8 Feb, 11 | by BMJ
Before Christmas I participated in an educational event for obstetricians and perinatologists from Kyrgyzstan, Uzbekistan, and Tajikistan. It was arranged by GTZ (German Technical Cooperation) as part of their project in the region.
Over the past few years, Central Asia has become the area for testing new approaches. First all the funding from donors was collected in one fund for coordinated technical assistance in healthcare development. Next USAID and GTZ initiated projects which are going to last for longer than before – each project is 9 years long.These changes are the result of lessons learned during 20 years of assistance to former Soviet republics.
One of the first changes to the transforming Soviet Union and the new states which emerged from its ruins was the introduction of a new criterion of live birth. In the 1970-80s in Europe, this new criterion was introduced and it was a serious shock to health care systems – even in the richest countries. Twenty years later the same step was offered to poor Central Asian countries by donors and their experts. It was offered when the postneonatal death rate in these countries was about 30 per 1000 births. The current rate is not known, but the estimates say that child and maternal mortality is improving. The gap between the reality and the numbers available for us at HFADB is probably decreasing, but we do not know for sure. At first sight it is just an order on a piece of paper – switching to a new criterion. In reality it leads to a huge new demand for trained specialists, equipment, and drugs.
Naturally, if you change the live birth criteria, you are obliged to help newborns with a very low birth weight (VLBM). So, at the same time resources from donors were spent on expensive equipment. A number of local obstetricians received training in donor countries. Now it is a great pleasure to see some of these people who benefitted from international cooperation and who gained a better understanding of the different healthcare systems and their own specialist field.
Of course, some of these specialists emigrated to countries with better economic conditions. Russia benefited most because there is mutual recognition of diplomas and no language barrier.
Unfortunately, the investments in the treatment of the newborns of very low birth weight and in related expensive equipment were not very effective. They may not be effective, because even big hospitals (200-400 beds) still function without a central water supply and in the winter the hospital is heated by stoves. Drug therapy in hospitals is provided for 10 US cents per day.
Despite best intentions, trying to offer the best Western practices to poor countries has resulted in the disproportional use of limited resources on these interventions, which are simply not cost effective.
The incompatibility of the reality and the efforts to introduce the most advanced technologies is now better understood, in my opinion, by both German and American projects. But there is a long road ahead to the most effective introduction of the most affordable practices, not only in healthcare, but also in how families look after their children.
Examples of child care, particular to Central Asia, which have been shamed by Western experts are the somek and bishik (these are Kyrgyz names, other Central Asian nations use more or less similar names for them). Bishik is a cradle. It is different from European ones in shape, so that it can be conveniently transported by horse. The most intriguing part is a hole in the middle of the bottom. It is for the somek. Somek is a wooden tube for urine. There are different shapes for boys and girls. The child with a somek on is bundled up and put on one’s back, for a long time, when his father, mother, grandmother or grandfather work around the house, with animals, etc. You can see photos of the Kazakh cradle and Uzbek bishik here.
Western experts advised that a more modern dressing should be used which allows the child to move around freely. Of course, since the fall of the Soviet Union, people are becoming more Westernised. But the problem is that disposable nappies are unaffordable for about 99% of the population of Central Asian countries. In places like the Pamir Mountains, there is plenty of water from snow in the winter, but there is not enough natural fuel to heat the cabin, let alone enough hot water for a child’s bath. Is the practice of using a somek and bishik harmful? We simply do not know. People say that children’s heads may be flat because of somek and bishik use. But is this flatness important for the personal development and health? We do not know.
We know that this practice was very widespread – at least from Iran and Iraq to the Caucasus and to Kazakhstan. But I am mostly interested in the behaviour of people in Central Asia today. Specifically: should modern physicians in Kyrgyzstan recommend their patients abstain from the old practice? To what extent should a good physician insist that families buy disposable diapers instead of milk, meat, and vegetables for the family? In my understanding, specific practices like the somek and bishik are the part of the culture, and they need to be eliminated only if they are harmful. If they are erased by people’s intention to be like Europeans – it is up to them, and it will not be our – physicians’ – responsibility.
What we may offer, is help in the study of the health consequences of these traditional practices, and to recommend abstaining only from harmful ones. Otherwise, the technical support is misaddressed, and is spent on unnecessary interventions, leads to unsustainable changes, and is an imposition on local cultures.
Vasiliy Vlassov is a professor of medicine at the Higher School of Economics, Moscow. His research interests are in epidemiology, evaluation of diagnostic tests, public health, and especially healthcare delivery with scarce resources. He is the co-founder and current president of the Russian Society for Evidence Based Medicine.