JECH Online First, published on August 7, 2015 as 10.1136/jech-2015-206251
Essay
Health challenges in Kazakhstan and Central Asia Shalkar Adambekov,1 Aiym Kaiyrlykyzy,1 Nurbek Igissinov,2 Faina Linkov3,4 1
Center for Life Sciences, Nazarbayev University, Astana, Kazakhstan 2 Central Asian Cancer Institute, Astana, Kazakhstan 3 Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA 4 Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Women’s Research Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA Correspondence to Dr Faina Linkov, University of Pittsburgh School of Medicine, 3380 Blvd of Allies, Room 307, Pittsburgh, PA 15213, USA, [email protected] Received 22 June 2015 Revised 10 July 2015 Accepted 14 July 2015
ABSTRACT The Central Asian region, which encompasses Kazakhstan, Uzbekistan, Tajikistan, Turkmenistan and Kyrgyzstan, is an interesting geographic region with a rich history dating back to the Silk Road, Mongol conquests and expansion of the Russian Empire. However, from a public health viewpoint, the Central Asian region is under-investigated, and many public health challenges exist, as countries of Central Asia inherited the centralised medical systems practiced in the Soviet Union, and are currently undergoing rapid transitions. A large number of low and middle-income countries around the world, including countries of Central Asia, face a double burden of chronic and infectious disease. This essay focuses on the exploration of the most important public health challenges in the Central Asian region, including limited scientific productivity, the double burden of chronic and infectious disease, the need for healthcare reform and the reduction in care variation. Central Asia has a large number of medical schools, medical centres, and emerging research institutes that can be used to foster a change in medical and public health practice in the region.
INTRODUCTION
To cite: Adambekov S, Kaiyrlykyzy A, Igissinov N, et al. J Epidemiol Community Health Published Online First: [ please include Day Month Year] doi:10.1136/jech-2015206251
The Central Asian region, which encompasses Kazakhstan, Uzbekistan, Tajikistan, Turkmenistan and Kyrgyzstan, is an interesting and underinvestigated geographic area from a public health point of view. The region has a rich cultural and scientific heritage dating back to the Silk Road, Mongol conquests and the expansion of the Russian Empire (figure 1, Map of Central Asia). Interesting genetic variations in populations living in the centre of the Eurasian continent make these populations highly unique for public health risk factor research. It is a multiethnic and multicultural region, which has dramatic implications for health practices.1 The Central Asian region is endemic territory for many infectious diseases, including viral hepatitis (conditions that increase the risk of liver cirrhosis and cancer), haemorrhagic fevers, and nosocomial and blood-borne infections. An additional public health challenge in Central Asia is the uncontrolled use of and self-medication with antibiotics,2 potentially leading to antibiotic resistance for conditions such as tuberculosis (TB). Maternal and child health continues to be an ongoing public health concern in this region, with many women of reproductive age suffering from anaemia and not receiving regular healthcare prior to becoming pregnant.3 Central Asia also has intriguing challenges when it comes to environmental health, including climate change, nuclear testing, water allocation and urbanisation, which makes it a unique site of research for
multiple disciplines.4 Along with geographical and ethnical diversity, the region is interesting from a medical system infrastructure point, as it has been undergoing economic transition from the Soviet era central planning system to more modern approaches to healthcare infrastructure, which has direct impact on healthcare systems and the health of the population. While there is a network of ‘feldsters’, or middle primary healthcare providers, the system is very cumbersome, needs restructuring, and is not always efficient in the use of existing resources. Evidence-based medicine is not always practiced due to the slow transition of scientific medicine into day to day medical and public health practice. Many of the public health challenges continue to exist in this region, as countries of Central Asia inherited the centralised medical system practiced in the Soviet Union. It must be noted that healthcare reforms occurring since the breakup of the Soviet Union in 1991 had different rates of success across the Central Asian region. The degree of success was largely dependent on the consistency of government policy and the state of economic development. Most countries of Central Asia started to embark on wide-ranging reforms in the second half of the 1990s; however, the pace has varied, with Kazakhstan only adopting a systematic approach after 2004, while reforms in Tajikistan were delayed by the civil war.5 While the public health challenges outlined in this essay can present themselves in any developing country, problems experienced in Central Asian health systems partially result from the collapse of the Semashko centralised healthcare system of the Soviet Union, and are associated with the subsequent transition period and the global restructuring of healthcare systems in these countries. In general, health facilities are still funded according to rigid budget line items, which reinforce excess hospital capacity and offer little opportunity for innovation by managers or staff, while potentially encouraging wasteful patterns of treatment.6 During the past two decades, countries of Central Asia attempted to transform their centrally planned, supply-driven healthcare systems and implemented many interesting innovations.7 For instance, since gaining independence, Kazakhstan has undertaken major efforts to reduce expenditures on the hospital sector and to focus on primary healthcare.8 However, developments from the region receive little attention in English language biomedical literature, as the majority of Central Asian scientists tend to publish in local journals. Moreover, renovations in healthcare systems in Central Asia must cope with the old problems that have never been resolved, as well as to rapidly adapt to the newly emerging challenges. Chronic
Adambekov S, et al. J Epidemiol Community Health 2015;0:1–5. doi:10.1136/jech-2015-206251
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
Essay
Figure 1 Map of Central Asia (from Wikipedia the free encyclopaedia).
diseases, such as cardiovascular disease and cancer, are the leading cause of mortality in Central Asia.9 With the epidemiological transition, we would expect to see more morbidity and mortality associated with chronic diseases, such as diabetes, and obesity, in Central Asia; however, current research publications coming out of the region do not reflect the importance of this problem. In addition, over the past two decades, there has been a resurgence of TB, viral hepatitis, HIV and other infectious diseases, which demonstrates that infectious disease continues to be a burden in the region. The proposed essay has been dedicated to highlight some of the important public health challenges that we are seeing in Central Asia today, and will be seeing in the next decades. These include: (1) the double burden of chronic and infectious disease; (2) the need to improve scientific productivity especially in the areas of public health and biomedical research; and (3) the need to focus on healthcare reform where prevention and reducing unnecessary variation in care are priorities. It will also provide a short overview of the research potential of the region, as it has a large number of research institutions and academic centres.
Double burden of chronic and infectious disease: special consideration needed for women’s health A large number of low and middle-income countries around the world, including those of Central Asia, face a double burden of chronic and infectious disease. These countries must deal with increasing prevalence of risk factors for chronic diseases, such as diabetes, heart disease and cancer, while at the same time struggling to reduce the rate of infectious diseases.10 Chronic disease, 2
especially in the area of women’s health, is a pressing public health priority in the Central Asian region due to several prevalent risk factors, such as high rates of smoking and increasing obesity rates.11 With the rising obesity epidemic, Central Asian populations are becoming at higher risk of obesity and its associated chronic diseases; however, awareness of obesity as a risk factor for cancer and some other diseases (such as diabetes), is deficient. Breast cancer is one of the most prevalent women’s cancers in Central Asia, and in Kazakhstan in particular and has been linked to obesity and environmental pollution.12 Limited access to mammography facilities for breast cancer detection and proper treatment facilities for those with diagnosed cancer, creates a big burden for breast cancer. Breast and other cancers (such as lung cancer), are exacerbated by high levels of smoking. One of the challenges faced by professionals dealing with cancer and other chronic diseases in Central Asia is the lack of formal chronic disease registries. There is hope that registries will be developed in the next decade, as in 2012, when Kazakhstan initiated the development of the electronic cancer registry, and in 2014, Astana, Kazakhstan, hosted one of the first training courses on cancer registry development methods.13 14 A recent publication suggests that in Kazakhstan and Kyrgyzstan, large gaps exist in public understanding of the negative health effects of tobacco use, particularly about the harm associated with the use of ‘light’ cigarettes.15 Thus, smoking cessation and smoking awareness programmes will gain significance in the Central Asian region over the next decades. Despite substantial advances in reducing HIV incidence, and expanding access to antiretroviral therapy (ART), Central Asia lags behind gains made in other countries.16 In addition, rates
Adambekov S, et al. J Epidemiol Community Health 2015;0:1–5. doi:10.1136/jech-2015-206251
Essay of tuberculosis in Central Asia are extremely high, and even more alarming are the very high rates of multidrug-resistant TB (MDR-TB) in Kazakhstan, Uzbekistan, Tajikistan and Kyrgyzstan.17 Rates of HIV infection related to injection drug use seem to be rising as well, thereby creating conditions for a potentially devastating coepidemic of TB/HIV and MDR-TB/ HIV, which would have terrible consequences for public health in these countries.17 Infection-associated cancers also pose a challenge. Resistance to uptake, lack of access to human papillomavirus vaccine and inconsistent Pap smear testing lead to cervical cancer rates that are higher in Central Asia than in the developed world, especially in Kyrgyzstan and Kazakhstan.18 Incidence of gastric cancer associated with Helicobacter pylori infection is also on the rise.19 When we evaluate the chronic disease burden of the region, interesting variations exist among various ethnic groups. For example, in Central Asia, ethnic Russians have exhibited higher adult mortality than native ethnic groups (eg, Kazakh, Kyrgyz and Uzbek) in spite of the higher socioeconomic status of ethnic Russians. The mortality disadvantage of ethnic Russians in adulthood appears to have even increased since the breakup of the Soviet Union.20 Ethnic variations also exist in women’s cancer morbidity, including gynaecological malignancies.21 22 Thus, more research is needed to explain and understand how to manage and alleviate the double burden of chronic and infectious disease in the Central Asian region.
Lack of formalised epidemiological research programmes and scientific productivity Despite the fact that the Central Asian region has a number of medical schools, very few schools and programmes target public health and epidemiological research. There is a lack of specialists with adequate training in epidemiology and biostatistics in existing medical research institutions, which leads to a lower number of quality publications. For example, there is a large gap in the numbers of publications by scientists in Kazakhstan compared to those by scientists in the developed world. Scientists in Kazakhstan and Central Asia have difficulty publishing in existing journals due to many reasons, including scientific isolation, language barriers, low motivation, high publication fees for open access journals, etc. While Kazakhstan is the second leading country in Central Asia in terms of the number of publications, the scientific productivity of scientists in Kazakhstan is still relatively low compared to high-income countries such as the USA and the UK, and even other middle-income countries, including Iran, Georgia and Cuba. Interestingly, whereas Iran ranks 23rd in the overall number of scientific publications, Kazakhstan ranks at 91st place, suggesting there is big potential for improvement (based on SCImago data23). The data on publications in Kazakhstan and other Central Asian countries is presented in figures 2 and 3 (based on SCImago data23). Starting in 2003, the number of publications by Kazakhstani authors has been steadily increasing. The breakdown by years (figure 2) shows a significant increase in the number of general publications starting from 2009. Particularly, Kazakhstani authors published 508 publications in 2011, 809 publications in 2012 and 1607 publications in 2013. Interestingly, the share of health-related sciences, such as Medicine, Public Health, Environmental and Occupational Health, Epidemiology and Health Policy, in the overall number of publications from Kazakhstan, is strikingly small, and accounts for no more than 6% of all the publications. In 2012,
Figure 2
General number of Central Asian publications 1996–2013.
Kazakhstani authors published a total of 93 articles in these areas.23 Despite the fact that these figures are still low, Kazakhstan has emerged as a leader in medical publishing from the Central Asian region (figure 3). In the overall SCImago ranking of scientific contribution to health-related disciplines, Kazakhstan ranks 130th in Medicine with 506 publications, 121st in Public Health, Environmental and Occupational Health with 93 publications, 94th in Epidemiology with 45 publications and 118th place in Health Policy with 11 publications, among the countries with documented existing publications in respective fields. Despite the overall increase in the number of published documents, the publishing pattern of Central Asian medical sciences is uneven, and publishing indexes vary significantly between years. The scientific publications of Central Asian authors in international journals are accessible for analysis due to commonly used databases such as PubMed, Scopus and Web of Science. However, it is much more difficult to assess scientific productivity of Central Asian authors publishing in local journals that are published in Russian or local languages. Most journals do not publish online; even abstracts are largely inaccessible. Out of 30 state approved medical journals in Kazakhstan,24 only 12 started publishing their articles online utilising pages of their home institutions. The largest Russian open access database, Cyberleninka,25 cites two Kazakhstani medical journals and 62 articles from Kazakhstan. As of 2015, existing Russian language scientific databases in the Central Asian region provide limited metadata on article authors or content. Using Kazakhstan as an example, individual analysis of each of the 12 journals with web pages shows that around 7000 articles, mostly in Russian, are accessible to the readership online, compared to 506 articles from Kazakhstan published in the Scopus database. Considering that most of the journals have
Figure 3 2013.
Adambekov S, et al. J Epidemiol Community Health 2015;0:1–5. doi:10.1136/jech-2015-206251
Number of Central Asian publications in Medicine for 1996– 3
Essay long publishing histories and have not digitalised their archives, the number of existing articles in Kazakhstan in the field of medicine could be much more than 7000. As a result, a vast number of medical research articles produced in Kazakhstan is unknown for non-Russian speakers, and is not cited in international databases. The information on Uzbekistan, Tajikistan and Kyrgyzstan, is even less accessible due to the use of national languages. The Central Asian Journal of Global Health is a new English language online scientific journal that aims to help Central Asian scientists to publish their scientific discoveries (cajgh.pitt.edu). This is a newly launched journal that focuses on publishing peer reviewed research data, reviews, and other important issues relevant to various fields of public health and biomedicine.26 The Central Asian Journal of Global Health has been initiated with the hope of improving scientific productivity in the region. With new online educational technologies, we believe that access to scientific publishing will be increasing over the next decade.27
Adherence to standard treatment recommendations and future directions Some of the healthcare challenges experienced in Central Asian countries include those associated with lack of access to standardised treatment. Although progress in developing evidencebased medicine is being made, the isolation of Soviet era science from Western developments has resulted in the widespread use of outdated and non-scientifically validated diagnostic procedures and treatment protocols, while finance mechanisms may still encourage unnecessary hospitalisations and treatments.28 29 For example, research indicates that, in various countries of the former Soviet Union, a high proportion of those who have been identified by health professionals as requiring hypertension treatment are not taking it daily.30 31 The system that aims to reduce variation in care while improving patient outcomes, which has been implemented in the USA and other developed countries, is the system of clinical pathways.32–35 A clinical pathway is a management tool for standardising the way physicians and other healthcare providers treat a disease. They are based on clinical guidelines or other commonly used clinical parameters. Pathways that were implemented for treatment of cancers have been expanded for use in other conditions. Further research on clinical pathways and integrating them into clinical care algorithms in Central Asian countries will have great potential in improving care, while containing the costs.
CONCLUSIONS This essay outlined some of the basic public health challenges faced by Central Asian countries. They include the double burden of chronic and infectious diseases, limited scientific productivity and problems associated with lack of treatment standardisation, especially across geographic and SES boundaries. Further research is needed to find the most effective strategies to resolve these problems and identify organisations that will be able to serve as agents of health system changes as the Central Asian region moves forward with transforming its healthcare systems. In the past two decades, many papers have been published on the interconnection and interdependence of health, inequality and human rights,36 a concept that is especially relevant to transitioning healthcare systems of the Central Asian region. The level of inequality within a country, as well as distribution of wealth and presence of democratic processes, may be important determinants of health.37 Central Asian states are attempting to 4
develop their own paths towards democracy by fusing established democratic standards with their own cultural and political norms.37 Despite developments in the past two decades, the World Bank reports that the GINI coefficient (the measure of income inequality) is still high in the Central Asian region.38 The hope is that as the region further develops, inequality will be reduced, leading to improvement in health. The Central Asian region has a large number of medical schools and research institutions, which potentially could be sites for public health and medical research. Specifically, the five Central Asian countries, Kazakhstan, Uzbekistan, Kyrgyzstan, Tajikistan and Turkmenistan, have around 24 schools, offering hope for improved public health and research methods training. Similarly, medical centres can be used for the same purpose of promoting public health research. These institutions can serve as a foundation for improving public health research in the region, starting with improving training in research methods and establishing disease registries in the region. Prevention of both infectious and chronic disease using effective smoking cessation programmes, weight loss programmes and screening tests are the low hanging fruits in improving the health of Central Asian populations. Allowing Central Asian scientists to publish their research findings will help to build the research capital of the region. Central Asia has a large number of medical schools, medical centres and emerging research institutes that can be used to foster change in medical and public health practice in the region.
Key messages ▸ Central Asian region has unique public health and medical challenges. ▸ One of the key public health challenges in Central Asia is double burden of chronic and infectious diseases ▸ Central Asian research is not known to the public health and medical scientists around the world. ▸ There are many organizations in Kazakhstan and other Central Asian countries that can be utilized to foster change in medical and public health practices of the region.
Twitter Follow Nurbek Igissinov at @Nurbek Igissinov Acknowledgements The authors would like to thank Drs Ronald LaPorte and Eugene Shubnikov for their contributions to the development of this article. The authors would also like to thank Ms Sharon Goughnour for her editorial help. Collaborators Ronald LaPorte, Eugene Shubnikov and Sharon Goughnour. Contributors FL took a lead on article finalising and submission. All contributors were responsible for study concept design, implementation and publishing. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Competing interests None declared. Provenance and peer review Commissioned; externally peer reviewed. Data sharing statement Data were collected for this study only.
REFERENCES 1
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Agadjanian V, Dommaraju P, Nedoluzhko L. Economic fortunes, ethnic divides, and marriage and fertility in Central Asia: Kazakhstan and Kyrgyzstan compared. J Pop Res 2013;30:197–211. Belkina T, Al Warafi A, Hussein Eltom E, et al. Antibiotic use and knowledge in the community of Yemen, Saudi Arabia, and Uzbekistan. J Infect Dev Ctries 2014;8:424–9. Tazhibayev SDO, Yessimsiitova Z, Bazarbayeva Zh, et al. Prevalence of anaemia in non-pregnant women of reproductive age in three counties of Kazakhstan:
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a cross-sectional study. Eur J Public Health 2014:24 http://dx.doi.org/10.1093/ eurpub/cku151.004 Siegfried T, Bernauer T, Guiennet R, et al. Will climate change exacerbate water stress in Central Asia? Climatic Change 2012;112:881–99. Kulzhanov MRB. Health Systems in Transition. 2007. http://www.euro.who.int/__ data/assets/pdf_file/0007/85498/E90977.pdf (accessed 1 Jul 2015). Research EOoHCS. Health care in Central Asia. In: McKee M, Healy J, Falkingham J, eds. Policy Brief: Open University Press, 2002. Fidler A, Bredenkamp C, Schlippert S. Innovations in health services delivery from transition economies in Eastern Europe and Central Asia. Health Aff (Millwood) 2009;28:1011–21. Katsaga A, Kulzhanov M, Karanikolos M, et al. Kazakhstan health system review. Health Syst Transit 2012;14:1–154. Aringazina AGG, Allegrante JP. Public health challenges and priorities for Kazakhstan. Cent Asian J Glob Health 2012;1. World Health Organization World Health Statistics Report 2011. http://www.who. int/whosis/whostat/2011/en/ (accessed Jul 27 2015). Kydyralieva RB. The state of cardiovascular disease in the Kyrgyz republic. Cent Asian J Glob Health 2013;2. Bilyalova Z, Igissinov N, Moore M, et al. Epidemiological evaluation of breast cancer in ecological areas of Kazakhstan—association with pollution emissions. Asian Pac J Cancer Prev 2012;13:2341–4. Electronic cancer registry of the Republic of Kazakhstan. 2012. https://www. cuba-platform.com/ru/case-studies/erob (accessed 28 Jun 2015). Cancer WIAfRo. Basic Cancer Registration and CanReg5 Course in Russian. 2014. http://gicr.iarc.fr/en/Actions/Astana (accessed 28 Jun 2015). Roberts B, Stickley A, Gilmore AB, et al. Knowledge of the health impacts of smoking and public attitudes towards tobacco control in the former Soviet Union. Tob Control 2013;22:e12. El-Bassel N, Strathdee SA, El Sadr WM. HIV and people who use drugs in central Asia: confronting the perfect storm. Drug Alcohol Depend 2013;132(Suppl 1):S2–6. Schluger NW, El-Bassel N, Hermosilla S, et al. Tuberculosis, drug use and HIV infection in Central Asia: an urgent need for attention. Drug Alcohol Depend 2013;132(Suppl 1):S32–6. Bray F, Lortet-Tieulent J, Znaor A, et al. Patterns and trends in human papillomavirus-related diseases in Central and Eastern Europe and Central Asia. Vaccine 2013;31(Suppl 7):H32–45. Benberin V, Bektayeva R, Karabayeva R, et al. Prevalence of H. pylori infection and atrophic gastritis among symptomatic and dyspeptic adults in Kazakhstan. A hospital-based screening study using a panel of serum biomarkers. Anticancer Res 2013;33:4595–602.
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Guillot M, Gavrilova N, Pudrovska T. Understanding the “Russian mortality paradox” in Central Asia: evidence from Kyrgyzstan. Demography 2011;48:1081–104. Igisinov N. Ethnic and age variation of cancer of the reproductive system in women of Kyrgyzstan. Asian Pac J Cancer Prev 2004;5:217–22. Igisinov N, Umaralieva G. Epidemiology of ovarian cancer in Kyrgyzstan women of reproductive age. Asian Pac J Cancer Prev 2008;9:331–4. SCImago Journal & Country Rank. 2008. http://www.scimagojr.com/index.php (accessed 30 Jun 2015). Catalogue of Dissertation Materials. 2015. http://lib-kguti.kz/index.php/2011–10– 19–06–40–50 (accessed 2 Jul 2015). CyberLeninka Online Electronic Information Repository. 2015. http://cyberleninka.ru/ (accessed 6 Jul 2015). Sharman A. Modernization and growth in Kazakhstan. Cent Asian J Glob Health 2012;1. Janz RF KA. The Case of NRENs in Central Asia. Cent Asian J Glob Health 2012;1. Danichevski K, McKee M, Balabanova D. Prescribing in maternity care in Russia: the legacy of Soviet medicine. Health Policy 2008;85:242–51. Rechel B, Kennedy C, McKee M, et al. The Soviet legacy in diagnosis and treatment: implications for population health. J Public Health Policy 2011;32:293–304. Roberts B, Stickley A, Balabanova D, et al. The persistence of irregular treatment of hypertension in the former Soviet Union. J Epidemiol Commun Health 2012;66:1079–82. Roberts B, Stickley A, Balabanova D, et al. Irregular treatment of hypertension in the former Soviet Union. J Epidemiol Commun Health 2012;66:482–8. Feinberg BA, Lang J, Grzegorczyk J, et al. Implementation of cancer clinical care pathways: a successful model of collaboration between payers and providers. J Oncol Pract 2012;8(3 Suppl):e38s–43s. Goozner M. Clinical pathways can lead to better cancer care. Mod Healthc 2014;44:24. Ellis PG. Development and implementation of oncology care pathways in an integrated care network: the Via Oncology Pathways experience. J Oncol Pract 2013;9:171–3. Brufsky A, Lokay K. How to develop and deliver pathway-based care. Hematol Oncol Clin North Am 2013;27:843–50, x. Mann JM, Gostin L, Gruskin S, et al. Health and human rights. Health Hum Rights 1994;1:6–23. Kukeyeva F, Shkapyak O. Central Asia’s transition to democracy. Procedia-Soc Behav Sci 2013;81:79–83. The World Bank GINI Index. 2015. http://data.worldbank.org/indicator/SI.POV.GINI/ countries?display=default (accessed 6 Jul 2015).
Adambekov S, et al. J Epidemiol Community Health 2015;0:1–5. doi:10.1136/jech-2015-206251
5
Essay
Health challenges in Kazakhstan and Central Asia Shalkar Adambekov,1 Aiym Kaiyrlykyzy,1 Nurbek Igissinov,2 Faina Linkov3,4 1
Center for Life Sciences, Nazarbayev University, Astana, Kazakhstan 2 Central Asian Cancer Institute, Astana, Kazakhstan 3 Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA 4 Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Women’s Research Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA Correspondence to Dr Faina Linkov, University of Pittsburgh School of Medicine, 3380 Blvd of Allies, Room 307, Pittsburgh, PA 15213, USA, [email protected] Received 22 June 2015 Revised 10 July 2015 Accepted 14 July 2015
ABSTRACT The Central Asian region, which encompasses Kazakhstan, Uzbekistan, Tajikistan, Turkmenistan and Kyrgyzstan, is an interesting geographic region with a rich history dating back to the Silk Road, Mongol conquests and expansion of the Russian Empire. However, from a public health viewpoint, the Central Asian region is under-investigated, and many public health challenges exist, as countries of Central Asia inherited the centralised medical systems practiced in the Soviet Union, and are currently undergoing rapid transitions. A large number of low and middle-income countries around the world, including countries of Central Asia, face a double burden of chronic and infectious disease. This essay focuses on the exploration of the most important public health challenges in the Central Asian region, including limited scientific productivity, the double burden of chronic and infectious disease, the need for healthcare reform and the reduction in care variation. Central Asia has a large number of medical schools, medical centres, and emerging research institutes that can be used to foster a change in medical and public health practice in the region.
INTRODUCTION
To cite: Adambekov S, Kaiyrlykyzy A, Igissinov N, et al. J Epidemiol Community Health Published Online First: [ please include Day Month Year] doi:10.1136/jech-2015206251
The Central Asian region, which encompasses Kazakhstan, Uzbekistan, Tajikistan, Turkmenistan and Kyrgyzstan, is an interesting and underinvestigated geographic area from a public health point of view. The region has a rich cultural and scientific heritage dating back to the Silk Road, Mongol conquests and the expansion of the Russian Empire (figure 1, Map of Central Asia). Interesting genetic variations in populations living in the centre of the Eurasian continent make these populations highly unique for public health risk factor research. It is a multiethnic and multicultural region, which has dramatic implications for health practices.1 The Central Asian region is endemic territory for many infectious diseases, including viral hepatitis (conditions that increase the risk of liver cirrhosis and cancer), haemorrhagic fevers, and nosocomial and blood-borne infections. An additional public health challenge in Central Asia is the uncontrolled use of and self-medication with antibiotics,2 potentially leading to antibiotic resistance for conditions such as tuberculosis (TB). Maternal and child health continues to be an ongoing public health concern in this region, with many women of reproductive age suffering from anaemia and not receiving regular healthcare prior to becoming pregnant.3 Central Asia also has intriguing challenges when it comes to environmental health, including climate change, nuclear testing, water allocation and urbanisation, which makes it a unique site of research for
multiple disciplines.4 Along with geographical and ethnical diversity, the region is interesting from a medical system infrastructure point, as it has been undergoing economic transition from the Soviet era central planning system to more modern approaches to healthcare infrastructure, which has direct impact on healthcare systems and the health of the population. While there is a network of ‘feldsters’, or middle primary healthcare providers, the system is very cumbersome, needs restructuring, and is not always efficient in the use of existing resources. Evidence-based medicine is not always practiced due to the slow transition of scientific medicine into day to day medical and public health practice. Many of the public health challenges continue to exist in this region, as countries of Central Asia inherited the centralised medical system practiced in the Soviet Union. It must be noted that healthcare reforms occurring since the breakup of the Soviet Union in 1991 had different rates of success across the Central Asian region. The degree of success was largely dependent on the consistency of government policy and the state of economic development. Most countries of Central Asia started to embark on wide-ranging reforms in the second half of the 1990s; however, the pace has varied, with Kazakhstan only adopting a systematic approach after 2004, while reforms in Tajikistan were delayed by the civil war.5 While the public health challenges outlined in this essay can present themselves in any developing country, problems experienced in Central Asian health systems partially result from the collapse of the Semashko centralised healthcare system of the Soviet Union, and are associated with the subsequent transition period and the global restructuring of healthcare systems in these countries. In general, health facilities are still funded according to rigid budget line items, which reinforce excess hospital capacity and offer little opportunity for innovation by managers or staff, while potentially encouraging wasteful patterns of treatment.6 During the past two decades, countries of Central Asia attempted to transform their centrally planned, supply-driven healthcare systems and implemented many interesting innovations.7 For instance, since gaining independence, Kazakhstan has undertaken major efforts to reduce expenditures on the hospital sector and to focus on primary healthcare.8 However, developments from the region receive little attention in English language biomedical literature, as the majority of Central Asian scientists tend to publish in local journals. Moreover, renovations in healthcare systems in Central Asia must cope with the old problems that have never been resolved, as well as to rapidly adapt to the newly emerging challenges. Chronic
Adambekov S, et al. J Epidemiol Community Health 2015;0:1–5. doi:10.1136/jech-2015-206251
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
Essay
Figure 1 Map of Central Asia (from Wikipedia the free encyclopaedia).
diseases, such as cardiovascular disease and cancer, are the leading cause of mortality in Central Asia.9 With the epidemiological transition, we would expect to see more morbidity and mortality associated with chronic diseases, such as diabetes, and obesity, in Central Asia; however, current research publications coming out of the region do not reflect the importance of this problem. In addition, over the past two decades, there has been a resurgence of TB, viral hepatitis, HIV and other infectious diseases, which demonstrates that infectious disease continues to be a burden in the region. The proposed essay has been dedicated to highlight some of the important public health challenges that we are seeing in Central Asia today, and will be seeing in the next decades. These include: (1) the double burden of chronic and infectious disease; (2) the need to improve scientific productivity especially in the areas of public health and biomedical research; and (3) the need to focus on healthcare reform where prevention and reducing unnecessary variation in care are priorities. It will also provide a short overview of the research potential of the region, as it has a large number of research institutions and academic centres.
Double burden of chronic and infectious disease: special consideration needed for women’s health A large number of low and middle-income countries around the world, including those of Central Asia, face a double burden of chronic and infectious disease. These countries must deal with increasing prevalence of risk factors for chronic diseases, such as diabetes, heart disease and cancer, while at the same time struggling to reduce the rate of infectious diseases.10 Chronic disease, 2
especially in the area of women’s health, is a pressing public health priority in the Central Asian region due to several prevalent risk factors, such as high rates of smoking and increasing obesity rates.11 With the rising obesity epidemic, Central Asian populations are becoming at higher risk of obesity and its associated chronic diseases; however, awareness of obesity as a risk factor for cancer and some other diseases (such as diabetes), is deficient. Breast cancer is one of the most prevalent women’s cancers in Central Asia, and in Kazakhstan in particular and has been linked to obesity and environmental pollution.12 Limited access to mammography facilities for breast cancer detection and proper treatment facilities for those with diagnosed cancer, creates a big burden for breast cancer. Breast and other cancers (such as lung cancer), are exacerbated by high levels of smoking. One of the challenges faced by professionals dealing with cancer and other chronic diseases in Central Asia is the lack of formal chronic disease registries. There is hope that registries will be developed in the next decade, as in 2012, when Kazakhstan initiated the development of the electronic cancer registry, and in 2014, Astana, Kazakhstan, hosted one of the first training courses on cancer registry development methods.13 14 A recent publication suggests that in Kazakhstan and Kyrgyzstan, large gaps exist in public understanding of the negative health effects of tobacco use, particularly about the harm associated with the use of ‘light’ cigarettes.15 Thus, smoking cessation and smoking awareness programmes will gain significance in the Central Asian region over the next decades. Despite substantial advances in reducing HIV incidence, and expanding access to antiretroviral therapy (ART), Central Asia lags behind gains made in other countries.16 In addition, rates
Adambekov S, et al. J Epidemiol Community Health 2015;0:1–5. doi:10.1136/jech-2015-206251
Essay of tuberculosis in Central Asia are extremely high, and even more alarming are the very high rates of multidrug-resistant TB (MDR-TB) in Kazakhstan, Uzbekistan, Tajikistan and Kyrgyzstan.17 Rates of HIV infection related to injection drug use seem to be rising as well, thereby creating conditions for a potentially devastating coepidemic of TB/HIV and MDR-TB/ HIV, which would have terrible consequences for public health in these countries.17 Infection-associated cancers also pose a challenge. Resistance to uptake, lack of access to human papillomavirus vaccine and inconsistent Pap smear testing lead to cervical cancer rates that are higher in Central Asia than in the developed world, especially in Kyrgyzstan and Kazakhstan.18 Incidence of gastric cancer associated with Helicobacter pylori infection is also on the rise.19 When we evaluate the chronic disease burden of the region, interesting variations exist among various ethnic groups. For example, in Central Asia, ethnic Russians have exhibited higher adult mortality than native ethnic groups (eg, Kazakh, Kyrgyz and Uzbek) in spite of the higher socioeconomic status of ethnic Russians. The mortality disadvantage of ethnic Russians in adulthood appears to have even increased since the breakup of the Soviet Union.20 Ethnic variations also exist in women’s cancer morbidity, including gynaecological malignancies.21 22 Thus, more research is needed to explain and understand how to manage and alleviate the double burden of chronic and infectious disease in the Central Asian region.
Lack of formalised epidemiological research programmes and scientific productivity Despite the fact that the Central Asian region has a number of medical schools, very few schools and programmes target public health and epidemiological research. There is a lack of specialists with adequate training in epidemiology and biostatistics in existing medical research institutions, which leads to a lower number of quality publications. For example, there is a large gap in the numbers of publications by scientists in Kazakhstan compared to those by scientists in the developed world. Scientists in Kazakhstan and Central Asia have difficulty publishing in existing journals due to many reasons, including scientific isolation, language barriers, low motivation, high publication fees for open access journals, etc. While Kazakhstan is the second leading country in Central Asia in terms of the number of publications, the scientific productivity of scientists in Kazakhstan is still relatively low compared to high-income countries such as the USA and the UK, and even other middle-income countries, including Iran, Georgia and Cuba. Interestingly, whereas Iran ranks 23rd in the overall number of scientific publications, Kazakhstan ranks at 91st place, suggesting there is big potential for improvement (based on SCImago data23). The data on publications in Kazakhstan and other Central Asian countries is presented in figures 2 and 3 (based on SCImago data23). Starting in 2003, the number of publications by Kazakhstani authors has been steadily increasing. The breakdown by years (figure 2) shows a significant increase in the number of general publications starting from 2009. Particularly, Kazakhstani authors published 508 publications in 2011, 809 publications in 2012 and 1607 publications in 2013. Interestingly, the share of health-related sciences, such as Medicine, Public Health, Environmental and Occupational Health, Epidemiology and Health Policy, in the overall number of publications from Kazakhstan, is strikingly small, and accounts for no more than 6% of all the publications. In 2012,
Figure 2
General number of Central Asian publications 1996–2013.
Kazakhstani authors published a total of 93 articles in these areas.23 Despite the fact that these figures are still low, Kazakhstan has emerged as a leader in medical publishing from the Central Asian region (figure 3). In the overall SCImago ranking of scientific contribution to health-related disciplines, Kazakhstan ranks 130th in Medicine with 506 publications, 121st in Public Health, Environmental and Occupational Health with 93 publications, 94th in Epidemiology with 45 publications and 118th place in Health Policy with 11 publications, among the countries with documented existing publications in respective fields. Despite the overall increase in the number of published documents, the publishing pattern of Central Asian medical sciences is uneven, and publishing indexes vary significantly between years. The scientific publications of Central Asian authors in international journals are accessible for analysis due to commonly used databases such as PubMed, Scopus and Web of Science. However, it is much more difficult to assess scientific productivity of Central Asian authors publishing in local journals that are published in Russian or local languages. Most journals do not publish online; even abstracts are largely inaccessible. Out of 30 state approved medical journals in Kazakhstan,24 only 12 started publishing their articles online utilising pages of their home institutions. The largest Russian open access database, Cyberleninka,25 cites two Kazakhstani medical journals and 62 articles from Kazakhstan. As of 2015, existing Russian language scientific databases in the Central Asian region provide limited metadata on article authors or content. Using Kazakhstan as an example, individual analysis of each of the 12 journals with web pages shows that around 7000 articles, mostly in Russian, are accessible to the readership online, compared to 506 articles from Kazakhstan published in the Scopus database. Considering that most of the journals have
Figure 3 2013.
Adambekov S, et al. J Epidemiol Community Health 2015;0:1–5. doi:10.1136/jech-2015-206251
Number of Central Asian publications in Medicine for 1996– 3
Essay long publishing histories and have not digitalised their archives, the number of existing articles in Kazakhstan in the field of medicine could be much more than 7000. As a result, a vast number of medical research articles produced in Kazakhstan is unknown for non-Russian speakers, and is not cited in international databases. The information on Uzbekistan, Tajikistan and Kyrgyzstan, is even less accessible due to the use of national languages. The Central Asian Journal of Global Health is a new English language online scientific journal that aims to help Central Asian scientists to publish their scientific discoveries (cajgh.pitt.edu). This is a newly launched journal that focuses on publishing peer reviewed research data, reviews, and other important issues relevant to various fields of public health and biomedicine.26 The Central Asian Journal of Global Health has been initiated with the hope of improving scientific productivity in the region. With new online educational technologies, we believe that access to scientific publishing will be increasing over the next decade.27
Adherence to standard treatment recommendations and future directions Some of the healthcare challenges experienced in Central Asian countries include those associated with lack of access to standardised treatment. Although progress in developing evidencebased medicine is being made, the isolation of Soviet era science from Western developments has resulted in the widespread use of outdated and non-scientifically validated diagnostic procedures and treatment protocols, while finance mechanisms may still encourage unnecessary hospitalisations and treatments.28 29 For example, research indicates that, in various countries of the former Soviet Union, a high proportion of those who have been identified by health professionals as requiring hypertension treatment are not taking it daily.30 31 The system that aims to reduce variation in care while improving patient outcomes, which has been implemented in the USA and other developed countries, is the system of clinical pathways.32–35 A clinical pathway is a management tool for standardising the way physicians and other healthcare providers treat a disease. They are based on clinical guidelines or other commonly used clinical parameters. Pathways that were implemented for treatment of cancers have been expanded for use in other conditions. Further research on clinical pathways and integrating them into clinical care algorithms in Central Asian countries will have great potential in improving care, while containing the costs.
CONCLUSIONS This essay outlined some of the basic public health challenges faced by Central Asian countries. They include the double burden of chronic and infectious diseases, limited scientific productivity and problems associated with lack of treatment standardisation, especially across geographic and SES boundaries. Further research is needed to find the most effective strategies to resolve these problems and identify organisations that will be able to serve as agents of health system changes as the Central Asian region moves forward with transforming its healthcare systems. In the past two decades, many papers have been published on the interconnection and interdependence of health, inequality and human rights,36 a concept that is especially relevant to transitioning healthcare systems of the Central Asian region. The level of inequality within a country, as well as distribution of wealth and presence of democratic processes, may be important determinants of health.37 Central Asian states are attempting to 4
develop their own paths towards democracy by fusing established democratic standards with their own cultural and political norms.37 Despite developments in the past two decades, the World Bank reports that the GINI coefficient (the measure of income inequality) is still high in the Central Asian region.38 The hope is that as the region further develops, inequality will be reduced, leading to improvement in health. The Central Asian region has a large number of medical schools and research institutions, which potentially could be sites for public health and medical research. Specifically, the five Central Asian countries, Kazakhstan, Uzbekistan, Kyrgyzstan, Tajikistan and Turkmenistan, have around 24 schools, offering hope for improved public health and research methods training. Similarly, medical centres can be used for the same purpose of promoting public health research. These institutions can serve as a foundation for improving public health research in the region, starting with improving training in research methods and establishing disease registries in the region. Prevention of both infectious and chronic disease using effective smoking cessation programmes, weight loss programmes and screening tests are the low hanging fruits in improving the health of Central Asian populations. Allowing Central Asian scientists to publish their research findings will help to build the research capital of the region. Central Asia has a large number of medical schools, medical centres and emerging research institutes that can be used to foster change in medical and public health practice in the region.
Key messages ▸ Central Asian region has unique public health and medical challenges. ▸ One of the key public health challenges in Central Asia is double burden of chronic and infectious diseases ▸ Central Asian research is not known to the public health and medical scientists around the world. ▸ There are many organizations in Kazakhstan and other Central Asian countries that can be utilized to foster change in medical and public health practices of the region.
Twitter Follow Nurbek Igissinov at @Nurbek Igissinov Acknowledgements The authors would like to thank Drs Ronald LaPorte and Eugene Shubnikov for their contributions to the development of this article. The authors would also like to thank Ms Sharon Goughnour for her editorial help. Collaborators Ronald LaPorte, Eugene Shubnikov and Sharon Goughnour. Contributors FL took a lead on article finalising and submission. All contributors were responsible for study concept design, implementation and publishing. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Competing interests None declared. Provenance and peer review Commissioned; externally peer reviewed. Data sharing statement Data were collected for this study only.
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