassed a huge external debt, although
it refuses to report the magnitude of this debt. As Figure 2 shows, it had been
increasing rapidly until 1998, when Turkmenistan ceased to report data.
In April 2003, the Russian Federation and Turkmenistan reached an agreement
on gas exports and security issues, making the Russian Federation its main
energy purchaser from 2006 onwards.
Dictatorship has meant that the economic potential of the country has not benefit-
ed the population. In 1998, the most recent year for which data are available,
the country was the second least equal among the Commonwealth of Independent
States (Table 1).
The presidential control over the financial system “makes the structure of the econ-
omy much more like a mafia-run enterprise than a normal functioning state” (ICG
2004). The President has spent “billions of dollars on vanity projects” (O'Donnell
2004a).
While Niyazov reportedly has control over a US$ 3 billion trust fund held by
Deutsche Bank in Frankfurt (Righter 2004), according to an estimate by the World
Bank about half of the population lives on less than the minimum wage (The World
Bank Group 2003). However, there are few data on poverty available, with most
0
500
1 000
1 500
2 000
2 500
1993 1994 1995 1996 1997 1998
US$ million
Figure 2 Total external debt: Turkmenistan
Source: World Bank
15
Economic and social situation
summary information in the public domain coming from the 1998 World Bank
Living Standards Measurement Survey (LSMS). Unfortunately, Turkmenistan has
not given the World Bank permission to distribute the raw data from that survey.
The Turkmen Government has continued the Family Budget Survey, a monthly
survey undertaken during the Soviet period, although non-response by wealthier
households has become a major problem and the data are not available to
researchers. Table 2 (overleaf) illustrates the findings of one of the few published
analyses that we have been able to locate from the 1998 LSMS, showing the
characteristics of households by expenditure quintile. In summary, this shows that,
Table 1 Gini coefficients in the Commonwealth of Independent States
(most recent data)
Gini coefficient Year
Armenia 37.9 1998
Azerbaijan 36.5 2001
Belarus 30.4 2000
Georgia 36.9 2001
Kazakhstan 31.3 2001
Kyrgyzstan 29.0 2001
Republic of Moldova 36.2 2001
Russian Federation 45.6 2000
Tajikistan 34.7 1998
Turkmenistan 40.8 1998
Ukraine 29.0 1999
Uzbekistan 26.8 2000
Note: A high Gini coefficient indicates high income inequality.
Source: World Bank
16
Human rights and health in Turkmenistan
Table 2 Household characteristics by expenditure quintile
Percentage of
population living in
rural areas
Dependent ratio of
children aged 17
or younger
Dependent ratio
of old people
aged above 60
Bottom 20% 79.5 51.0 4.5
II 66.6 46.7 6.0
III 64.7 41.4 6.1
IV 46.8 39.6 9.7
Top 20% 27.9 27.8 19.5
Average years
of education of
household head
Average age of
household head
Mean expenditure
per capita
(Manat/month)
Bottom 20% 9.6 47 63 476
II 9.9 46 107 228
III 9.9 48 151 124
IV 9.7 47 224 523
Top 20% 10.4 50 494 496
Food budget
share
Square metres
per person
Percentage of
population with
piped water
Bottom 20% 54.5 12.2 24.0
II 54.7 12.6 32.4
III 54.8 14.1 39.3
IV 51.6 15.0 60.3
Top 20% 44.4 15.5 74.2
Source: World Bank, 2000
17
Economic and social situation
at that time, there was very little difference in living standards according to edu-
cation. The share of household expenditure on food also varied relatively little,
possibly because of widespread subsidies for essentials. Households with greater
numbers of older people tended to have higher living standards. Households with
low living standards were much more likely to live in rural areas and to have
children. Only 24% of the households in the lowest quintile had access to piped
water and it is likely that access to piped water is extremely uncommon in rural
areas, similar to the situation in the rest of the former Soviet Union.
The LSMS was, however, conducted seven years ago and there is anecdotal
evidence that the economic situation has deteriorated considerably since then.
Although for a number of years the population has received free gas, water,
electricity and salt (Eurasianet 2004a; RFE/RL 2004; WHO 2000a), poverty is
reported to be growing, with direct implications for the health of the population.
Even in 1998, the World Bank reported (based on the LSMS) that 44% of the
population was living on under US$ 2 per day (World Bank 2004). Estimated
unemployment in urban areas in 2003 was 50%, amounting to 70% in rural
areas, and many persons lacked the resources to maintain an adequate diet (US
Department of State 2004). Poverty is growing partly because of the failure of the
government to pay public sector wages on time (IWPR 2004k), while the private
sector has remained limited.
Economic statistics are at present treated as state secrets and actual socioeconom-
ic data from later than 1998 are lacking or unknown (CIA 2004; Mamedkuliev
et al. 2000). Official statistics are exaggerated and hard to believe. While the
population is starving, official festivities are under way to celebrate alleged record
harvests (IWPR 2004m).
Agriculture
Given the prominent role of cotton production in the economy of Turkmenistan, it
is appropriate to consider how it is being affected by current developments. After
a grain harvest of 490 000 tons in 2002, Niyazov announced a record harvest
of 2.5 million tons for 2003 – while the true figure might have been around
480 000 tons (Novruzov 2004c). In the winter of 2003, police units were
embarking on a Stalin-like requisition of grain from the impoverished population
in rural areas (IWPR 2004m), where more than half of the population work as
farmers (The World Bank Group 2003). In July 2004 the President announced yet
another record grain harvest: the country had allegedly reaped 2.84 million tons
of wheat, setting a target of 3.1 millions for next year (IWPR 2004m). A customs
official described these figures as “pure fantasy” (IWPR 2004m).
In reality, harvests seem to be falling and the country seems to be in a serious
agricultural crisis, while entirely unrealistic targets for the harvest of grain and
cotton are set (IWPR 2004f). Farmers are forced to grow wheat or cotton and sell
it to state monopoly firms at below market prices, leaving more and more farmers
18
Human rights and health in Turkmenistan
in debt (IWPR 2004f; IWPR 2004m). Degradation of the soil through over-
exploitation could render large areas unusable (IWPR 2004m). The environmen-
tal crisis facing the country, with its consequences for health, will be discussed in
more detail in Chapter 4.
Child labour
The regime has been violating the rights of children by forcing those aged seven
and over to participate in the country’s cotton harvest from September to
November (ICG 2004; IHF 2004; Templeton 2004;
The Economist
2004). The
forced and uncompensated participation of pupils and students in the cotton
harvest of Turkmenistan, Uzbekistan and Tajikistan is “one of the worst legacies of
the Soviet era” (Eurasianet 2004c). The cotton is exported to Western countries
largely for the production of jeans. Turkmenistan has started to produce its own
jeans from the cotton it grows with the use of child labour, gaining US retailer
Wal-Mart as a bulk buyer (Reuters 2004a). On 31 January 2005, the Turkmen
parliament adopted a law banning child labour (IRIN 2005b). However, it
remains to be seen whether this law will be actually implemented in practice.
Education
The educational system has markedly deteriorated in recent years (Eurasianet
2004c; IHF 2004), with detrimental long-term consequences for children’s health.
The governmental policy in this area has been described by a former teacher as
“a conscious effort to increase the number of uneducated people” (IWPR 2004a).
In fact, the main goal of the educational system has become the brainwashing of
the country’s new generation (Templeton 2004). It is producing an “increasingly
ill-educated, ideologically indoctrinated generation” (ICG 2004). Both the
European Parliament and the UN Human Rights Committee have expressed their
concern about the restrictions on the right to education (European Parliament
2003; UN 2003b).
Primary and secondary education
There has been a significant decline in the quality of school education. In 2002,
mandatory education was reduced from 10 to 9 years (Auswärtiges Amt 2004;
Terzieff 2004). Enrolment rates are reported to be declining and drop-outs
increasing, while the quality of education is poor (UNICEF 2004a).
The curriculum has been increasingly geared towards vocational skills and politi-
cal indoctrination (Eurasianet 2004c; Human Rights Watch 2004;
The Economist
2004). Since 1997 schools have focused on qualifications “in one of 57 areas,
ranging from tailoring and hairdressing to tractor driving and carpet weaving”
(IWPR 2004a). Schools have been instructed to devote a day a week to the study
of the Ruhnama. Since September 2002, each child is required to bring to school
a personal copy of this book (US Department of State 2004). Mandatory labour
19
Economic and social situation
by children, teachers and administrators, consuming 2–3 months of every academ-
ic year, further reduces the quality of education available to school-aged children.
The official promotion of the Turkmen language has contributed to the isolation of
the country. Since independence, the country has switched from Cyrillic to the
Latin alphabet and sidelined Russian as the language of instruction (
The Economist
2004). The requirement to use the Turkmen language, combined with the limited
availability of Turkmen-language textbooks, has contributed to a declining quality
of education (US Department of State 2004).
A presidential decree in 2000 continued to reduce the number of teachers (US
Department of State 2004). During 2000 and 2001, 1100 teachers were dis-
missed (IHF 2004). According to the Turkmenistan Helsinki Foundation, as many
as 12 000 teachers were fired over the past two years (Eurasianet 2004c). Class
sizes continued to increase rapidly in recent years, facilities deteriorated and
funds for textbooks and supplies decreased (US Department of State 2004).
Wages for teachers and educational administrators, as well as being low, are
routinely paid 2–3 months late, leading teachers to look for other jobs (US
Department of State 2004). There is also a lack of up-to-date textbooks (IHF
2004). Corruption in the school system is rampant and both grades and
admission to schools are sold (IHF 2004;
The Economist
2004).
Higher education
The system of university education has been almost completely dismantled and the
number of students in higher education has dropped dramatically. The number of
students enrolled in universities has declined from 42 031 in 1989 to 14 859 in
2003 (UNICEF 2004d). Only 3900 students were reported to have entered
higher education in 2003 (Reuters 2004b). The higher education enrolment rate
declined from 10.2% of 19–24-year-olds in 1989 to 2.6% in 2002 (UNICEF
2004b).
Since 2000, universities have reduced the period of classroom instruction from
four to two years (Righter 2004;
The Economist
2004; US Department of State
2004). This limited education prevents students from achieving the education
required for higher degrees. It is also at odds with the State Health Programme of
the President, which envisaged basic studies for physicians for six years (WHO
1998). Since 2002, it has been necessary to complete two years’ work experi-
ence before entering university, something hard to achieve, as there are few jobs
and many unemployed qualified people (Auswärtiges Amt 2004; IWPR 2004a).
The possibility to gain a doctorate was abolished in 1997 (Auswärtiges Amt
2004), and since 1998, no master’s degrees or doctorates have been granted in
the country (US Department of State 2004). In the 1990s, the Academy of
Sciences, the majority of whose members were Russians (IHF 2004), was closed
(Eurasianet 2004c; Human Rights Watch 2004; US Department of State 2004).
20
Human rights and health in Turkmenistan
At all institutes of higher education, students are required to study the Ruhnama
(US Department of State 2004). All teaching in Turkmen universities is to be
conducted in the Turkmen language (Atamanov 2003a). As in schools, corruption
and bribery are common and bribes need to be paid to gain acceptance to
universities (Atamanov 2003a; ICG 2004).
Study abroad, in particular in the Russian Federation, has been discouraged, with
the exception of those selected by the state to study in countries that have a close
relationship with Turkmenistan, such as Ukraine (IWPR 2004i). On 21 February
2003, two days after Turkmen youths studying in Moscow joined a demonstration
against Niyazov’s rule, a decree was passed that prevented students from buying
foreign currency. The decree had the apparent aim of preventing foreign univer-
sities becoming centres of Turkmen dissent (Atamanov 2003a). The only students
exempted by the decree were those sent abroad by the Ministry of Education and
those who study in countries with inter-governmental agreements with
Turkmenistan (Belarus, Malaysia, Turkey and Ukraine) (Atamanov 2003a).
The decree of 21 February 2003 also stated that all higher education degrees
received after 1993 from institutions abroad were invalid and bearers of such
degrees working in the public sector, including doctors, lawyers and teachers,
were to be dismissed after 1 June 2004 (Human Rights Watch 2004; IHF 2004;
Novruzov 2004b; Righter 2004;
The Economist
2004). The decree was intended
to dissuade people from sending their children to study abroad, a practice which
has become more common since higher education was cut to two years
(Novruzov 2004b). However, it was reported in late July 2004 that the decision
has not comprehensively been put into force (ICG 2004;
The Economist
2004).
Medical education has deteriorated significantly, affected by the reduction of
years of university education and the lack of training materials. Very few medical
works are published in the Turkmen language and there is no access to informa-
tion relating to health and health care in Turkmenistan or to international medical
literature. In addition, health professionals are rarely allowed to take part in
international conferences. Medical knowledge is outdated and relies on treatment
protocols developed under the Soviet Union. There has also been an officially
promoted return to often ineffective homeopathic remedies (THF 2005).
21
Health and health care
The precise extent to which Turkmenistan’s authoritarian regime affects population
health is hard to quantify, although there are clear signs of a health crisis (
The
Lancet
2004). There are few international organisations active in the health sector
and “government health statistics are scarce and unreliable” (
The Lancet
2004).
The fictitious nature of government statistics even extends to the size of the
country’s population, the denominator on which all health statistics would be
based. According to the US State Department, the Turkmen Government estimated
in 2003 that the total population was 6.1 million (US Department of State 2004).
A more reliable estimate of the United Nations Population Division put the popula-
tion at 4.867 million in 2003 and 4.940 million in 2004 (UN 2003c; UNAIDS
2004b). Data from the Turkmen Statistical Office provide a slightly higher figure,
putting the population size at 5.089 million in 2003 (UNICEF 2004d). The last
official health data reported by the country to the WHO Regional Office for Europe
refer to 1998, which makes it difficult to evaluate the status of population health
and health care provision in the country, although the Turkmen Statistical Office has
continued to provide relevant data to the MONEE (Monitoring in Central and
Eastern Europe, the Commonwealth of Independent States and the Baltics) project
of UNICEF, so that some official data have entered the public domain.
Health care system
When it became independent in 1991, Turkmenistan inherited the Soviet health
system, which had a number of inherent flaws. In particular, it placed a strong
emphasis on hospital services, and paid little attention to disease prevention and
modern public health. In addition to these structural problems funding for health
declined in all parts of the former Soviet Union after 1991. In Turkmenistan, health
sector spending fell from 3.2% of GDP in 1991 to 0.8% in 1994, increasing to
4.6% in 1997 (Mamedkuliev et al. 2002). However, these data have to be treat-
ed with caution, as there are other estimates of the proportion of GDP spent on
health care (Mamedkuliev et al. 2000). Expressed in purchasing power parity
terms, which take account of the relative domestic purchasing power, total health
expenditure per capita in Turkmenistan declined from 177 PPP US$ in 1991 to
49 in 1994 (WHO 2004b). Following the decline in funding for health and the
disruption caused by the breakdown of the Soviet Union, health services deterio-
rated, with shortages of medicines and medical equipment. Years of underinvest-
ment in the almost entirely state-owned and managed health system have led to
deteriorating buildings and equipment (Mamedkuliev et al. 2000; Mamedkuliev
et al. 2002; WHO 2000a).
22
Human rights and health in Turkmenistan
Health “reform”
State Health Programme of the President (1995)
In July 1995, the State Health Programme of the President was set out for the peri-
od 1995–1999. The programme envisaged a shift from hospitals to prevention
and primary care, the introduction of a family physician role, and a reduction in
the number of hospitals and health professionals. Its main objectives were to:
• improve the management of health care;
• reform health financing;
• develop family medicine based primary health care;
• increase the efficiency of inpatient services; and
• increase the quality of training and retraining of personnel.
(Mamedkuliev et al. 2000; WHO 2000a).
To develop the Plan for Realisation of the Presidential Health Programme, the
Lukman Health Project was initiated in December 1995, in collaboration with the
WHO Regional Office for Europe, the United Nations Development Programme
and the Turkish International Cooperation Agency. Only in 1999, however, was
the Implementation Plan for the State Health Programme published (Mamedkuliev
et al. 2000). The plan identified the health of women and children, communica-
ble diseases and non-communicable diseases as the most important health issues
(WHO 1998). The State Health Programme has only partially been implemented
so far, reflecting a lack of commitment and informed decision-making, an absence
of political participation, inadequate funding and ad hoc decisions that are incon-
sistent with the programme (Mamedkuliev et al. 2000). A team was established
in the Ministry of Health and Medical Industry to implement the Lukman health
project, but was disbanded after the development of the master plan, due to a lack
of political commitment. A pilot project in the Tejen district, to be financed by the
World Bank, was prepared but then suspended before implementation (Savas et
al. 2002).
Nevertheless, the country has made progress towards some of the goals of the
reform programme in the second half of the 1990s. In 1996, the Ministry of
Health and Medical Industry started to reduce bed capacity and to merge
hospitals (Mamedkuliev et al. 2000). Until 1998, a considerable amount of hos-
pital capacity has been reduced, along with reduced admissions to medical and
nursing schools (WHO 1998). Between 1991 and 1997, acute care beds were
reduced by 38%, acute care hospitals by 29% and the total number of hospitals
by 10% (Vang and Hajioff 2002), although data from the WHO HFA database
on the number of hospitals and hospital beds in 1997 still showed them to be
23
Health and health care
above the average for the 15 countries constituting the European Union before
May 2004 (EU-15) (WHO 2004b). According to figures from the Turkmen
Statistical Office, the number of hospitals decreased from 332 in 1989 to 125 in
2003, with a smaller reduction in the number of hospital beds, from 39 941 in
1989 to 26 221 in 2003 (UNICEF 2004d).
In January 1996, a process intended to introduce family medicine throughout the
country was initiated (WHO 2000a). However, this activity was limited and poor-
ly organised. Rural clinics and feldsher-midwife posts were renamed as “rural
health houses”, without any change in their functions (Gedik et al. 2002).
Although some programmes to retrain specialists as family physicians were pro-
vided, most specialists were simply re-labelled as family physicians by presiden-
tial decree (Gedik et al. 2002; Healy 2002; Mamedkuliev et al. 2000). In
2000–2004, the German Agency for Technical Cooperation provided some bilat-
eral assistance for the strengthening of primary care in Dashoguz velayat. USAID
has provided training for family doctors and nurses in two retraining centres.
Alongside the introduction of family medicine, a government-run system of volun-
tary medical insurance started in January 1996, which was “greatly encouraged”
among public sector workers (Mamedkuliev et al. 2000). It contributed about 8%
of total official health expenditure in 1999 (Mamedkuliev et al. 2002). The
benefits of the voluntary medical insurance were a 90% discount on prescribed
outpatient drugs, a 25% discount on the cost of dentures, guaranteed hospitalisa-
tion within seven days of referral and free choice of family doctor (Kutzin and
Cashin 2002; Mamedkuliev et al. 2000). The health insurance scheme, however,
may have been exacerbating the financial problems in the health sector, as its fee-
for-service reimbursement of drugs has induced cost escalation (Kutzin and Cashin
2002). In addition, the fact that the non-insured did not pay for hospital treatment
created a perverse incentive to seek hospital care, which was free for the patient,
rather than ambulatory care, where the patient had to pay some of the cost of
drugs. Inevitably, this increased overall costs (Mamedkuliev et al. 2000).
Socioeconomic Reform Strategy (2000)
The government’s Socioeconomic Reform Strategy until 2010, which came into
effect on 1 January 2000, envisaged the introduction of compulsory medical
insurance in 2006 (WHO 2000a). The official foci of the strategy were mother
and child health, prevention and control of tuberculosis, sexually transmitted
diseases, viral hepatitis and HIV/AIDS. Reform plans included the continued ratio-
nalisation of hospital services and the strengthening of primary care
(Mamedkuliev et al. 2002).
However, no comprehensive reform has been undertaken and the restructuring of
the health sector has been based on ad hoc decisions of the President and the
attempt to cut governmental health financing. Since there is no budget transparen-
cy, it is impossible to verify the required level of cutbacks, or determine if any are
24
Human rights and health in Turkmenistan
necessary. Moreover, the government’s routine fabrication of official data and high
levels of corruption make the alleged budgetary belt-tightening implausible. In
addition, budgetary problems do not seem to be so much due to a lack of funds,
but rather due to the diversion of income to a presidential Foreign Exchange
Reserve Fund, from where revenue is channelled into grandiose presidential proj-
ects (ICG 2004). As will be discussed in more detail later, the government is cur-
rently denying the existence of certain communicable diseases, such as HIV/AIDS.
The frequent practice of dismissing mid- and senior-level government executives
and experts has led to an absence of qualified and experienced experts in
management positions. Key decisions are being made by non-experts who are
subservient to the President.
“Reforms” in 2004
The most far-reaching move so far to “reform” the health services was taken in
January/February 2004, when the President signed a decree envisaging the dis-
missal of 15 000 health care workers (including doctors, nurses, midwives, med-
ical attendants and orderlies) to take effect on 1 March 2004. This affected an
estimated one third of the medical workforce, who were to be replaced by unqual-
ified military conscripts, with the aim of reducing state expenditure on health care
(BBC 2004a; BBC 2004b; Reuters 2004b; Righter 2004; Templeton 2004).
The decree declared that the dismissal would encourage the “effective use of
[remaining] medical personnel and the transition to a system of private or partly
self-financing health care” (Reuters 2004b). The move forms the latest in a series
of cuts to the country’s health care system (Pannier 2004). It aimed to “cover up a
large deficit in the government budget” (Novruzov 2004b), attributed in part to
corruption (IWPR 2004b). In 2001, the number of state-employed health care
workers had already been cut by several thousands to save money (RFE/RL 2004).
In what is in effect slave labour, conscripts have already been working in the
public sector, for example as lorry drivers, bakers, train attendants and traffic
police, for no extra wages, reducing state expenditure (IWPR 2004b). Military
service lasts two years and usually starts at 17 years of age (Templeton 2004).
Increasingly, activities such as road-mending, factory work, the cotton harvest and
providing emergency services are carried out by conscript soldiers, with 100 000
young men called up each year (Reuters 2004b; Templeton 2004).
One midwife in Ashgabat asked “Will young people lacking specialist education
really be able to help deliver babies or give injections?” (Reuters 2004b). While
those dismissed were expected not to complain (BBC 2004b), a nurse noted that
“[t]hey usually fire women who have a poor sick-leave record – normally mothers
with young children who are often ill and need attention” (Muradov 2004a).
There is no systematic research into the effects on those losing their jobs, but there
have been a number of personal accounts, such as that of a nurse who reported-
25
Health and health care
ly committed suicide after being dismissed (Muradov 2004a). Elena, a former
health care worker interviewed by the Institute for War & Peace Reporting (IWPR),
is a trained doctor, but was required to work as a nurse in recent years and then
even lost this job when hospital staff were replaced with conscript
soldiers. Her son took to begging on the streets (IWPR 2004k).
The decree of January 2004 also introduced user fees for an increased range of
medical services as of 1 March 2004 (BBC 2004a). User fees had been intro-
duced incrementally since independence. In 1998, they were extended to include
self-referred patients, some diagnostic procedures and consultations, cosmetic sur-
gery, dental care and physical therapies (Healy et al. 2002; Mamedkuliev et al.
2000). Medical facilities specialising in ophthalmic, dental, skin, gastrointestinal
and cardiovascular diseases charged fees for their services from March 2004
onwards, after the ordinance on state guarantees of health protection of the
citizens of Turkmenistan, in force since 1995, was declared null and void
(Kurbanova 2004). First aid, maternity services, inpatient treatment, treatment for
children aged under 14 years, disabled people and war veterans were planned
to remain free of charge. The government also guaranteed formally free treatment
for patients with oncological, endocrinal, tuberculosis and mental diseases, as
well as for drug addiction and alcoholism. The government decree envisaged
making the voluntary health insurance scheme, introduced in 1996, compulsory
by 2006. It is estimated currently to cover two million people, or 85% of those in
formal employment (BBC 2004f; Kurbanova 2004).
While details of possible exemptions to fees are currently unclear, this can be
expected to increase inequality and impoverishment if families have to bear the
cost of illness. Any adverse effects will be exacerbated by the loss of subsidies for
basic services described earlier. The payments required for specialist care have
made diagnosis and treatment unaffordable for large numbers of patients (THF
2005).
As already mentioned, grandiose presidential projects are being pursued at the
same time. Just after deciding to lay off the 15 000 health care professionals,
Niyazov announced the construction of a new building for the Ministry of Health
and Medical Industry for the cost of US$ 12 million, allocated from the budget of
the Ministry of Health and Medical Industry. The building is to be constructed in
the shape of the snake that symbolises medicine (Turkmenistan.ru 2004).
Health services today
The dismissal of 15 000 health care workers in March 2004 fuelled fears that
already poor health services will deteriorate further. So far, it can be said that the
“reforms” in the health sector have not led to an improvement of services
(Muradov 2004a). In its resolution on Turkmenistan in October 2003, the
European Parliament expressed its concern about the deterioration of the health
system (European Parliament 2003). At a time when official finance for health still
26
Human rights and health in Turkmenistan
comes predominantly from the state budget, with very few private sector providers
of health care, the government is reducing investment in the health sector. Overall
social spending in Turkmenistan is being compromised by prestigious presidential
projects and corruption (Pomfret 2002). Although additional sources of funding
have been introduced, such as the voluntary medical insurance scheme and user
fees for certain services, resource allocation continues to be based on normative
criteria developed in Soviet times, leading to an inefficient health care system
which does not reflect the health needs of the population and wastes scare
public resources (Mamedkuliev et al. 2000).
While in April 2004 Niyazov opened a new hippodrome with state-of-the art vet-
erinary facilities for the animals and new medical centres were built in Ashgabat
in recent years, many people, especially in rural areas, are denied basic health
care (McElroy 2004; Penketh 2004). The reported massive reduction in health
care workers has been accompanied by deteriorating infrastructure and lack of
essential medicines and supplies. Only a very limited number of drugs are
available and most are procured through barter agreements with former Soviet
countries in exchange for gas deliveries (Mamedkuliev et al. 2000; THF 2005).
Much of the medical equipment is obsolete and in a poor state of repair. Health
facilities suffer from years of under-investment and treatment methods are obsolete
and ineffective. Primary health care facilities in particular are often very dilapidat-
ed and poorly equipped (Mamedkuliev et al. 2000), although in recent years new
diagnostic centres were built and equipped across the country.
Although recent data are lacking, even by the end of the 1990s it was clear that
access to health services had deteriorated dramatically. Health care workers were
being paid irregularly and informal payments were widespread (Ensor and
Amannyazova 2000; Mamedkuliev et al. 2000; Mamedkuliev et al. 2002; WHO
2000a). According to a Turkmen medical practitioner, “[a] person will be dying
at home and not go to a hospital because he cannot afford to pay for his treat-
ment” (BBC 2004b; Eurasianet 2004b). There are worrying signs that the neglect
of the health sector will continue or even worsen. At the beginning of October
2004, Niyazov announced that 3 000 draftees would be sent to medical centres,
although it was not clear if this would entail further dismissals of health care work-
ers (BBC 2004c).
In February 2005, Niyazov ordered the closure of all hospitals outside Ashgabat
and all but one diagnostic centre in each oblast centre (IRIN 2005a; Prima-News
2005; The Independent 2005; Whitlock 2005). Although it was unclear if or how
this order will be codified or implemented, it is likely to compromise access of the
population to health care even further.
Life expectancy
Life expectancy offers a widely used summary measure of population mortality.
Although anecdotal reports suggest that life expectancy is falling (Templeton
27
Health and health care
2004), official data indicate an increase in life expectancy. Table 3 shows life
expectancy in Turkmenistan according to nationally reported data, as well as
according to estimates of various international organisations for the latest
available years.
1998 is the last year for which Turkmenistan reported population and mortality
statistics to the WHO Regional Office for Europe. Officially reported life expectan-
cy of 66.1 years in 1998 was lower than in all other Central Asian countries,
when considering the most recent data for all countries (WHO 2004b). It was also
lower than official life expectancy in Turkmenistan in 1990, when it reached 66.6
years, declining to 63.95 in 1994, and recovering in the years thereafter (WHO
2004b).
More up-to-date data on life expectancy have been reported by the country to the
MONEE database of UNICEF. According to these data, life expectancy reached
69.1 years in 2003 and so is significantly higher than in 1990, exceeding life
expectancy in Kazakhstan and Kyrgyzstan (UNICEF 2004d).
Yet estimates of life expectancy in Turkmenistan by international organisations are
considerably lower. Although the ways in which these estimates have been calcu-
lated are in no way clear, it is likely that they take account of two broad factors.
First, life expectancy is highly sensitive to the infant mortality rate and it is certain
Table 3 Life expectancy at birth
Year Rate Source
National registration data
reported to WHO 1998 66.1 (WHO 2004b)
National registration data
reported to UNICEF 2003 69.1 (UNICEF 2004d)
World Health Report 2004 2002 62.7 (WHO 2004b)
UNICEF 2002 67 (UNICEF 2004a)
The World Bank Group 2002 64.6 (The World Bank
Group 2004)
CIA 2004 61.3 (CIA 2004)
UNDP 2003 66.6 (UNDP 2004a)
28
Human rights and health in Turkmenistan
that the official data seriously underestimate the true situation in Turkmenistan.
Second, the worsening socioeconomic situation and declining access to health
care will have a negative impact on life expectancy.
Using the WHO estimate of life expectancy from the World Health Report,
Turkmenistan, at 62.7 years in 2002, had the lowest value in any country in
Europe and Central Asia, more than 16 years lower than the EU-15 (WHO
2004b). Some of the other Central Asian countries, such as Tajikistan, Kyrgyzstan
and Uzbekistan, achieved higher life expectancies in spite of their much lower
economic capacities, when measured in real gross domestic product per capita
(WHO 2004b).
As in all European countries, there is a gender gap in life expectancy at birth.
While females are estimated by WHO to have a life expectancy of 66.9 years in
2002, males could expect to live only 58.8 years. According to these estimates,
female life expectancy in Turkmenistan was the lowest in the WHO European
Region (WHO 2004b). Again, official data show much higher values, giving a
female life expectancy of 72.4 years for 2003, and a male life expectancy of
69.1 years (UNICEF 2004d).
In 1995, life expectancy among women in rural areas was reported to be 10
years lower than in the capital, reflecting in part a lower survival of female infants
in rural areas (McKee and Chenet 2002). However, the most recent data on cases
of death in the first year of life, covering the period until 2003, show higher death
rates for male than for female infants, at least at the national level (UNICEF
2004d).
The latest publicly available mortality statistics by cause of death, from 1998,
demonstrate the broad patterns of mortality that exist in Turkmenistan. The coun-
try exhibits high rates of deaths due to cardiovascular diseases, as well as from
infectious diseases and diseases of the respiratory system. Standardised death
rates form cardiovascular diseases, the main cause of death in Turkmenistan, have
increased significantly after 1990, and were the highest in the WHO European
region, being more than three times higher than those in the EU-15 (WHO
2004b). Death rates from infectious diseases in 1998 were also very high, the
second highest in the WHO European region after Kazakhstan, while death rates
from diseases of the respiratory system according to latest available data were the
second highest in the WHO European region after Kyrgyzstan (WHO 2004b). It
can be assumed that this overall pattern of mortality, with high rates of cardiovas-
cular diseases, infectious diseases and diseases of the respiratory system, has
persisted over recent years, although the actual rates remain unknown.
Child health
Turkmenistan has a large and growing child population. As in other countries, the
health of children in Turkmenistan is influenced by a number of factors, including
29
Health and health care
the provision of medical care, nutrition and their access to education. Children are
also at particular risk of poverty. One of the most disturbing trends in recent years
has been an increase in children begging in the capital. While exaggerated
reports about economic growth rates are disseminated by the official Turkmen
media, rising poverty is driving an increasing number of children to beg on the
streets. According to an IWPR report of May 2004, “the number of children
begging in Ashgabat has risen dramatically in recent months” (IWPR 2004k) and
“[m]ore and more children are being forced to beg or do odd jobs just to feed
themselves or their families” (IWPR 2004k).
Infant and under-five mortality
Turkmenistan has a high rate of infant mortality. The officially recorded infant
mortality declined from 57.3 per 1000 live births in 1986 to 32.8 in 1998.
However, this rate was still the highest in the WHO European region and
compares to 4.66 per 1000 live births in the EU-15 in 2001 (WHO 2004b).
According to the Turkmen Statistical Office, however, the rate declined to 16.4 in
2003 (UNICEF 2004d).
Yet the actual infant mortality rate is likely to be much higher. One of the reasons
for this is that the more restrictive Soviet definition of live birth is still in use. The
Demographic and Health Survey (DHS) of 2000 estimated that the infant mortal-
ity rate was 74 for the years 1995–2000 and 72 for the years 1990–2000.
There were marked differences between urban and rural areas. In rural areas, the
rate was 79.9 per 1000 live births for 1990–2000, compared to 60.1 per 1000
live births in urban areas (Population Council 2003). However, the rate in the city
of Ashgabat was even lower, at 47.7 per 1000 live births, compared to the
region of Mary, where at 98.8, the rate was highest. Infant mortality, at 73.5 per
1000 live births, was higher in Turkmen families than in Uzbek families, where it
was 60.5 (Charyeva et al. 2001).
Estimates of the true infant mortality made by international organisations take
account of these results and are much higher than official rates, as shown in Table
4 (overleaf), although it is not clear how exactly these estimates were derived
(Rechel et al. 2004).
Most recent international estimates of infant mortality in Turkmenistan are many
times higher than nationally reported data for 2003. The country ranks among
those with the highest estimated infant mortality rates in Europe and Central Asia
(UNICEF 2004a) (The World Bank Group 2004).
Going beyond mortality in the first year of life, under-five mortality is also very high,
although driven to a considerable degree by high infant mortality. The officially
recorded rate of 53.18 per 1000 live births in 1998 was the highest in the WHO
European region and compares to 6.1 per 1000 live births in the EU-15 in 2001
(WHO 2004b), although it reportedly declined to 28.5 per 1000 live births in
30
Human rights and health in Turkmenistan
2003 (UNICEF 2004d). Again, actual rates are likely to be much higher.
International estimates of under-five mortality in Turkmenistan are shown in Table 5.
As with infant mortality, there are substantial variations according to family char-
acteristics. Taking mortality between the ages of 1 and 5, so as to eliminate the
effect of infant mortality, the 2000 DHS survey found the rate in rural areas to be
Table 5 Under-five mortality rate per 1000 live births, latest available years
Year Rate Source
National registration data
reported to WHO 1998 53.18 (WHO 2004b)
National registration data
reported to UNICEF 2003 28.5 (UNICEF 2004d)
UNICEF 2002 98 (UNICEF 2004a)
The World Bank Group 2002 86 (The World Bank
Group 2004)
UNDP 2003 99 (UNDP 2004a)
Table 4 Infant mortality rate per 1000 live births, latest available years
Year Rate Source
National registration data
reported to WHO 1998 32.78 (WHO 2004b)
National registration data
reported to UNICEF 2003 16.4 (UNICEF 2004d)
WHO/UNICEF estimate 2000 51 (WHO 2004b)
UNICEF 2002 76 (UNICEF 2004a)
The World Bank Group 2002 70 (The World Bank
Group 2004)
CIA 2004 73.13 (CIA 2004)
UNDP 2003 76 (UNDP 2004a)
31
Health and health care
Table 6 Association between previous birth intervals, mother’s status and infant
and child mortality
Neonatal
mortality
Post
neonatal
mortality
Infant
mortality
Child
mortality
(1–4)
Under-5
mortality
Previous birth interval
< 2 years 39.3 54.9 94.2 27.7 119.3
2–3 years 26.8 37.1 63.9 15.6 78.6
4+ years 33.2 15.8 49 8.8 57.4
Number of decisions with women having final say
052.4 50.6 103.1 * *
1–2 36.6 51.7 88.2 27.4 113.2
3–4 37.1 38.2 75.3 14.9 89.1
529.2 35.1 64.3 16.7 79.9
Note: * cells with under 250 cases
Source: (Charyeva et al. 2001)
almost double that in urban areas (21.6 versus 13.4 per 1000 live births). This
measure of child mortality was strongly associated with maternal education (22.1
for mothers with primary or secondary; 9.7 for mothers with special secondary;
and 6.7 for mothers with higher education) and ethnicity (19.5 for Turkmen, com-
pared to 10.2 for Uzbeks) (Charyeva et al. 2001).
For both infant and child mortality, one of the strongest determinants was the
status of the mother within the family. In families in which women were more
involved in decision-making, infants and children had higher chances of survival.
Infant and child mortality also decreased with increasing birth intervals (Table 6).
Immunisation
Immunisation coverage is another important indicator of child health.
Immunisation against vaccine-preventable diseases is a cheap and effective way
32
Human rights and health in Turkmenistan
Table 7 Immunisation coverage according to official country estimates (as a percentage)
1995 1996 1997 1998 1999 2000 2001 2002 2003
Poliomyelitis 96 98 99 99 98 98 94.3 99 66
Measles 92 98 100 99 97 97 97.6 88 97.1
Tetanus 93 97 98 99 98 97 95.4 97.7 83.3
Diphtheria 93 97 98 99 98 97 95.4 97.7 83.3
Pertussis 93 97 98 99 98 97 95.4 97.7 83.3
Tuberculosis 93 97 96.6 98.2 99.1 99.5 99 99.2 98.8
Hepatitis B 096.4 97
Source: (WHO 2004b)
33
Health and health care
to improve the health of children. The Soviet health system, with its emphasis on
the control of communicable diseases, achieved a high immunisation coverage,
with declines in most successor states in the early 1990s. This was also the case
in Turkmenistan. The incidence of measles and diphtheria increased, with 23% of
cases of diphtheria being fatal (Mamedkuliev et al. 2000). With support from
external agencies, immunisation coverage has improved since then and, for most
vaccine-preventable diseases of childhood, the country has achieved high immu-
nisation coverage. Immunisation coverage according to official country estimates
is shown in Table 7. These very high figures are supported by independent data
from the 2000 DHS (Turayeva et al. 2001).
Given the high rates achieved previously, it is particularly worrying that, even
according to official sources, rates of poliomyelitis, tetanus, diphtheria and pertus-
sis immunisation have fallen significantly in 2003, to levels much lower than in
any other country in Central Asia, reportedly because the Ministry of Health and
Medical Industry could not purchase the necessary vaccines in time due to
financial problems. As the maintenance of high immunisation rates can be quick-
ly jeopardised, it is worrying that the crisis in the Turkmen health system is already
making itself felt in the decrease of immunisation rates.
The number of officially reported cases of major childhood illnesses is shown in
Table 8. According to official data, very low numbers of childhood illnesses have
been detected in recent years. Turkmenistan was certified by WHO as polio-free
in June 2002 (UNICEF 2004a) and the last case of virologically confirmed polio
was in 1996. This was achieved through improved immunisation coverage,
Table 8 Number of officially reported cases of major childhood illnesses
1990 1999 2000 2001 2002 2003
Poliomyelitis 00000
Measles 2806 452 113 911 1
Tetanus 01010
Diphtheria 449 30 212
Pertussis 260 711 849 0
Source: (WHO 2004a)
34
Human rights and health in Turkmenistan
enhanced surveillance and national immunisation days in the 1980s and early
1990s. Yet while Europe and Central Asia were certified as “polio-free” in 2002,
in November 2004, cases were still being detected in Afghanistan and the Indian
subcontinent, which could spill over to Turkmenistan. The policy of the Turkmen
government to deny health problems makes it very unlikely that any detected case
of polio would be reported to international organisations, even if the necessary
laboratory equipment and expertise existed in Turkmenistan. At present, testing is
only done for acute flaccid paralysis (AFP), with virological testing for polio
undertaken in a WHO certified laboratory outside the country. The deterioration
in the health sector creates the risk that the AFP surveillance system will not be
maintained.
The rates of all vaccine-preventable diseases reported for 2003 are very low and
it is possible that they understate actually registered rates. The drop in vaccination
rates in 2003 certainly increases the risk of new outbreaks in the future.
Nutrition
There are hardly any data on the nutritional status of children in Turkmenistan
except from the 2000 DHS. It is likely, however, that the reported high rates of
poverty and unemployment have a detrimental impact on child nutrition. The DHS
found moderate or severe signs of acute undernutrition (low weight for height,
“wasting”) among 5.7% of children and moderate or severe signs of chronic
undernutrition (low height for age, “stunting”) among 22.3% of children
(Population Council 2003). The survey also found that 36% of children under five
had anaemia and unlike the situation with many other health indicators, moder-
ate to severe anaemia was more common in urban areas (Kariyeva et al. 2001).
Women’s health
The health of women in Turkmenistan is much worse than in any other part of the
former Soviet Union (McKee and Chenet 2002). As already mentioned, WHO
estimated that female life expectancy in Turkmenistan in 2002 at 66.9 years was
the lowest in the WHO European Region (WHO 2004b). A similar picture
emerges according to national registration data reported to WHO. Officially
reported life expectancy of women in Turkmenistan in 1998 was at 69.84 years
the lowest in Europe and Central Asia, as against 81.31 years in the EU-15
(WHO 2004b). However, according to the Turkmen Statistical Office, female life
expectancy reached 72.4 years in 2003 (UNICEF 2004d).
The development of life expectancy in Turkmenistan following the dissolution of the
Soviet Union differs from those in other former Soviet republics in its gender
pattern. While in other countries of the former Soviet Union the decline in life
expectancy in the 1990s was mainly due to increased male mortality, in
Turkmenistan a sharp decline in female life expectancy occurred in 1993 and
1994 (WHO 2000a). Female life expectancy fell from 70 in 1990 to 66.6 in
35
Health and health care
1994, and was still below its pre-transition level in 1998 (WHO 2004b). The
determinants of the high female mortality in Turkmenistan remain poorly understood
but it seems likely that it is linked to the low status of women in Turkmen society.
Domestic violence
Although men and women are formally equal, profound discrimination against
women and domestic violence have been described by the International Helsinki
Federation as “one of the most serious human rights problems” (IHF 2004) in the
country. Although Niyazov claimed that “women are the nation’s spiritual pillars”
(BBC 2004g) and “mothers and children are golden treasures of the golden age
of the Turkmen people” (BBC 2004e), domestic violence is believed to be wide-
spread, corresponding to a traditional model of male behaviour, although more
detailed empirical data are lacking (US Department of State 2004; UNIFEM
2004).
Sex work
In recent years, an increase in sex work has been observed (US Department of
State 2004). While the government denies that sex work exists in the country
(USAID 2003), shortened school education, the requirement to work for two years
before entering university, the lack of jobs and increasing drug use is driving
young women into sex work (IWPR 2004j). In Ashgabat girls as young as 13 are
offering their services for as little as US$ 1 (Annagurban 2004; IWPR 2004j;
USAID 2003). The number of sex workers in 2003 was estimated to be 3000
(USAID 2003). Drug use is rife (IWPR 2004j) as are, presumably, unsafe sexual
practices. As many as 66% of sex workers are injecting drug users, putting them
at an increased risk of violence and HIV/AIDS infection (USAID 2003).
Reproductive health
In spite of the overall bleak picture of health in Turkmenistan, progress seems to
have been achieved in some areas. One of these areas is reproductive health.
IRIN (Integrated Regional Information Networks) reported in August 2004 that
reproductive health “shows signs of improvement” (IRIN 2004h).
In Soviet times, contraception relied overwhelmingly on intra-uterine devices
(IUDs), called “spirals”, with almost no use of oral contraceptives or condoms
(IRIN 2004h; WHO 2000b). In 1997, the Ministry of Health and Medical
Industry, supported by UNFPA and WHO, adopted a national strategy on
reproductive health until 2010 (IRIN 2004h). The first programme cycle included
three national projects, encompassing the delivery of contraceptive supplies and
equipment, information, education and communication (IEC), and increased
access to good quality contraceptive services. An evaluation in 1999 found that
the project has been very successful in terms of increased access to good quality
contraceptive services (WHO 2000b). Training was provided for a large number
36
Human rights and health in Turkmenistan
of health professionals and 12 reproductive health centres have been established
and equipped (2 in each velayat), with 47 reproductive health cabinets at etrap
(district) level. There has also been “impressive progress […], given the prevailing
cultural conditions, in raising awareness and increasing knowledge and skills of
adolescents on RH issues” (WHO 2000b).
One of the main aims of the project was to increase birth intervals in the country,
although, among the population, the perceived need was rather for limiting than
for simply spacing births. A variety of IEC measures were employed, using
television, radio, newspapers, theatre and information brochures and leaflets
(WHO 2000b). A 34-hour curriculum on reproductive health has been developed
for the 9th grade and was started in 1999 (WHO 2000b).
An evaluation in 1999 found that all reproductive health centres visited were
staffed by “enthusiast[ic], well-informed and trained” (WHO 2000b) gynaecolo-
gists and obstetricians. The role of the government was found to be “strong and
cooperative” (WHO 2000b). According to one WHO consultant, the share of
IUDs dropped from 97–98% in 1995 to 88% in mid-1999, the share of hormon-
al methods increased to 10–12%, while the use of condoms remained below 1%
(WHO 2000b). According to the DHS 2000, which carried out interviews with
7919 women, 39% of married women used IUD as a contraception method, 2%
used male condoms and 1.2% the contraceptive pill (Population Council 2003).
The abortion rate in the country is much lower than in some former Soviet
republics, but higher than in most other Central Asian countries, at 320.35 per
1000 live births in 1997 (WHO 2004b). A fee has been introduced for abortion
in the second half of the 1990s, posing a “very heavy financial burden on most
of the women concerned” (WHO 2000b).
UNFPA has continued to provide contraceptives to reproductive health centres and
to conduct training for family doctors and other medical personnel (IRIN 2004h).
According to Turkmen TV, the construction of a modern 100-bed maternity and
children’s hospital in Ashgabat, co-financed by a grant from the United Arab
Emirates, is planned for 2005 (BBC 2004e).
Although progress seems to have been achieved in some areas of reproductive
health, the overall level of knowledge about reproductive and sexual health
continues to be low, in particular among young people (IRIN 2004h; WHO
2000b). Condoms are reportedly not available at government-run pharmacies,
but only at commercial shops, where they are not always properly stored (IRIN
2004h). Most crucially, reproductive health services are certain to have declined
as a result of cuts in the health budget and the dismissal of health care workers
and more recent information on reproductive health is generally missing.
An example of how the politics of the Turkmen regime impact on reproductive
health are the restrictions on marrying foreigners or stateless persons, introduced
in the summer of 2001 (US Department of State 2004). A presidential decree
37
Health and health care
Table 9 Maternal mortality rate per 100 000 live births
Year Rate Source
National registration data
reported to WHO 1996 44.03 (WHO 2004b)
National registration data
reported to UNICEF 2003 16.4 (UNICEF 2004d)
UNICEF 2000 31 (UNICEF 2004a)
made the payment of US$ 50 000 obligatory for any foreigner wishing to marry
a Turkmen citizen and some young people have fled to Uzbekistan to avoid pay-
ing the “bride tax” (IWPR 2004e).
Maternal mortality
While progress in reproductive health has reportedly been achieved, apart from
the 2000 DHS, valid and reliable data on reproductive health indicators are lack-
ing (WHO 2000b). According to officially reported data by the Turkmen Statistical
Office, maternal mortality has stagnated between 1981 and 1996, although with
considerable variations. In 1981 maternal mortality stood at 40.74 per 100 000
live births, having slightly increased to 44.03 per 100 000 live births in 1996,
the latest year on which data were reported to WHO (WHO 2004b).
Data from the Ministry of Health and Medical Industry, which may be more
accurate, showed much higher rates of maternal mortality, declining from 132.3
per 100 000 live births in 1992 to 105 in 1996 and 41.2 in 1999, with consid-
erable regional variety. In 1999, in Balkan velayat, the rate stood at 134.7 per
100 000 live births, compared to 27.9 in Dashoguz velayat and 52.2 in
Ashgabat (CARINFONET 2000). WHO also noted that according to estimates
based on facility data, actual maternal mortality was much higher than officially
reported to the WHO database (WHO 2000a).
Nevertheless, a decline in maternal mortality has been reported in recent years
by the Turkmen Statistical Office, with a decline to 12.5 per 100 000 live births
in 2003, after an all-time low of 3.3 per 100 000 live births in 2000 (UNICEF
2004d). There was strong regional variety, with the highest rate recorded in 2003
in Balkan velayat, reaching 59 per 100 000 live births (UNICEF 2004d).
Although these data might underestimate actual maternal mortality rates, interna-
tional organisations, too, believe that a decline in maternal mortality has occurred
in recent years. UNICEF estimated that maternal mortality declined to a rate of 31
per 100 000 live births in 2000, as shown in Table 9.
38
Human rights and health in Turkmenistan
Mental health
Mental health services are orientated towards hospitalisation rather than commu-
nity-based treatment of patients (Mamedkuliev et al. 2000). No systematic infor-
mation is available on the mental health of the population of Turkmenistan, but it
is very likely that the psychological pressure of dictatorship, pervasive corruption
and lack of prospects for the future have taken their toll in the population. Drug
addiction has risen markedly in recent years and it has also been reported that
suicides have become much more common. Reportedly, the central psychiatric
hospital in Ashgabat was demolished several years ago, creating serious prob-
lems of access to mental health services for the population.
In addition, as mentioned above, psychiatry in the country is abused for political
purposes. In the Soviet Union, dissidents were routinely locked up in psychiatric
institutions. This practice has been revived in Turkmenistan, where political dissi-
dents are committed to psychiatric hospitals against their will, one of the most
obvious implications of dictatorship on health (Kaplan 2004;
The Lancet
2004).
Drug use
Economic hardship, corruption, large-scale trafficking of opium and heroin from
Afghanistan, and an increase in sex work and crime have led to an alarming
increase in drug use in Turkmenistan in recent years (UNAIDS 2004a; UNODC
2004b). While drug use has been a traditional phenomenon in Turkmenistan, the
users were mainly elderly men using marijuana and opium. After independence,
heroin became much more prevalent, used by younger people and also linked to
sex work (IWPR 2004n; Kerimi 2000), reflecting a shift occurring throughout
Central Asia (UNODC 2002). In Ashgabat heroin is cheap and easily available
(IRIN 2004f). It is also very pure, increasing the risk of overdoses.
The extent of drug use in the country can only be estimated. The number of drug
users officially registered by the Ministry of Health and Medical Industry increased
massively, from 3704 in 1989 to 43 947 in 2003 (UNICEF 2004d), with about
20% of drug users injecting drugs (IRIN 2004f; UNICEF 2004a). However, the
limited quality and accessibility of drug treatment services, combined with the stig-
matisation of drug users and their police registration, mean that many drug users
are unwilling to seek treatment and are not recorded in official statistics (Kerimi
2000; UNODC 2004b). Unsafe injecting practices are widespread and harm
reduction measures largely absent, contributing to the spread of communicable
diseases, including HIV/AIDS (IRIN 2004f; UNICEF 2004a). According to a
former prisoner, “[h]alf the prisoners are drug addicts, and syringes are passed
from one person to the next” (IWPR 2005).
The United Nations Office on Drugs and Crime (UNODC) estimated that, through-
out Central Asia, a 17-fold increase of opiate use occurred in the period 1990–
2002. Approximately 1% of the total population of the region are estimated to be
39
Health and health care
injecting drug users (UNODC 2004b). It has also been estimated that up to
20 000 people in Ashgabat alone are involved in the drugs trade (IWPR 2004n)
and that 70% of young sex workers in Ashgabat are addicted to heroin (IWPR
2004j). One university student observed that “I’ve yet to reach my 20th birthday,
but already half of my classmates and neighbours – the friends I grew up with –
are seasoned drug addicts” (IWPR 2004n). Reportedly, some young people now
offer heroin at weddings (IRIN 2004f; IWPR 2004n).
The government has at best been reluctant to deal with the drug problem, while
many observers believe it is actively involved in drug trafficking. Reportedly, the
President claimed that there is no drug problem in Turkmenistan (Herman 2004).
In 1998, the government started an anti-drug campaign with the title “To the 21st
Century – Drug-Free”. The campaign’s main message was that drug consumption
is alien to Turkmen culture (Kerimi 2000). There have also been a series of
amnesties for those convicted of drug-related offences (Kerimi 2000). In
November 2004, a new law “On narcotic drugs, psychotropic substances, pre-
cursors and measures to fight their trafficking” was published in the government
newspaper
Neytralnyy Turkmenistan
(BBC 2004h). However, it is too early to
know whether this will be implemented and, in view of deteriorating living
standards, unemployment, corruption and failing drug control it is questionable if
it will have much effect. Young people lack any perspectives for the future and
drugs are widely available and cheap (IRIN 2004f). Treatment of drug addiction
is medically focused and, after independence, there were shortages of pharma-
ceuticals and a lack of clear treatment protocols (Kerimi 2000). Many of the HIV
prevention projects for drug users and sex workers initiated by UNDP, USAID and
the Open Society Institute have ground to a halt.
One of the main reasons for increased drug use is increased availability of drugs.
Turkmenistan shares more than 700 km of poorly policed border with
Afghanistan, the largest producer of opium in the world. It also shares a long bor-
der with Iran, one of the main conduits for illegal drugs from Afghanistan
(UNODC 2002). In 2002, 76% of the world’s total seizures of opium were report-
ed from Iran, with Turkmenistan ranking 10th in the world (UNODC 2004a). At
least 25-30% of narcotics produced in Afghanistan are currently transiting Central
Asia on their way to Russian and Western European markets (UNODC 2004b).
Turkmenistan has not joined several regional activities aimed at preventing the
trafficking of drugs, although it has recently decided to participate in Operation
Topaz, which aims to prevent the proliferation of precursor chemicals for the man-
ufacture of heroin (UN 2004a). Since 2000, when an annual survey concerning
events in 1998 was completed, the authorities have not reported any seizures of
opiates or chemicals, although significant quantities had been seized in previous
years (IRIN 2004a; UNODC 2004c).
There have been serious concerns that the Niyazov regime is actively involved in
40
Human rights and health in Turkmenistan
the drug trade (IRIN 2004f). Widespread corruption, fuelled by low public sector
salaries, is a problem in all Central Asian countries (UNODC 2004b). Many
claim that corrupt officials in Turkmenistan are turning a blind eye to the problem
or are complicit in drug trafficking (IWPR 2004n). “Many foreign observers
believe that narcotics trafficking has become a major source of revenue for the
Niyazov regime” (Freedom House 2004) and it has been speculated that, before
11 September 2001, Turkmenistan’s cordial relations with the Taliban regime in
Afghanistan were based on the profitable drug trade (Freedom House 2004).
Niyazov himself conceded that high-ranking security officers use and sell drugs
(Annagurban 2004). The President reportedly ordered that people should not be
prosecuted for the possession of opium if it was intended for their own use. When
caught with more than one kilogram of soft drugs, a crime originally punished
with the death sentence, it is now possible to escape prison by paying a fine of
US$ 100 000 (Annagurban 2004). In the regions close to the Afghan border, the
majority of men have reportedly been convicted of drug trafficking, although it is
possible to be released from prison when paying a bribe and many convicted of
drug trafficking are released through the annual prison amnesties (Annagurban
2004).
If the regime is indeed complicit in the trafficking of drugs, it would be directly
responsible for ruining the lives of many in Turkmenistan and the destination coun-
tries of the drug trade. This would also explain the official denial of drug problems
in the country. What is equally worrying is the absence or inadequacy of meas-
ures addressed to meet the needs of drug users and other vulnerable populations.
Tobacco
Smoking has been reported to be widespread among the male population in
Turkmenistan (WHO 1998). Central Asia has been a key target of the internation-
al tobacco industry, which does not shy away from “unscrupulous tactics”
(Gilmore and McKee 2004; WHO 2003). When Niyazov underwent heart sur-
gery in 1997 and had to quit smoking, he ordered all his government ministers
to follow suit and imposed a ban on smoking in public places (Osborn 2004).
According to a report by ITAR-TASS, Niyazov signed a decree in 2002 banning
smoking “in ministries, departments, enterprises, institutions and organisations,
military units, educational institutions, theatres and cinema halls, on public trans-
port and in public places” (BBC 2004i). According to a third source, a public
smoking ban was instituted towards the end of 1999 (Mamedkuliev et al. 2000).
The punishment for smoking in public places is a fine equivalent to the minimum
monthly wage (US$ 50) (BBC 2004i). A decree of August 2004 banned the con-
sumption of nas (chewing tobacco) in all public and private places and restricted
the places where nas can be sold, “in confirmation of Turkmenistan’s adherence
to the world community’s efforts to minimise the damaging impact of tobacco and
tobacco products on human health” (BBC 2004d). Those found consuming nas
41
Health and health care
face a fine of twice the minimum monthly wage (BBC 2004d). It remains unclear,
however, how far these decrees are being implemented. There does not seem to
be a coherent and sustainable strategy for tobacco control. Although implementa-
tion would by no means be guaranteed, by 28 November 2004 Turkmenistan
had neither signed nor ratified the WHO Framework Convention on Tobacco
Control.
Alcohol
A World Bank health sector review in mid-1995 recommended an alcohol abuse
prevention programme (WHO 1998). Although overall alcohol consumption is
comparatively low, consumption is much higher among men in towns and in the
1990s there has been an increase in the cases of chronic liver disease, cirrhosis
and liver cancer (WHO 2000a). The officially registered incidence of “alcoholism
and alcoholic psychosis” has increased from 15 058 in 1989 to 22 432 in 2003
(UNICEF 2004d).
Communicable diseases
While the Soviet health care system notionally paid much attention to the preven-
tion of communicable diseases, in reality its systems were obsolete, making little
use of modern epidemiological methods. With the dissolution of the Soviet Union,
a disruption in the provision of pharmaceuticals, increasing poverty and chang-
ing behaviour, the rates of tuberculosis, hepatitis and sexually transmitted diseases
have increased markedly in Turkmenistan. Overall, infection control is underdevel-
oped, dangerous infectious diseases are often officially diagnosed as self-limiting
viral infections and strict control measures are rarely enforced (Eurasianet 2004b).
Ban on diagnosing infectious diseases
“Repressive regimes foster ignorance” (
The Lancet
2004). Instead of addressing
the health problems of the country, the regime has decided to deny them. The
“solution” to health care problems is seen in their concealment rather than in pre-
vention (Eurasianet 2004b). An unofficial ban on diagnosing infectious disease
was issued in 2004 by the Turkmen Ministry of Health and Medical Industry,
although underreporting of communicable disease was already common.
According to the Watan opposition site and the Turkmenistan Helsinki Foundation,
Turkmen health care officials have issued secret instructions banning, from 1 May
2004, any mention of diseases such as tuberculosis, measles, dysentery, cholera
and hepatitis, which may lead to epidemics (Eurasianet 2004b; THF 2004;
Watan 2004), in order to
“assure the international community of the absolute well-being and the
complete non-existence of any contagious diseases and problems with
medication and treatment in Turkmenistan” (Eurasianet 2004b; THF 2004).
Doctors are prohibited from mentioning these diseases in any documents, such as
42
Human rights and health in Turkmenistan
death certificates (IWPR 2005; THF 2004). The ban on diagnosing and reporting
communicable diseases means that there is a total lack of information about actu-
al rates of diseases, which is likely to extend to government level. It also means
that, in combination with cutbacks in medical staff, favourable conditions for the
spread of communicable diseases are created (IWPR 2005).
The devastating consequences of secrecy and denial have recently been demon-
strated by the SARS virus, which was kept secret by the Chinese government for
months, after which it caused a number of major outbreaks around the world
(Orent 2004).
Plague outbreak in 2004
The outbreak of plague in Turkmenistan in the summer of 2004 was viewed with
considerable concern by neighbouring countries and international experts.
Occasional cases of plague are common in Central Asia (Hill 2004) and the
disease circulates in natural populations of gerbils, with cases in humans fluctuat-
ing in parallel with the rodent population. In 1950, according to an account by
Russian plague expert Lev Melnikov, a large plague outbreak in Turkmenistan
killed several hundred people, but was brought under control through rigorous
measures. Yet today, “the Soviets and their hundreds of trained plague experts no
longer run the show” (Orent 2004). What makes an outbreak in Turkmenistan so
dangerous is the tendency of officials to cover it up, as well as the poor state of
infection control (Hill 2004).
The recent plague outbreak was reported in June 2004 by a Russian newspaper
and by Gundogar, an opposition website. Various sources have claimed that the
outbreak was responsible for up to 10 deaths (Hill 2004). The Turkmenistan
Helsinki Initiative reported that plague victims were taken to a hospital outside
Ashgabat, where they were secretly treated. The district hospital was cleared of
all other patients, and surrounded by soldiers and special services employees
(Novruzov 2004a). Health workers were told to keep silent about the outbreak.
According to a clinic worker, “if any of us said that there was plague in the city,
they would be arrested and charged with revealing state secrets” (Novruzov
2004a). Doctors were ordered to diagnose “food poisoning” as the cause of
death (Novruzov 2004a).
The government responded to the outbreak by declaring the word “plague”
illegal and instituting border controls “to prevent disease from entering
Turkmenistan from neighbouring states” (Orent 2004). Officials have denied any
outbreak of plague. The Anti-Epidemic Emergency Commission claimed that “The
epidemiological situation on the territory of Turkmenistan is safe. There are no
cases of dangerous diseases” (Eurasianet 2004b). International experts worry
that the health care system will be unable to cope with a plague epidemic.
According to an American epidemiologist, “the expertise on the local level to
diagnose anything is limited” (Eurasianet 2004b).
43
Health and health care
HIV/AIDS
The government does not publish credible data about the incidence of HIV/AIDS
in Turkmenistan and denies that there have been new HIV infections in recent
years. According to UNAIDS, there were only two cases of HIV/AIDS ever report-
ed in Turkmenistan in 2002 (UNAIDS 2004a; UNICEF 2004a), while according
to the Turkmen Statistical Office, five newly registered HIV/AIDS cases had been
reported by 2003, with not a single case reported since 2000 (UNICEF 2004d).
In spite of these very low official numbers, the country has a considerable poten-
tial for an HIV/AIDS epidemic, because of widespread injecting drug use, sex
work and high rates of sexually transmitted infections (UNAIDS 2004a). In addi-
tion, the surveillance system is poorly developed (UNAIDS 2004a) and diagnosis
of communicable diseases has been banned. Anonymous testing for HIV/AIDS is
unavailable and there are no support services for people living with HIV/AIDS
(IWPR 2005). The absence of civil society organisations means that the needs of
vulnerable groups are generally ignored.
In its 2004 epidemiological fact sheet, UNAIDS estimated that there are actually
between 200 and 400 HIV/AIDS cases in the country, equivalent to less than
0.2% of the population (UNAIDS 2004b). According to a source in the Ministry
of Health and Medical Industry, however, there were more than 300 confirmed
cases of HIV infection in Ashgabat alone, with the real figure considerably
higher (IWPR 2005).
The government formulated a five-year National Programme on HIV/AIDS/STI
Prevention in 1999 (1999–2003) and adopted a law “On preventing HIV infec-
tion”. A National AIDS Centre was established, with the main office in Ashgabat
and branches in all five velayats. Information campaigns were launched, target-
ing youth, sex workers and prisoners (USAID 2003). However, the government
has “limited capacity to address the problem in a comprehensive way” (UNAIDS
2004a).
During 2002–2003, UNDP with funding from USAID and the Open Society
Institute supported five HIV/AIDS prevention projects among sex workers, drug
users and prisoners (USAID 2003), all implemented by “quasi-NGOs” closely
linked to the government. Most inmates in prisons, as well as general and med-
ical prison staff, have “little or no knowledge of HIV/AIDS” (USAID 2003), lead-
ing to high risk sexual and drug use behaviour. The HIV/AIDS prevention projects,
however, were undermined by the crackdown on civil society unleashed by the
Law on Public Associations of 21 October 2003, imposing severe restrictions on
the existence and work of NGOs. The two NGOs involved in the projects were
informed by the National AIDS Centre that they could not continue (USAID 2003).
These moves by the government increase the risk of an HIV/AIDS epidemic, in
particular as the government pursues a policy of secrecy and denial.
However, at present the government is working with WHO on applying to the
44
Human rights and health in Turkmenistan
Global Fund for AIDS, Tuberculosis and Malaria and elaborating a national
programme, giving rise to the hope that the Turkmen authorities will officially
acknowledge the scale of the HiV epidemic in due course.
Tuberculosis
Tuberculosis incidence in the country is high, recorded at 74.46 per 100 000
population in 2002 (WHO 2004b). An article in
The Lancet
in October 2002
found “little optimism in Turkmenistan’s TB wards” (Hargreaves 2002). Patients
were not provided with food and there were no appropriate drugs to treat them.
In the past 10 years, drug supplies have been sporadic, Moscow-based expertise
lost, and financial support ceased (Hargreaves 2002).
A DOTS (Directly Observed Treatment, Short Course) tuberculosis programme was
introduced in Turkmenistan in 1998. Before the start of international programmes,
“intermittent shortages of most first-line anti-TB drugs” were common (Cox et al.
2004). Médecins Sans Frontières have been working to set up a DOTS treatment
programme in Dashoguz velayat. In 2002 all medical facilities in this velayat were
covered by the DOTS programme (Cox et al. 2004). At the end of 2003, the DOTS
programme in Dashoguz velayat was handed over to the Ministry of Health and
Medical Industry. At present, the DOTS programme is being piloted in Ashgabat,
Mary and Turkmenbashy. However, in 2002 it was reported that the supply of anti-
tuberculosis drugs is entirely dependent on outside donors (Hargreaves 2002).
Particularly worrying is that, as in other areas of the former Soviet Union, mul-
tidrug-resistant tuberculosis is becoming more common. A drug-susceptibility sur-
vey conducted by Médecins Sans Frontières of 213 smear-positive tuberculosis
patients in 4 of the 9 districts of Dashoguz velayat between July 2001 and March
2002 found that 11% were infected with multidrug-resistant strains of tuberculo-
sis, including 4% of new patients and 18% of previously treated patients (Cox et
al. 2004). Struggling with the most basic tuberculosis services, treatment of mul-
tidrug-resistant tuberculosis so far remains a “distant dream” (Hargreaves 2002).
Sexually transmitted diseases
As in other countries of Eastern Europe and Central Asia, sexually transmitted
diseases became much more common in the 1990s. The reported incidence of
syphilis in Turkmenistan increased from 4.62 per 100 000 in 1990 to 56.06 in
1997 (WHO 2000a). In 2002, the city of Ashgabat had the highest rates of sex-
ually transmitted infections, with rates for syphilis at 72.9, and gonorrhoea at
93.4 per 100 000 population (USAID 2003). According to data from the
Turkmen Statistical Office, the number of newly registered cases of syphilis and
gonorrhoea was 52.8 per 100 000 in 2002 (UNICEF 2004d). The limited knowl-
edge of the population on how to prevent sexually transmitted diseases has not
been addressed sufficiently by the government and it is unlikely that current rates
will decrease any time soon.
45
Health and health care
Hepatitis
According to an American health worker, the prevalence of hepatitis B in
Turkmenistan is “one of the highest in the world” (Eurasianet 2004b) and hepati-
tis A infection among the young is ubiquitous. The spread of hepatitis A can be
attributed to poor sanitation and, in particular, exposure to water contaminated by
human waste (Eurasianet 2004b). According to the WHO Health for All database,
the incidence of viral hepatitis in 1997 was 347.61 per 100 000 population,
constituting one of the highest rates in Europe and Central Asia (WHO 2004b).
Malaria
Malaria seems to be largely under control in Turkmenistan. Endemic malaria was
reported to be eliminated in the country by 1960. In 1998, significant local trans-
mission resumed, with 137 recorded malaria cases, compared to 14 in 1997
(Amangeldiev et al. 2000). In 1999, 49 cases of malaria were recorded in
Turkmenistan (Amangeldiev 2001). The risk of new malaria outbreaks is influ-
enced by the use of water in the country. Seventeen large reservoirs have been
constructed in the area around the Karakum canal and associated river basins.
These have become breeding grounds for mosquitoes (Amangeldiev 2001). The
country developed a plan for preventive malaria control measures for 1999-2001,
providing large-scale prophylaxis and mosquito elimination activities
(Amangeldiev 2001), although anti-malaria activities have been continuously
underfunded in recent years. In the light of growing evidence from other parts of
the world about the high frequency of misdiagnosis of malaria (Amexo et al.
2004), it is also likely that there are failures of diagnosis, recording and treatment.
Environment
In the Soviet Union hardly any attention was paid to the long-term environmental
costs of ambitious economic development projects. This pattern is being continued
in Turkmenistan, which faces serious environmental problems, but instead of
addressing them follows grandiose development schemes that are certain to
exacerbate current problems.
For all countries in Central Asia, access to water is of paramount importance. The
region hosts the Aral Sea, “one of the world’s foremost ecological disaster zones”
(O'Hara et al. 2000). The Aral Sea was once the world’s fourth largest lake. It
began shrinking in the 1960s, as Soviet engineers diverted large amounts of water
from its main feeding rivers, the Amu Darya and Syr Darya, to irrigate vast cotton
fields in Turkmenistan and Uzbekistan, regardless of environmental costs. By
1990, the Aral Sea had lost 66% of its original surface area (Hinrichsen 1996;
O'Donnell 2004a). A report by the United Nations in June 2004 warned that if
present trends in water use and desertification continue, the Aral Sea will disap-
pear altogether (Cage 2004). The overuse of water for the production of cotton
has resulted in major environmental health problems and there is increasing con-
46
Human rights and health in Turkmenistan
cern for the health of the millions of people living in the Aral Sea region (O'Hara
et al. 2000). Dust deposition rates across eastern Turkmenistan are among the
highest in the world and the dust is contaminated with pesticide (O'Hara et al.
2000). Intensive cotton monoculture and primitive irrigation techniques have also
resulted in a decline in cotton production (Foreign & Commonwealth Office 2004).
In Turkmenistan in 1998, approximately 40% of the population did not have
access to safe drinking water (WHO 1998). Decades of intensive cotton farming
have drained freshwater reserves. Drainage water, salinated and contaminated
with fertilisers and pesticides, flows back into the Amu Darya River, one of the
main water sources in Central Asia and the main water source for Turkmenistan
(Blua 2004; IRIN 2004d; Eurasianet 2004a). According to UNICEF, only about
20% of the 1.2 million people in the Dashoguz region have access to clean drink-
ing water (Blua 2004; O'Donnell 2004a).
The limited supply of clean water in the country leads to major health problems.
The majority of the rural population uses open and potentially infected water
sources for drinking purposes, leading to outbreaks of typhoid and viral hepatitis
(Mamedkuliev et al. 2000; WHO 2000a). The consumption of salinated water
poses a long-term threat to health and up to 40% of the population living in the
Aral Sea region are reported to suffer from kidney problems (Blua 2004;
O'Donnell 2004a).
Although the President has repeatedly called on citizens to protect water resources
as a national treasure, this has not led to credible action, as the regime has shown
little concern for environmentally sustainable use of water and the development of
an improved supply of drinking water to the population. Current policies waste
precious water resources. There has been no investment in the water infrastructure
and the Karakum canal, providing water to major cities, is falling into disrepair
(Eurasianet 2004a). According to the World Bank, the country has been “at best
a reluctant participant in regional cooperation activities” (O'Donnell 2004a) to
address environmental problems (Cage 2004).
While insufficient amounts are spent on the ageing water infrastructure and on
providing the country’s residents with clean drinking water, vast sums are spent on
“high-profile projects that glorify Niyazov’s regime”, notably the construction of
Lake Turkmen (Eurasianet 2004a). Lake Turkmen, also called the “Golden Age
Lake”, is an artificial lake under construction in the middle of the Karakum desert,
being built at an estimated cost of between US$ 6.5 and 9 billion (Eurasianet
2004a; Pannier 2004; Templeton 2004). Work on the lake began in 2001 and
the construction site is “reminiscent of a prison camp, with much of the labour
force press-ganged from Ashgabat’s homeless people, or the country’s penal
system” (IWPR 2004k). The project has been described as “one of mankind’s most
foolhardy attempts at harnessing nature” (O'Donnell 2004a). It is likely to
compound existing problems of waste, desertification and salinisation (O'Donnell
47
Health and health care
2004a). Experts characterise the project as a “Soviet-style environmental disaster
waiting to happen” (Eurasianet 2004a). They have warned that the lake (120
kilometres long, 60 kilometres wide) will deplete precious water resources from
the already overused Amu Darya river (Eurasianet 2004a).
Niyazov also announced plans to create an artificial river in Ashgabat, so that
the capital does not “lag behind” other world capitals (Eurasianet 2004a). He has
also ordered the construction of an ice palace in the mountains outside Ashgabat
and the French firm Bouygues was scheduled to start on it in November 2004
(Osborn 2004; Templeton 2004). Meanwhile, a legendary underground lake is
reportedly being polluted by Turkmen soldiers working in agricultural projects
nearby (IWPR 2004h).
Public health
In Turkmenistan, as in other countries of the former Soviet bloc, “public health” has
had a very narrow focus, being mainly concerned with environmental hazards
and communicable diseases (Mamedkuliev et al. 2000). Public health services
have been the responsibility of the Sanitary Epidemiological Inspectorate,
renamed State Sanitary Epidemiological Inspectorate in 1998 (Mamedkuliev et
al. 2000). The Inspectorate suffers from “insufficient legislation and financing;
lack of qualified personnel and training facilities; poor physical conditions; and
insufficient intersectoral cooperation” (Mamedkuliev et al. 2000).
Public health education and health promotion were neglected areas in the Soviet
Union. In Turkmenistan, they used to be the task of the “health centre” service of
the Ministry of Health and Medical Industry. However, to “increase efficiency”,
with the exception of Ashgabat, health centres have been abolished throughout
the country and their functions have been formally handed over to the new pri-
mary health care network in 1997 (WHO 2000a). It is unclear to what extent pri-
mary health care providers are actually delivering these services (Mamedkuliev et
al. 2000).
Most public health initiatives do not originate from evidence-based health plans,
but from ad hoc decisions by the President, implemented to varying degrees. One
example of these “initiatives” was the presidential order in 2000 to construct a
36 km “Leader’s Path” in the foothills of the Kopetdag mountain near Ashgabat.
All government members were expected to use the route at least once a week.
Niyazov said that “[h]owever great the achievements of modern medicine, a
healthy lifestyle will remain the most reliable guarantee of longevity, fitness, and
willpower” (Countrywatch 2004). He also introduced a National Health Day,
although the pursuit of public health seems in general to have been confined to
official rhetoric and was not followed by the allocation of budgetary resources.
An example of the absurd nature of presidential “public health initiatives” is the
decree in February 2004 that young people should no longer have long hair and
48
Human rights and health in Turkmenistan
beards or earrings. This decree might have been as short-lived as similar ones in
the past, such as those banning students without a suit and tie from universities
(Ovezov 2004). An unofficial ban on gold teeth was reported in 2004, following
some “off-the-cuff remarks” (IWPR 2004g) by the President, at a ceremony at
Niyazov Agricultural University on 5 April 2004, that gold teeth don’t look good
on young people (IWPR 2004g). As anything uttered by the President carries the
force of an unwritten law, university authorities and employers reportedly forced
students and employees to replace gold teeth with white implants (IWPR 2004g).
Iron and iodine deficiency
Turkmenistan, as the other countries of Central Asia, is an iodine-deficient area
and the traditional diet is low in iron. The country therefore displays a high
incidence of anaemia and iodine deficiency disorders (WHO 1998). Iodised salt
for the prevention of iodine deficiency disorders was produced from 1976 to
1991, after which production halted. After 1991 a rise in the cases of anaemia
was observed in children, due to lack of breastfeeding and insufficient diets for
mothers (WHO 2000a). Iodisation restarted in 1995 (WHO 2000a), although
iodine content in salt was insufficient and in 2003 the government agreed with
UNICEF to increase the iodine content (IRIN 2004i). The Demographic and Health
Survey in 2000 showed that 75% of households used iodised salt (UNICEF
2004a).
Turkmenistan has developed anaemia prevention and control policies with the
assistance of UNICEF, based on education and promotion, oral supplementation
of high risk groups and iodisation of salt (Gleason and Sharmanov 2002). The
country’s campaign for universal salt iodisation began in 1994, supported by
USAID. In 1996 a decree was issued to enforce the use of iodised salt (UNICEF
2004c). The government issued a decree that iodised salt produced in the
country will be given to the population free of charge up to 2020 and that any
non-iodised salt is banned from entering the country (IRIN 2004i). In November
2004 the country, according to UNICEF, achieved universal salt iodisation, the
first Central Asian state to do so. UNICEF is now advocating the fortification of
wheat with iron and other micronutrients (IRIN 2004i).
49
The reaction from the
international community
Although Turkmenistan’s human rights violations have been criticised on many
occasions, according to Aaron Rhodes, executive director of the International
Helsinki Federation for Human Rights, there is a “tremendous tendency to support
the status quo. People don’t want to rock the boat, they don’t want to have
another failed state on their hands” (Templeton 2004). Another observer noted
that “[d]espite his despotism, Niyazov receives respectful treatment from foreign
governments mindful of Turkmenistan’s energy wealth and its strategic position
bordering Iran and Afghanistan” (Zarakhovich 1999). Yet Turkmenistan’s depend-
ence on gas and oil exports, for which it needs extensive investment to increase
production and exports, offers opportunities for international pressure (IHF 2004).
Alexei Malashenko, a regional expert at the Carnegie Moscow Centre, maintains,
however, that the most important foreign policy goal for the west in this region is
to maintain stability, a stability that is seen as being assured by the presence of
authoritarian regimes in Turkmenistan and other Central Asian states (IWPR
2004o).
The human rights violations in Turkmenistan have been condemned by the OSCE
and the UN. On 20 December 2003, ten participating states of the OSCE
invoked the “Moscow Mechanism” to investigate the human rights situation in
Turkmenistan following the attempted coup in November 2002. A highly critical
report by the OSCE Rapporteur on Turkmenistan, Emmanuel Decaux, was
published on 12 March 2003 (IHF 2004). The Commission on Human Rights of
the Economic and Social Council of the United Nations issued resolutions on the
human rights situation in Turkmenistan on 16 April 2003 and 15 April 2004,
condemning the violation of all human rights and fundamental freedoms (UN
2003b; UN 2004c). In December 2003 and December 2004, the UN General
Assembly adopted resolutions on human rights in Turkmenistan, expressing “its
grave concern about the serious and continuing human rights violations occurring
in Turkmenistan” (UN 2003a; UN 2004b). The European Parliament noted on 23
October 2003 that the
“already appalling human rights situation in Turkmenistan has deteriorated
dramatically recently, and there is evidence that this Central Asian state
has acquired one of the worst totalitarian systems in the world” (European
Parliament 2003).
Several international financing institutions have downscaled or ceased their
support to the country. The World Bank is not currently providing new loans to the
50
Human rights and health in Turkmenistan
country because of Turkmenistan’s failure to report its external debt and its poor
management of public resources (The World Bank Group 2003). The country
is the only state from the former communist bloc not to have concluded an IMF-
backed stabilisation programme (EU 2004). The European Bank for
Reconstruction and Development (EBRD) is currently pursuing a “baseline
scenario” in Turkmenistan, confining its activities to the promotion of private
sector activities, particularly in the areas of small and medium enterprises and
micro-finance. Expansion of its activities to an “intermediate scenario” and a
“regular scenario” will depend on achievement of a number of benchmarks,
including the registration of independent opposition parties, strengthening of the
legislature and judiciary, free elections, freedom of the press and improved human
rights (EBRD 2004).
The European Union provides multilateral assistance to Turkmenistan in the frame-
work of its Technical Assistance to the Commonwealth of Independent States
(TACIS) national programme since 1991. It signed a Partnership and Association
Agreement with Turkmenistan in 1998, but never implemented it. In June 2004,
the European Union announced that it plans to dramatically increase its assistance
to the country, with an envisaged spending of up to €35 million over a period of
five years (IRIN 2004e).
The engagement of the United States in Turkmenistan is complex. While it pro-
motes human rights and democracy, it also cultivates cooperative relations with
the abusive regime to help achieve military and investment goals. For example,
the Bush government supported Niyazov’s proposal of May 2002 to revive plans
to construct a trans-Afghanistan pipeline that would bring Turkmen gas to Pakistan
and other South Asian countries (AP 2004; Human Rights Watch 2003). The idea
was to build a pipeline to Karachi that would be operated by a US/Saudi
Arabian joint venture (EU 2004). After having been deemed unviable “due to
regional instability and Niyazov’s unpredictability” (Templeton 2004), the Asian
Development Bank’s recently released feasibility study on the pipeline has
returned the project to active consideration (ICG 2004).
While the United States has spent more than any other country on programmes
supporting pluralism, a free media, and human rights in Central Asia (IWPR
2004o), many believe that human rights have been downgraded in the list of US
priorities in favour of economic and strategic interests (IWPR 2004o). Although
noting that the “goal of democracy and human rights is our most important goal”
(RFE/RL 2003), the US ambassador to Turkmenistan, Tracey Ann Jacobson, said
in an interview with Radio Free Europe/Radio Liberty in November 2003 that
“Turkmenistan deserves recognition for its cooperation in the international coali-
tion against terrorism” (RFE/RL 2003). The so-called “war on terror” has made the
Central Asian states, in particular Uzbekistan, allies of the United States.
Turkmenistan has granted the US landing and refuelling rights for warplanes
operating in Afghanistan (Dow Jones International News 2004). In return, the
51
The reaction from the international community
Bush administration has maintained and recently renewed Turkmenistan’s normal
trade relations status (Terzieff 2004). In the summer of 2004, the country was
invited to sign a Trade and Investment Framework Agreement (TIFA) with the
United States, along with the other Central Asian countries (Luxner 2004).
Demands that Turkmenistan should be censured as being in violation of the
Jackson Vanick amendment of 1974, which obliges the US to impose sanctions
on countries that do not permit freedom of emigration (RFE/RL 2003), have so far
not been met. The US government decided in June 2004 to continue a waiver of
the amendment for a further 12-month period. Likewise, the US has consistently
resisted designating Turkmenistan as a “country of special concern” under the
terms of the International Religious Freedom Act of 1998. Designation would
authorise a variety of sanctions in response to violations of religious rights.
According to the US Institute for Foreign Policy Analysis in February 2004,
current US policy is “potentially lending credence to Islamic extremist characteri-
sations of the United States as a cynical, self-serving power” (IWPR 2004o).
The term “cynical, self-serving powers” might also be used to refer to
Turkmenistan’s relations with Russia, its most influential bilateral partner.
According to the European Union, Turkmenistan enjoys “excellent relations” with
Iran and Turkey and a “close bilateral relationship” with Russia (EU 2004). In
2004, a high-level delegation from Russia failed to find any human rights prob-
lems in the country and described Niyazov’s achievements as “fantastic” and the
Ruhnama as a “serious philosophical work” (Templeton 2004). It is very likely that
Turkmenistan’s oil and gas reserves influenced these findings. The “lure of cheap
gas has kept Moscow silent about the worst abuses” (ICG 2004). Russia’s semi-
public enterprise and the government of Turkmenistan have reached an agreement
on gas exports and security issues in April 2003. The deal contains a 25-year
agreement on gas cooperation and guarantees Turkmenistan regular gas sales,
making Russia its main energy purchaser from 2006 onwards, when agreements
with Ukraine and Iran expire, and allowing Gazprom to make lucrative exports
to Europe. The security deal includes a provision for the extradition of “terrorist”
suspects from Russia, in support of efforts by Niyazov to crack down on the Russia-
based opposition (Dubnov 2003).
As has been highlighted in other parts of the world, most notably Burma, private
industry does not shy away from doing business with dictatorships. Several of the
500 largest US companies entertain business relationships with the Niyazov
regime, including General Electric, Sikorsky, Boeing, John Deere and Caterpillar
(Luxner 2004). Israel’s Merhav Group, France’s Bouygues Group and numerous
Turkish companies under the direct and indirect ownership of businessman, Ahmet
Calik, have also concluded multimillion-dollar contracts with the Turkmen govern-
ment (Ovezberdiyev 2004).
The health crisis in Turkmenistan has yet to stimulate an adequate response from
the international community. UN organisations, including UNICEF, UNDP and
52
Human rights and health in Turkmenistan
UNFPA, have maintained their country presence, but their activities were limited
by the Turkmen Government. While there are some apparent successes in the
areas of reproductive health, immunisation and salt iodisation, these have not
prevented a deterioration in many other areas of health and health care. More
profound interventions for improving the health of the people in Turkmenistan have
yet to be undertaken and even in the areas of reproductive health and immunisa-
tion, cracks in the Turkmen health system are becoming apparent.
Under the current dictatorship, prospects for the health of the people in
Turkmenistan are bleak. An improvement will require recognition of the scale of
the current health crisis, both domestically and internationally, a sustainable
allocation of state resources to the health sector, and more carefully conditioned
foreign assistance programmes. Ultimately, however, sustained improvements
hinge on the democratisation of the country, although even then it will take many
years to overcome the disastrous legacy of the current regime.
53
Recommendations
To the Government of Turkmenistan
• Develop and implement comprehensive national health care policies and
programmes that are designed to meet the needs of the whole population of
Turkmenistan. These should be transparent, appropriately resourced from state
budget allocations, and should ensure the capacity to respond to emerging
health concerns and emergencies
• Ensure that comprehensive national health care policies and programmes are
based on international standards on the right to health and internationally
accepted goals for health care and social development, such as the resolutions
and guidelines of the World Health Organization
• Immediately rescind the order given by the President in February 2005 for the
closure of all hospitals outside the capital
• Where appropriate, re-employ health care workers dismissed in March 2004
and ensure that health care personnel are appropriately qualified and that
health care facilities are staffed in sufficient numbers
• Immediately remove the prohibition on the diagnosis of certain communicable
diseases, as well as any informal obstacles to a culture of integrity, respect for
medical ethics, and openness to appropriate scientific inquiry in the field of
diagnosis
• Report all detected cases of notifiable diseases to the international community
• Report accurately and comprehensively all health-related data to relevant UN
bodies, including statistics on communicable diseases and drug use
• Ensure adequate policy responses and budgetary allocations to the health
problems encountered by children, in particular the high infant mortality rate,
undernutrition, the decline in immunisation coverage, and the appropriate
diagnosis and treatment of childhood illnesses
• Adopt and implement the WHO definition of a live birth
• Implement fully the law of January 2005 banning child labour
54
Human rights and health in Turkmenistan
• Ensure adequate policy responses and budgetary allocations to the health
problems of women, in particular the problems of domestic violence and sex
work
• Establish or extend harm reduction measures for vulnerable population groups,
in particular prisoners, drug users and sex workers
• Ensure that NGOs, including in the health sector and those supporting vulner-
able groups, are free to register and operate without state interference
• Ensure humane conditions in prisons, including appropriate nutrition, space
and medical care, and allow international observers, including the
International Committee of the Red Cross, access to all prisoners
• End the misuse of psychiatry for political purposes and address the reported
increase in mental health problems and suicides
• Improve environmental protection, in particular ensuring the supply of safe
drinking water
• Implement the body of existing recommendations contained in resolutions of
the UN Commission on Human Rights, the UN General Assembly and the
report of the OSCE Rapporteur on Turkmenistan
To the United Nations
• Appoint a Special Rapporteur on Human Rights for Turkmenistan
• Include health-related demands in future resolutions on Turkmenistan, such as
the above recommendations addressed to the government of Turkmenistan
To the European Union
• Re-examine the technical assistance provided to Turkmenistan in the framework
of the TACIS programme, in view of the human rights and public health situa-
tion in the country
• Ensure that relevant proposals for EU external assistance programmes for
Turkmenistan for 2007 onwards maintain clear and unambiguous references
to supporting public health as well as to promoting and defending human
rights
• Ensure that European Parliament recommendations and Council and
Commission statements on Turkmenistan include health-related demands, such
as the above recommendations addressed to the government of Turkmenistan
55
Recommendations
To the Government of the United Kingdom
• Designate Turkmenistan a priority country under the terms of the Foreign and
Commonwealth Office’s Sustainable Development Programme for
2005/2006 and its core human rights priorities of child rights and combating
torture
• Systematically monitor violations of human rights and the right to health care
in Turkmenistan and document them in the Foreign and Commonwealth
Office’s Annual Report on Human Rights
• Expand support to Turkmenistan through the Foreign and Commonwealth
Office’s Drugs and Crime Fund to include an approach based on prevention
and harm reduction
• In conjunction with the British Embassy in Ashgabat, facilitate the issuance of
visas and scholarships for medical personnel from Turkmenistan wishing to
study or train in the UK, and help supply up-to-date textbooks for distribution
inside the country
• Work in the EU, the OSCE and the UN to raise awareness of the health crisis
in Turkmenistan
• Use the occasion of the UK Presidency of the European Union in the second
half of 2005 to initiate new EU statements reflecting human rights and health
concerns in Turkmenistan
To the Government of the Russian Federation
• Exert pressure for an improvement of the situation of Russian-speaking minori-
ties in Turkmenistan, including access to Russian-language education and
media
• Prosecute vigorously and punish violent attacks on Turkmen dissidents living in
Russia
To the Government of the United States
• Unless measurable, sustained improvements in compliance with religious
freedom guarantees are achieved, invoke the International Religious Freedom
Act and declare Turkmenistan a “country of particular concern”
56
Human rights and health in Turkmenistan
To all international actors and donors
• Agree on a list of health and human rights benchmarks as a condition for the
provision of external assistance
• Exert pressure on companies that cooperate with the Turkmen government, in
particular where they rely on child labour
• Support media and NGO activities inside and outside the country, including
support for international Turkmen- and Russian-language broadcasts
• Exert pressure on the government of Turkmenistan to report publicly, accurate-
ly and comprehensively all health-related data and to adopt measures to
provide adequate health care to all citizens in conformity with international
obligations
• Increase aid to those activities that will benefit the population directly, in
particular the health sector, paying particular attention to medical and public
health training and the provision of up-to-date medical literature
• Create affordable educational opportunities for students from Turkmenistan,
including in the fields of medicine and public health, both in Turkmenistan and
abroad
• Assist Turkmen institutions in the fight against infectious diseases by supporting
harm reduction activities
57
Appendices
Abbreviations
AFP Acute Flaccid Paralysis
AP Associated Press
BBC British Broadcasting Corporation
CIA Central Intelligence Agency
DHS Demographic and Health Survey
DOTS Directly Observed Treatment, Short course
EBRD European Bank for Reconstruction and Development
EU European Union
EU-15 The 15 countries constituting the European Union before May 2004
GDP Gross Domestic Product
HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency
Syndrome
Source: The United Nations Cartographic Section, Map No. 3772 Rev. 8, 2004.
Map of Turkmenistan
58
Human rights and health in Turkmenistan
ICNL International Center for Not-For-Profit Law
IEC Information, Education, Communication
ICG International Crisis Group
IHF International Helsinki Foundation
IRIN Integrated Regional Information Networks
IUD Intra-Uterine Device
IWPR Institute for War & Peace Reporting
KGB Committee for State Security
KNB National Security Committee
LSMS Living Standards Measurement Survey
MNS Ministry of National Security
NGO Non-governmental organisation
OSCE Organisation for Security and Cooperation in Europe
OSI Open Society Institute
RFE/RL Radio Free Europe/Radio Liberty
STI Sexually Transmitted Infections
TACIS Technical Assistance to the Commonwealth of Independent States
THF Turkmenistan Helsinki Foundation
TIFA Trade and Investment Framework Agreement
UN United Nations
UNAIDS Joint United Nations Programme on HIV/AIDS
UNDP United Nations Development Programme
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
UNODC United Nations Office on Drugs and Crime
USAID United States Agency for International Development
WHO World Health Organization
59
Appendices
Useful websites
Turkmenistan Helsinki
Foundation www.tmhelsinki.org/english/index.htm
Eurasianet www.eurasianet.org/resource/turkmenistan/index.shtml
Open Society Institute
Turkmenistan Project www.eurasianet.org/turkmenistan.project
Radio Free Europe/Radio
Liberty www.rferl.org/reports/centralasia
Institute for War & Peace
Reporting www.iwpr.net/centasia_index1.html
IRIN News www.irinnews.org
BBC http://news.bbc.co.uk/1/hi/world/asia-pacific/
country_profiles/1298497.stm
WHO www.who.int/countries/tkm/en
European Observatory on
Health Systems and Policies www.observatory.dk
UNICEF www.unicef.org/infobycountry/Turkmenistan.html
World Bank www.worldbank.org/tm
UNDP www.undptkm.org
CIA World Factbook www.cia.gov/cia/publications/factbook/geos/tx.html
Amnesty International http://web.amnesty.org/report2004/tkm-summary-eng
Human Rights Watch www.hrw.org/doc?t=europe&c=turkme
Watan opposition site www.watan.ru/eng/main.php?razd=new_nov_en
Gündogar opposition site www.gundogar.org
Official government site www.turkmenistan.gov.tm/index_eng.html
Pro-government news site www.newscentralasia.com
60
Human rights and health in Turkmenistan
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