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Trip of the First Lady to Central Asia, Russia, and the Ukraine-Speechwriter Trip Book (Laura) [Binder][2]
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Trip of the First Lady to Central Asia, Russia, and the Ukraine-Speechwriter Trip Book (Laura) [Binder][2]
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Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
D
First Lady's November Trip to Russia, Ukraine, Kazakhstan,
Kyrgyzstan and Uzbekistan
UZBEKISTAN
Background Papers
-- Main Issues in Bilateral Relations
-- Political/Social Overview
-- Economic/Commercial Overview
-- Human Rights Overview
-- Ethnic and Religious Issues
-- Education System and Issues
-- Women's Issues
-- Population and Family Planning Issues
-- Children's Issues
-- Health Issues
-- Overview of U.S. Assistance Program
-- Environmental Issues
-- Overview of U.S. Embassy
Other Materials
-- Biographies
-- Background Notes/Fact Sheets
-- Scenesetters
UZBEKISTAN: MAIN ISSUES IN BILATERAL RELATIONS
Interest in U.S. ties. Despite its slow pace of internal reform,
Uzbekistan actively seeks closer U.S. ties. It has supported U.S.
positions in the UN on controversial issues such as Iran and Cuba;
it has cooperated actively in efforts against weapons
proliferation and narcotics; and it has been an active participant
in Western security initiatives under Partnership for Peace, OSCE
and the Euro-Atlantic Partnership Council. Uzbekistan is also a
member of the Central Asian Peacekeeping Battalion (Centrasbat)
with Kazakhstan and Kyrgyzstan, which in September held joint
military exercises that included U.S. participation.
Mutual benefits. Uzbekistan values closer relations with the
U.S. to assure its independence, counter the regional ambitions
of Russia and Iran, assert its own regional role, and attract
western investment. The U.S. in turn recognizes Uzbekistan as a
regional leader, representing relative stability in a turbulent
region; a growing market for U.S. exports ($350 million in 1996) ;
a producer of natural resources such as gold, uranium, and
natural gas; and as a likely regional hub for infrastructure such
as pipelines, transportation, and communications, in which U.S.
firms seek a leading role.
Joint commission. The desire for closer relations on both
sides has led to an agreement to form a Joint Commission,
chaired by Ambassador-at-Large Sestanovich and Foreign
Minister Kamilov, to be inaugurated in Washington, most likely
in January 1998. Formation of the Joint Commission, an idea
endorsed by President Clinton in his June 1996 meeting with
Karimov, institutionalizes our effort to build closer
relations. While both sides seek to deepen military and
regional cooperation, the Commission will also serve to push
political and economic reform.
Differences. Despite close cooperation in a number of areas,
there are sources of friction in our bilateral relationship.
These arise from Uzbekistan's slow pace of economic reform, poor
human rights record and sometimes meddlesome regional activities.
a) Economic reform. Reform has stalled since Uzbekistan's
October 1996 decision to restrict currency convertibility. This
has reduced IFI programs and hampered foreign companies seeking
to invest. Other concerns are slow movement on medium/large-
enterprise privatization and bureaucratic obstacles to investment
and trade. More positively, a new tax code was passed in April;
we will monitor its implementation closely.
b) Human rights. President Karimov, a former Uzbek Communist
Party First Secretary, has fallen far short of his declarations
in favor of a democratic society and free press: the government
refuses to register human rights NGOs or real opposition parties;
there remains pervasive press censorship; and there have been
numerous reports of beatings and torture by police. Karimov, a
former Uzbek Communist Party First Secretary, defends his
political record by claiming the need to defend the state against
ethnic and fundamentalist unrest.
c) Regional aspirations. Despite its fear that the conflict,
instability and Islamic fundamentalism in neighboring countries
could spill across its porous borders and threaten its own
secular state, Uzbekistan has taken some potentially
destabilizing actions within the region. Uzbekistan has
supported renegade ethnic Uzbek officers in neighboring
Tajikistan, which threatens to disrupt that nation's fragile
peace process. Moreover, in Afghanistan -- although it has at
times played a moderating and constructive role -- the Uzbek
government has supported ethnic Uzbek military activity, which
helps perpetuate Afghanistan's civil conflict.
Future relations. The U.S. believes that Uzbekistan's stability
and prosperity could better be assured by a firmer commitment to
economic and political reform, an issue we will pursue in the
Joint Commission. Lack of progress on both fronts will
jeopardize continuation of some USG assistance and undermine the
overall relationship. We also continue to encourage Uzbekistan
to maintain a neutral role in the civil conflicts in neighboring
Tajikistan and Afghanistan. In addition, we want to build on the
success of September's Centrasbat exercise by making it an annual
event, and to expand IMET and other forms of training for Uzbek
military forces.
UZBEKISTAN: POLITICAL AND SOCIAL OVERVIEW
Uzbekistan is politically one of the least changed states in the
former Soviet Union. Power is now concentrated in the hands of
President Karimov instead of the Communist Party, but the
legislature functions largely as it did in the Soviet era. There
is no independent judiciary.
Consolidation of presidential power. During his first few years
as President, Karimov focused on consolidating power. He
outmaneuvered his rivals within the government and crushed the
largest non-Communist political opposition movement in Central
Asia, although he did SO largely without resort to force. A
former First Secretary of the Uzbek Communist Party, Karimov was
elected President in a contested election in December 1991 in
which the most popular prospective candidate, Abdurahim Pulat,
leader of the main opposition movement, was not allowed to run.
Opposition. Following a student riot in early 1992 and mounting
opposition criticism of the regime, police suppressed Birlik and
Erk, the two main independent political movements that had
emerged during the era of perestroika. The authorities also
cracked down on Islamic activists in the Ferghana Valley.
Opposition and religious leaders were harassed, beaten or
arrested. Others, including Birlik Chairman Pulat, Erk Chairman
Solikh and former Grand Mufti of Uzbekistan Sadiq were forced
into exile.
Popular support. Despite his use of repression, Karimov appears
to have popular support. A 1996 International Foundation for
Election Systems (IFES) poll showed that over two-thirds of the
respondents said that they were satisfied with "the situation in
Uzbekistan today, and three-fourths said that the overall
quality of their life today was either "very good" or "fairly
good" -- indicating high levels of satisfaction, according to
U.S. polling experts.
Status quo. Absent a rapid deterioration in the economic
situation, Karimov is likely to succeed in his bid to stay in
office past the year 2000. This reflects not only his successful
repression of opposition and public acceptance of his approach to
reform, but also the cohesive nature of the population (three-
quarters ethnic Uzbek), an unbroken history of authoritarian
rule, and the a growing sense of national identity that Karimov
has helped build. Although the legacy of repression in
Uzbekistan probably stifled the level of dissent expressed to the
pollsters, the uniform results nevertheless suggest that many
Uzbekistanis appreciate the stability that Karimov has brought to
the country and accept his claim that political reform must be
implemented gradually to prevent chaos.
Attention to western concerns. As Karimov has attempted to
attract foreign investment, he has sought to accommodate, at
least superficially, Western concerns about human rights and
democratization. Karimov allowed Radio Liberty to reopen an
office in Tashkent and has allowed the establishment of local
independent television stations. The government invited the OSCE
to hold a seminar on human rights in Tashkent and permitted the
brother of Birlik Chairman Pulat, Abdumannob Pulat, who was given
political asylum in the U.S., to return to Uzbekistan and attend
the meeting.
Superficial reforms. Nevertheless, democratic reforms have been
largely cosmetic. In practice, the Uzbekistani Government
continues to restrain, either directly or indirectly, fundamental
freedoms. Karimov broke his promise to consider his current term
in office -- extended by a March 1995 referendum -- as his last,
by having parliament to declare in August 1995 that he is
eligible to run again in the year 2000.
UZBEKISTAN: ECONOMIC AND COMMERCIAL OVERVIEW
Energy and agriculture. Uzbekistan's labor-intensive economy is
centered on agriculture and mineral extraction. It has been less
vulnerable to the disruptions experienced by other countries of
the former Soviet Union, because rapid growth in the production
of oil and gas -- which grew by 180 and 19 percent, respectively,
between 1991 and 1996 -- allowed Uzbekistan to reduce its oil
imports at a time when energy prices were increasing sharply.
Uzbekistan -- a net gas exporter -- took advantage of these
higher prices and increased gas exports. In addition, the
government's policy of shifting crop acreage from cotton to
grains and other crops increased domestic food supplies, heading
off social tensions and the need for food imports.
Economic performance. Uzbekistan's GDP declined 17 percent, but
industrial production held steady, between 1990 and 1996 --
easily the best performance of all the CIS countries.
Nevertheless, rapid energy growth has masked steep drops in other
industrial sectors, including metallurgy, chemicals, and
construction materials, ranging from 33 to 59 percent between
1990 and 1995.
Trade. Foreign trade has performed better than in other CIS
countries. Although total two-way trade in 1996 was an estimated
50 percent of the 1990 level, exports to hard currency non-CIS
partners -- mostly of cotton -- more than doubled during that
period, and Uzbekistan was the only CIS country to import more
from non-CIS partners than it had in 1991.
Reform. While initially rejecting serious economic reforms, in
mid-1994 Uzbekistan implemented a macro-economic stabilization
policy and other reforms with IMF guidance to deal with high
inflation and to attract greater foreign investment. State
control over the economy, however, remains strong. The
government's tight rein on credits and deficit spending has
reduced average monthly inflation from more than 20 percent in
1994 to four percent in 1996 and an estimated three percent in
1997.
Privatization. Housing and small-scale enterprises, mostly in
retail and services, have been almost fully privatized.
Employment in the state sector dropped from 67 percent in 1991 to
43 percent in 1996, and 95 percent of retail sales last year went
through enterprises not owned by the government. Large-scale
privatization has barely begun, however, and the government's
approach has favored current employers and managers over a
process more open to the public. In 1996, the government further
changed privatization procedures to encourage the participation
of foreign investors. The government has permitted private
ownership of livestock and expanded privatized cotton production.
While most consumer prices are close to world levels, Uzbekistan
maintains artificially low prices on cotton and wheat. Moreover,
the government retains state orders -- as high as 50 percent --
on the cotton and wheat crops, as well as complete control over
cotton exports, and it strictly controls participation in hard
currency exchanges.
Foreign investment. Economic reforms have improved the foreign
investment climate in Uzbekistan, but potential investors
continue to face problems from an inadequate legal infrastructure
and a cumbersome, often corrupt, bureaucracy. In October 1996,
the government restricted the number of banks authorized to
conduct foreign exchange transactions. Several small-scale
investors have shut down operations, and major foreign investors
have noted difficulties in purchasing foreign exchange to meet
external obligations and repatriate profits. Although more than
1,200 joint ventures have been registered in Uzbekistan, only
about half were operating in 1996.
UZBEKISTAN: HUMAN RIGHTS
Slow progress. Uzbekistan is an authoritarian state with limited
civil rights. The government has failed to make significant
progress on human rights concerns and political reforms. Chosen
President by a 1991 election that was neither free nor fair,
Islam Karimov had his term extended to 2000 by a 1995 Soviet-
style referendum. The government continues to deny registration
to independent political parties and other groups critical of the
government, while creating several parties to support itself. It
also continues to hold political prisoners. Police and security
services use torture, harassment and illegal searches against
activists. Police often beat criminal suspects to obtain
confessions.
Freedom of the press. Press censorship remains pervasive.
Almost all newspapers are government-owned, and citizens have
little access to foreign newspapers. Radio Liberty, the Voice of
America, BBC radio and expensive local cable television channels
are among the few sources of uncontrolled news, but even their
reporters face harassment. Freedom of expression is constrained
by an atmosphere of repression and concrete measures including a
law against "offending the honor and dignity of the President."
Positive steps. Nevertheless, some potentially positive steps on
human rights were taken in 1996 and 1997. It remains to be seen
to whether these measures are truly reforms or merely
superficial. In 1997, legislation was enacted to increase access
to information and protect journalists; to reform the penal
system and protect the rights of prisoners; and to establish an
ombudsman's office to monitor and investigate human rights
abuses. During the summer of 1996 authorities permitted Human
Rights Watch/Helsinki and Radio Liberty to open bureaus in
Tashkent. In addition, just prior to a meeting with President
Clinton in June 1996, President Karimov released fifteen
political prisoners and invited exiled human rights activists to
return to Uzbekistan. Later that year he established a National
Center for Human Rights devoted to training professionals in
human rights issues.
UZBEKISTAN: ETHNIC AND RELIGIOUS ISSUES
Discrimination claims. Despite official Uzbekistani government
policy favoring the development of a multi-ethnic society, a
number of non-Uzbek ethnic groups claim official discrimination.
For example, some groups claim that their communities are
shortchanged in distribution of government resources. This
discrimination appears to apply particularly to those groups who
are most isolated, such as the Karakalpaks who occupy the
ecologically-devastated northwestern corner of the country near
the Aral Sea.
Language issues. The government is moving to replace Russian
with Uzbek as the official language by the year 2000, a move that
is seen as disadvantaging the quarter of the country's 24 million
people for whom Uzbek is not the first language. In addition,
legal proceedings are often conducted in Uzbek without Russian
translation, even when they involve Russian speakers, and Russian
suspects are routinely forced to sign confessions written in
Uzbek.
Freedom of religion. Uzbekistan's constitution provides for
freedom of religion and separation of religion and state. Many
groups worship freely, including the majority of (Sunni) Moslems,
Jews, Russian Orthodox and several other Christian denominations.
However, the government suppresses some religious groups and
activities. For example, to counter what it perceives as
extremist Islamic views, the government limits the expression of
political views by religious leaders in sermons and elsewhere,
and effectively controls the Islamic religious hierarchy.
Authorities continue to use the tactic of convicting Islamic
religious leaders on trumped-up criminal charges (e.g.,
possessing drugs and ammunition) to suppress their suspected
criticism of government policy. Moreover, at least one
evangelical leader has been arrested and briefly jailed for
operating an unregistered church. Other evangelical groups have
had difficulty registering and, as a consequence, operate in
legal limbo. Acting on orders from presidential staff, customs
officials confiscated and held for most of 1997 a shipment of
29,460 Bibles belonging to the Uzbekistan Bible Society.
UZBEKISTAN: EDUCATION ISSUES
High literacy. The high educational level of the Uzbek
population is a great asset to this Central Asian nation.
Literacy is near universal at over 98 percent in both rural and
urban areas. Educational methods and curricula, however, are
often outmoded and inappropriate, and rural schools are less
well-equipped than their urban counterparts.
Deteriorating conditions. As in other social sectors, the Uzbek
educational system experienced significant material and financial
constraints following the breakup of the former Soviet Union. As
a result, serious problems relating to the maintenance of
educational institutions and the provision of necessary equipment
and supplies such as textbooks have emerged. For instance, many
schools, especially in rural areas, have no telephone, no running
water, and no sewage system. In addition, low teacher salaries
have caused many of the most talented teachers to leave teaching.
Length of schooling. Despite this bleak financial situation, the
total mean years of schooling for both men and women in
Uzbekistan exceeded 11 years in 1994. Also, the percent of all
persons aged 6 to 23 enrolled in school was approximately 50
percent in 1994. However, this figure is over 10 percent lower
than the equivalent figure for 1992. Also disturbing is the fact
that the percentage of 19-year-olds still enrolled in full-time
education declined from 31 percent in 1992 to 26 percent in 1994.
Continued decline? The needs in the educational sector must be
addressed fairly quickly to preserve the quality and availability
of education for all children and young adults. Hence, during
coming years, Uzbekistan must try to maintain its educational
achievements by revising and restructuring curricula to meet the
requirements of a modern, independent nation. Assistance is also
urgently needed for maintenance of the basic educational
infrastructure, especially in rural areas. Education has not
been a sector of specific concentration for USAID work.
UZBEKISTAN: WOMEN'S ISSUES
Women's rights. Uzbekistan has acceded to a number of
international human rights-related treaties, almost all of which
prohibit discrimination based on gender. Both the Constitution
and the 1992 law on citizenship prohibit discrimination on the
basis of sex. However, enforcement mechanisms are inadequate,
and women are unaware of their rights and too poorly organized to
advocate for themselves effectively.
Traditional society. Uzbekistan is a traditional society in
which Islamic culture is becoming more of a presence. Women
assume that raising children and managing the home are
exclusively the domain of women. Early, arranged marriages are
common, and young brides are expected to have a child within the
first year of marriage and to care for their mothers-in-law.
Education. The female literacy rate in 1990 was 96 percent,
which compares very favorably with a 60 percent rate worldwide.
Opportunities for women to obtain an education are declining,
however. Because traditional attitudes toward women favor early
marriage and child rearing, education for women receives a low
priority. The government has abolished the compulsory attendance
law, making it easier to keep girls out of school. Declining
financial support for state schools has resulted in the best
educational opportunities requiring entry payments amounting to
bribes. Economically hard-pressed families are more likely to do
this for sons, for whom a career is considered as required, while
keeping daughters at home.
Economic Participation. Women's employment and labor force
participation is high (71%), but women tend to be employed in
low-skilled occupations or in low-paying occupations such as
education and health. Women make up three-fourths of the
country's doctors and nurses and 60% of teachers, but only a
third of technicians and engineers. Women seeking to be
entrepreneurs face a host of obstacles, including cultural
attitudes, family and household responsibilities, and lack of
access to family assets, which reduces access to scarce credit.
Political representation. The proportion of women represented in
Parliament has dramatically decreased since independence. Before
the 1989 elections, due largely to a quota system, women
comprised 35% of the Supreme Soviet. Now, only 13 of the 250
deputies in Parliament, or five percent, are female. Few women
hold influential positions in the executive branch and those that
do tend to serve in ministries dealing with social issues such as
health and education. A woman deputy prime minister was
appointed to handle women's affairs. She is the only female in
the Cabinet and has no program funds or real power. Women serve
as deputy governors for women's affairs at the province and
district levels, but have no program funds and limited chances to
put issues forward in a male-dominated environment.
NGOs. The Republican Women's Committee, a government-sponsored
NGO headed by the Deputy Prime Minister, has supported a few
useful projects. A number of women-oriented, grassroots NGOs
deal with specific gender issues but, as with most NGOs in
Uzbekistan, they are weak and lack depth in their leadership.
International activities. A national delegation was sent to the
United Nations Fourth World Conference on Women in Beijing as
well as to the 1996 meeting in Bucharest. Support from outside
the country permitted key women leaders not affiliated with the
government to attend the Beijing conference. Since Beijing, the
government has prepared a paper entitled "The Government's
Conception on Improving the Status of Women". In May 1997, a
Gender in Development Unit under the Republican Women's
Committee, financed by the UN, began developing a National Action
Plan to be based on the Government's concept paper.
Social benefits. Under the Soviet Government, a comprehensive
system of social benefits assisted women and gave them
preferential treatment, including child allowances, maternity
leave, and favorable retirement pensions allowing earlier
retirement than men. Unfortunately, this system of social
welfare is grossly underfunded. Benefits are too small and often
paid late. Until it is reformed, women are likely to suffer
disproportionately.
Demographics.
Female population - 11.5 million (50.5% of population) (1995)
Number of women 15-45 in 1995 = 5.6 million; in 2015 = 8.9 million
Life expectancy - 72 years (as opposed to 66 for men)
Total fertility rate - 3.8
UZBEKISTAN: POPULATION AND FAMILY PLANNING
Projected trends. With a total population of approximately 23.7
million, Uzbekistan is the third most populous country in the
former Soviet Union. With the current population growth rate of
2.5 percent, the population will dramatically increase in the
next fifteen years and is projected to reach 35.7 million by the
year 2025. Forty percent of the population of Uzbekistan is less
than 14 years of age. Fertility in Uzbekistan has declined in
recent years by one child. Total Fertility Rate (TFR) for women
is 3.3 children.
Contraception. Currently, reproductive health services are
available at hospitals and polyclinics at the oblast, rayon, and
city levels, and at primary health care institutions through the
public sector. According to demographic and health data,
knowledge of contraceptive methods is virtually universal among
Uzbekistani women and 51 percent of currently married women are
using a modern method of contraception, primarily in-uteri
devices. Most of the women obtain their contraceptive method
from the public sector.
International assistance. The United Nation Fund for Population
(UNFPA) with the EU credit has supplied the contraceptive for the
public sector. This may change in the future as the commercial
sector becomes more active. USAID is helping the Ministry of
Health to improve the accessibility and availability of
contraceptives through the commercial sector. However, the
recent adoption of regulations to control and limit foreign
exchange for businesses have affected USAID's efforts.
Abortion. An abortion rate of 0.7 abortions per woman in
Uzbekistan is lower than estimates for other areas in the former
Soviet Union. These lower rates are largely due to greater
availability and use of alternative contraceptive methods.
UZBEKISTAN: CHILDREN'S ISSUES
Decline in social services. Despite recently increased efforts
on the part of the government of Uzbekistan to address the
general downturn in the country's social indicators,
preoccupation with macroeconomic issues as well as real budgetary
constraints has meant that social services for the most
vulnerable groups -- especially children -- are shrinking and in
danger of not furnishing even minimum support. Some 41 percent
of the population is under the age of 16; this places high
demands on scarce social services.
Nutrition. A wide range of serious nutritional problems affect a
large percentage of children, especially in rural areas. Among
the major reasons are large families, low family incomes and
sporadic supplies of major food products. The USAID-funded 1996
Uzbekistan Demographic and Health Survey (UDHS) found that close
to 15 percent of the child population is stunted and another
three percent wasted. This is in line with percentages generally
found in Central Asia, but higher than those for other areas.
Breast-feeding is almost universal in Uzbekistan; 96% of all
children are breast-fed during their first four to six months of
life. This satisfies the World Health Organization recommended
minimum four months of breast feeding.
Infant health care. Almost all births in Uzbekistan (94%) take
place in health facilities and under the care and supervision of
trained medical personnel. Uzbekistan provides a full range of
inoculations (polio, measles, BCG and DPT/DT) to 85 percent of
the children aged 12 - 23 months. The highest coverages are for
Polio 1 and Diphtheria 1, 99 percent. The lowest is for measles,
89 percent. USAID addressed vaccine security issues early on in
Uzbekistan and Central Asia. It provided technical assistance to
modernize antiquated and inefficient immunization protocols.
USAID has also been in the forefront of helping combat other
diseases by providing vaccines and associated assistance.
Aral Sea. In the Aral Sea zone, children have been especially
susceptible to the air and waterborne diseases associated with
the ecological disaster area. Although the infant mortality rate
has fallen in recent years, it remains higher than in other areas
of Uzbekistan. USAID mobilized resources quickly in 1994 to
fulfill Vice President Gore's commitment to the area. Uzbekistan
shared with Kazakhstan in USAID's $22 million Aral Sea Initiative
to bring potable water to people of the Aral Sea region. This
initiative has now shifted from infrastructure projects to ones
addressing water policy and sustainability.
Adoption law. While international adoptions of Uzbekistani
orphans are legal, government officials are not in agreement on
who has authority over such adoptions. Only three foreign
adoptions took place in FY 1997. Uzbekistan is not a party to
the Hague Convention on the Civil Aspects of International Child
Abduction. Thus, cases of children abducted to or from
Uzbekistan must be handled in the family courts of the country to
which they have been taken. When such cases are brought to the
attention of the Department of State, the natural parents are
advised to retain legal counsel in the country to which the
children have been taken. The Department of State is not aware
of any pending cases in Uzbekistan.
UZBEKISTAN: HEALTH ISSUES
Major problems. Uzbekistan's major health problems include high
maternal and infant mortality rates; poor women's health,
including reproductive health; intestinal and parasitic
infections; high rates of cardiovascular diseases; and increasing
incidence of tuberculosis and vaccine-preventable diseases,
including polio, diphtheria, and anemia, particularly in women
and children.
Deteriorating conditions. Historically, the national health care
system in Uzbekistan was comprehensive. Services available to a
large percentage of the population were provided mainly free of
charge. However, health sector resources have declined since the
breakup of the former Soviet system, reducing health care
quality, accessibility and efficiency.
Drinking Water. Lack of access to potable water continues to be
a major problem for half a million people in the Aral Sea area.
This is a main cause of higher incidences of diarrheal disease in
the region. The government and USAID have already improved two
large water treatment plants serving half a million people in the
Aral Sea region through installation of chlorination and other
water cleaning equipment. These efforts immediately improved
drinking water quality, which in turn reduced health risk. A
regional effort in water management and water pricing is
underway.
Reform and USAID assistance. Recently the Government of
Uzbekistan has indicated readiness to pursue health reforms more
consistent with a market-oriented economy. USAID is focusing on
issues of health care financing and improved primary health care.
This complements USAID's existing assistance in improving access
to contraceptives through the private sector; reducing vaccine-
preventable infant deaths; strengthening epidemiological
monitoring of infectious diseases; and developing hospital
partnerships with U.S.-based hospitals to transfer modern
clinical technologies. USAID has provided some $3 million to the
health sector in the past two years, in addition to roughly $5
million to improve water supply systems. USAID works closely on
health issues with the World Bank, the World Health organization,
and other United Nation Agencies.
UZBEKISTAN: ASSISTANCE PROGRAM OVERVIEW
Total funding commitment. The United States has provided
approximately $137.5 million to fund humanitarian aid, technical
assistance and investment promotion activities in Uzbekistan
since 1992. These programs seek to lay a basic foundation for
market economic and democratic reform in an effort to encourage
the government of Uzbekistan to embrace such reforms in earnest.
The U.S. has contributed an additional $16.6 million to the UNHCR
and International Organization of Migration's 1997 Joint Appeal
for the CIS Migration Conference follow-up for programs in
Uzbekistan, as well as Kyrgyzstan and Kazakhstan.
Funding for economic reform. U.S. funding since 1992 for private
sector development and economic restructuring in Uzbekistan
totals approximately $18 million. This relatively low figure
compared to aid to other NIS reflects the slow pace of economic
reform in Uzbekistan to date. Despite declarations to the
contrary, the Uzbek government has been reluctant to implement
many of the reform ideas generated by U.S.-funded programs. In
addition, Uzbekistan's restrictions on currency convertibility
undercut its efforts to attract foreign investment.
Economic programs. Our programs are nevertheless helping to lay
the groundwork for a market-oriented economy by working with
selected, reform-minded GOU officials. USAID has fielded a team
of resident advisors that has been working closely with
Uzbekistan's government on tax, fiscal, and financial reform.
These advisors played a key role in drafting Uzbekistan's new tax
code, which parliament passed in April 1997. USAID advisors are
also working to draft new laws on budget formulation, reform the
pension system, train banking system supervisors and streamline
Uzbekistan's legal framework for international trade and
investment in preparation for possible WTO membership.
Central Asian-American Enterprise Fund. The USG has also pledged
$150 million to capitalize the Central Asian-American Enterprise
Fund, which operates in Uzbekistan, Kazakhstan, Kyrgyzstan and
Turkmenistan. We created this fund to support the development of
small and medium-sized enterprises in Central Asia by making
equity investments and providing micro-lending services. The
fund has invested $23.4 million in 10 Uzbek businesses in the
manufacturing, food processing, construction, and service
sectors. Unfortunately, currency convertibility problems have
prevented even greater Fund activity in Uzbekistan thus far.
Democracy and human rights. The GOU has moved slowly on
democratic reform, continues to repress its political opponents
and resists the emergence of an independent media. Democracy-
building aid activities have consequently been limited to working
to strengthen civil society by supporting the development of a
variety of NGO's in areas such as women's rights, advocacy for
the handicapped and general human rights. People-to-people
programs such as USIA exchanges, farmer-to-farmer programs, and
the Department of Commerce's SABIT Business Internship Program
contribute to the development of Uzbekistan's civil society.
Another project assists 16 local television stations.
Health care programs. Since 1992, the U.S. has allocated
approximately $7 million for improvements in Uzbekistan's health
care system which have benefited women and children in
particular. At the national level, the U.S. is helping
Uzbekistan create a computerized national disease surveillance
system. At the local level, USAID is beginning a major project
that will develop pilot programs for financing rural hospitals.
Family planning programs. Underlying these programs is a focus
on women's reproductive health and children's health. USAID
supports two family planning programs that seek to reduce rates
of maternal morbidity, infant mortality and abortions by creating
model training clinics and conducting public education campaigns
on the use of modern contraceptives. Recent data from project
sites throughout Central Asia indicate a significant decline in
abortions and increase in contraceptive use in recent years.
USAID and the U.S. Center for Disease Control are also operating
training programs aimed at battling infectious diseases such as
polio, diphtheria, and Uzbekistan's two major causes of child
mortality -- pneumonia and diarrhea. A medical partnership
between Tashkent State Medical Institute and the University of
Illinois at Chicago Teaching Hospital has been awarded over $1.5
million in grants since April 1995 for work on treatment of high-
risk pregnancies, training in neo-natal resuscitation, and
establishment of a Women's Wellness Center.
Environmental programs. The USG has provided nearly $9 million
for environmental programs in Uzbekistan since 1992. A large
portion of these funds have financed projects that address the
environmental disaster zone surrounding the Aral Sea. USAID has
provided $7 million for capital improvements in water treatment
facilities in communities near the Aral Sea. USAID has also
sponsored intense efforts to promote regional cooperation on
water management and sharing. Thanks to this initiative, the
presidents and prime ministers of Uzbekistan, Kyrgyzstan and
Kazakhstan are close to agreement on a common water management
policy. USAID has also funded pollution control projects at a
major oil refinery and cement plant.
Energy programs. The U.S. has recently initiated a new project
that aims to develop a legal and regulatory structure for
Uzbekistan's energy sector. The goal of this program is to
create the necessary conditions to attract foreign investment.
Humanitarian Assistance. We have delivered $58.7 million in
medical equipment, medicines, and other commodities donated by
the U.S. Department of Defense and private voluntary
organizations since 1992.
UZBEKISTAN: ENVIRONMENTAL ISSUES
Serious problems. Caused largely by the former Soviet regime's
mismanagement of natural resources in the region, Uzbekistan's
environmental problems include depletion of water supply,
deteriorating water quality, water contamination from both
agricultural pesticides and fertilizers and industrial
enterprises, increasing water salinity, public health crises,
improper waste and wastewater disposal, and air pollution from
the industrial sector, concentrated in Tashkent province.
Uzbekistan's economy relies largely on agriculture and extraction
of natural resources, both carried out in an unsustainable
manner, particularly with respect to water use.
Aral Sea disaster. Uzbekistan includes the southern portion of
the Aral Sea. Due to Soviet agricultural development policies,
large amounts of water were diverted from this sea for
irrigation, leading to its shrinkage to slightly more than half
its previous volume. The massive diversion of water from the two
main tributaries, the Amu Darya and the Syr Darya, in combination
with unsustainable agricultural practices, has destroyed the Aral
Sea as a viable ecosystem and ruined local economies in the
process. The U.S., along with the World Bank, UNDP, the EU, and
Canada, is now focused on trying to stabilize the situation; any
hope of restoration is dim at best.
USAID assistance. Much of USAID's initial focus has been on the
urgent public health needs arising from the sea's degradation.
Several million people living in the sea's basin have been
deprived of access to safe water and have experienced abnormally
high rates of morbidity, non-specific diarrheas, and viral
hepatitis. In response, USAID undertook a series of multi-
million dollar potable water projects to provide increased clean
water access to over a million Central Asians. Some $7 million
of capital improvements including new disinfection systems,
coagulation units, and expanded testing capabilities were
provided to potable water treatment facilities in the major towns
of northwestern Uzbekistan. Uzbekistan has committed resources
to insure the ongoing maintenance and operation of these
renovated facilities. USAID has provided legal and regulatory
review to help develop Uzbekistan's National Environmental Action
Plan, and has emphasized use of economic instruments to promote
environmental improvements and discourage liability hazards.
Water sharing and management. Donors including USAID, the World
Bank, UNDP and the EU have sponsored intense efforts to promote
cooperation among the five new Central Asian Republics in water
management and sharing, thereby addressing the underlying causes
of the Aral Sea disaster. From workshops and a demonstration
project to promote concepts of water pricing, protection of water
resources for beneficial uses, and water demand management,
donors have shifted to application of these principles at the
Toktogul Reservoir, the largest multi-year storage facility in
Central Asia, used primarily for irrigation and secondarily for
power production. Acreage under irrigation provided by Toktogul
water generates hundreds of millions of dollars from cotton and
other crops in Uzbekistan and somewhat less from rice and other
agricultural production in Kazakhstan.
Competing needs. Acute tension has arisen from competing needs
for power generation for winter heating of homes in Kyrgyzstan
and irrigation of crops in the summer for downstream countries.
A series of year-long agreements between the countries on the
dam's operation and the sharing of water have collapsed.
Water management agreement. Over the last year and a half, USAID
has worked with the Interstate Council of the Republics of
Kazakhstan, Kyrgyzstan, and Uzbekistan (ICKKU) to establish a
multi-year agreement applying the principles of water pricing and
demand management. The result is a draft agreement which ICKKU
will submit for approval by the three governments by early 1998.
USAID intends to assist in successful implementation of the
agreement. Based upon the lessons learned through Toktogul,
USAID also plans to assist with the development of other water
basin management agreements along the Syr Darya. On a more local
level, USAID is helping to form agricultural water user
associations through training seminars and drafting of sample
incorporating documents.
Waste minimization. Over half of Uzbekistan's industry is
centered in Tashkent Oblast. Principal environmental problems
are air emissions of particulates from power plants and cement
plants, wastewater from chemical plants, and disposal of solid
wastes from mineral extraction and processing. To tackle these,
USAID funded demonstration projects in waste minimization in two
industries. An oil refinery and a cement plant installed
pollution reduction equipment, resulting in large energy and
dollar savings and substantial reductions in carbon dioxide and
particulate emissions.
Environmental NGO Development. Non-governmental organizations
are a key means of overcoming the Soviet legacy of environmental
mismanagement. USAID has funded ISAR, a non-profit organization
that supports NGOs working on environmental issues in the Newly
Independent States since 1993. ISAR has awarded $500,000 in
small grants (from $300 to $5,000) to local NGO's to conduct
concrete actions in environmental education, awareness,
monitoring, and law; alternative energy; sustainable development;
sustainable agriculture; and related areas.
EMBASSY OVERVIEW: TASHKENT, UZBEKISTAN
Location and staff. Embassy Tashkent opened in March 1992 and
moved to its present site in a former Soviet Youth Center about
five miles from downtown Tashkent later the same year. Staffed
initially by fewer than ten full-time Americans, the Embassy has
grown substantially to reflect the increasing complexity of
U.S.-Uzbek relations and U.S. interests in the region. The
Embassy now has about 32 full-time direct hire American
positions plus several local hire Americans.
Offices and programs. The State Department complement includes
political/economic, political/military, administrative and
consular sections. In addition, the newly-created regional
environmental office is located here, covering the five Central
Asian states most affected by the Aral Sea crisis. The
following agencies also are present in Tashkent:
USIS. USIS is staffed by a Public Affairs Officer and a
Regional English Language Specialist.
USAID. USAID for Central Asia is based in Almaty, but
represented in Tashkent by one direct-hire American.
Foreign Commercial Service. The Foreign Commercial Service is
represented by a Senior Commercial Officer, who also oversees
the operations of the American Business Center here.
Defense Attaché. The Defense Attaché Office (DAO) is headed by
an Army Lieutenant Colonel assisted by an Operations
Coordinator. DAO oversees the Partnership for Peace Program and
the bilateral military educational and training exchanges.
Peace Corps. The Peace Corps maintains two programs
countrywide, one focusing on English teaching and the other on
small business development and education, with about 50-60 total
volunteers.
Other. Family services for resident Americans are developing
gradually as funding increases and Uzbek officials become more
comfortable dealing with an international business and
diplomatic presence. There is a locally organized International
School and an International Clinic. The U.S. government
contributes significantly to both institutions.
UZBEKISTAN: TASHKENT SCENESETTER
History. Tashkent was the fourth largest city in the Soviet
Union and the Russian/Soviet administrative center for central
Asia. Until its conquest by the Czar's armies in 1863,
Tashkent had been a minor town (its name means "stone village" in
Uzbek). By the mid-nineteenth century, however, Tashkent had
grown into a prosperous trading town.
City setting. Tashkent has the appearance of a modern city,
owing mostly to its near-total destruction by an earthquake in
1966. It was rapidly rebuilt in a "Soviet modern" style. Post-
independence, much new building is going on and the government
has encouraged a more Asian architectural style. Many new
buildings have white columns and turquoise domes. The
combination of this new style with the broad, tree- lined
boulevards built by the Soviets makes Tashkent a pleasant city to
visit.
UZBEKISTAN: SAMARKAND SCENESETTER
History. Samarkand, which celebrated its 2, 500th birthday last
year, was already a major urban center when it was conquered by
Alexander the Great. For almost a thousand years, beginning in
the second century B.C., virtually every caravan on the Silk
Route passed through Samarkand. It remained an important trade
city until sea routes between Europe and the Orient were opened.
The city's glory ended with its destruction at the hands of
Genghis Khan in 1220. However, by early in the thirteenth
century, Samarkand recovered when Tamerlane (known here as Amir
Timur, the "Iron Emir") chose it as his capital.
City setting. Today Samarkand, with a population of about
500,000, is a center of commerce supporting agricultural activity
in the surrounding countryside. There has been some light
industrial development. Samarkand is set apart from other
Central Asian cities by its spectacular historic sights.
UZBEKISTAN: BUKHARA SCENESETTER
History. Considered by many to be Uzbekistan's most beautiful
city, Bukhara celebrated the purported 2500th anniversary of its
founding on October 19, 1997. Successively ruled by Achaemenids,
Greeks, Seleucids, Parathions, and Kushans before being captured
by Arabs in the eighth century, it was a major trading, cultural,
and educational center for much of its history. It was the
capital of the Saminid empire -- the first independent central
Asian state -- in the tenth century. Largely destroyed by
Genghis Khan, the city's fortunes improved in the second half of
the sixteenth century as it became the center of various Khanates
or Emirates until 1920. The Emirate of Bukhara became a
protectorate of Russia in 1873, although the Emir was allowed to
continue to rule. Bukhara was a center of counter-revolution
during the Russian civil war and was taken by the Red Army in
September 1920. Any semblance of Bukharan independence (under a
Bukharan People's Republic) was ended in September 1924 when the
region officially joined the Soviet Union.
City setting. Today, Bukhara is a quiet city of roughly 300,000
inhabitants. While there are some industrial enterprises in the
new part of the city, the city was not as heavily industrialized
as others in central Asia. Moreover, the old city, with its
narrow, twisting streets, maintains a separate atmosphere from
more modern sections of Bukhara, and kept its historic identity
intact.
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UZBEKISTAN
Tashkent - Chicago, Illinois
TASHKENT, UZBEKISTAN - CHICAGO, ILLINOIS PARTNERSHIP
AIHA's Medical Partnership Program between the cities of Tashkent, Uzbekistan and Chicago,
Illinois, funded under a cooperative agreement with the United States Agency for International
Development (USAID), was formed in October 1992. The Uzbek partner, the Second Tashkent
State Medical Institute (TashMI II). is one of the ten largest hospitals in the NIS. Further, TashMI
II is the largest medical facility in Central Asia. The US partner, the University of Illinois at
Chicago (UIC) Medical Center, is a major academic medical center, and it includes the UIC
Hospital.
The general areas of focus for this partnership have been Neonatology and perinatal medicine,
women's health, hospital and clinic administration, nursing and medical education, general surgery
and neurosurgery, and various medical specialty areas (such as orthopedics and anesthesiology).
Program Outcomes
Neonatology and Perinatal Medicine: Partnership efforts have resulted in tangible advances in
the services and quality of care provided at TashMI II. There has been a steady decline in the
number of infant and maternal deaths within the Institute's facilities. A new neonatal intensive care
unit (NICU) was equipped and staffed by physicians trained at UIC, and substantial improvement
has occurred in resuscitation techniques and the care of premature infants. Teaching programs have
been developed for nurses and physicians utilizing lecture materials and videos made available by
UIC.
The Ministry of Health of Uzbekistan has played an active role in dissemination efforts and
provided support by allocating five million Uzbek som (approximately US $2000) to TashMI II in
order to renovate facilities for a high-risk pregnancy center which would be developed as a center
of excellence for perinatal care. In the spring of 1995, TashMI II established the Center for Extra-
Genital Pathology, which identifies and treats women of child-bearing age who have pathologies
that could impact their health and the health status of their children.
The Ministry, TashMI II and UIC faculty has cooperated in providing a number of conferences
designed to improve the identification and treatment of high-risk women and neonatal outcomes.
In the fall of 1994, a partnership-sponsored neonatology conference took place in Tashkent. The
conference was attended by over 100 health care professionals from TashMI II and various oblasts
across Uzbekistan as well as from AIHA partnership institutions in Kyrgyzstan, Russia,
Turkmenistan and Ukraine. The conference continued an unprecedented dialogue on modern
problems in perinatology/neonatology between the NIS and the US health care community.
During the past year, a focus of partnership activities has been to develop a Neonatal Resuscitation
Training Center at TashMI II. The Center was officially opened in April 1997, with visiting UIC
faculty participating in opening ceremonies as well as the initial training sessions provided at the
Center. The Center trains physicians, nurses and midwives from both TashMI II and other health
care institutions in the region through monthly courses in neonatal resuscitation. A medical institute
in Urgench, another city in Uzbekistan, also has an interest in developing such a training center.
Both UIC and TashMI II have provided assistance to facilitate this effort. During June and July of
1997, a neonatologist from Urgench was part of a visiting delegation from Uzbekistan. She was
TASHKENT, UZBEKISTAN - CHICAGO, ILLINOIS PARTNERSHIP
oriented to approaches for training physicians and nurses in neonatal resuscitation, and she spent
time in observing the delivery of care in UIC's perinatal and neonatal high-risk units.
Women's Health: The involvement of TashMI II in improving care to high-risk women was a
factor in the Institute's selection as one of several NIS sites for development of a Women's Wellness
Center. The Center is scheduled to open in the fall of 1997; it will provide a model for delivery of
a full range of preventive, primary care, diagnostic and treatment services to women. During June
and July of 1997, the designated Medical Director (an obstetrician) and the Nurse Manager for the
Center visited UIC, together with another obstetrician and nurse who will also work in the Center.
The group visited various women's health programs associated with UIC, and they gathered ideas
for marketing the Center, recruiting patients, and assuring the effective delivery of the care to be
delivered at the Women's Wellness Center. The need to develop expertise in prevention and early
diagnosis was emphasized during the visit. The group was also exposed to innovative approaches
to family planning and reproductive health and the delivery of services to women experiencing
problems related to menopause and aging.
Hospital Administration and Financial Reform: Exchanges in hospital management and
financial administration have focused on the reorganization of the hospital's management structure
and the development of improved relationships between the medical institute and the clinical
departments. Several physicians in high-level positions at TashMI II have taken advantage of
AIHA/AUPHA's management training seminars, and the administrative practices at UIC have been
studied by TashMI II visitors. TashMI II has improved the financial standing of its hospital
facilities by retiring nearly two-thirds of its beds, reducing average inpatient stays (from more than
18 days in 1992 to less than 10 days now), opening an outpatient unit (or day hospital), and shifting
part of the patient base into outpatient care. As a result, costly inpatient services have been reduced,
decreasing general overhead costs, while outpatient services have grown.
TashMI II previously ventured into fee-for-service care in both outpatient and inpatient settings,
with patients demonstrating a willingness to pay for services in internal medicine and gynecology.
An attempt was also made to relate the salaries of physicians to productivity. However,
governmental policies have been implemented recently which discourage fee-for-service
arrangements in public institutions such as TashMI II. Major Uzbek employers are likely to assume
greater responsibility for ensuring access to quality health care for employees and their families,
although future directions related to financing care are difficult to predict with precision at this time.
Nursing Reform: Nursing reform efforts have resulted in the establishment of performance and
competency standards at TashMI II. Nurses are now required to pass clinical performance reviews
in their specialty to ensure quality of patient care. Nurses are provided with remedial training to
improve their clinical skills if performance is low. Within the Chronic Disease Hospital of TashMI
II, the nurses have primary responsibility for patient care and management of a unit (in a manner
comparable to what is usual in the US).
Nurses from TashMI II have been well represented at AIHA nursing conferences held in recent
years. These conferences have been instrumental in providing direction to the development of
standards for nursing practice, the enhancement of nursing roles, the assertion of nursing leadership
through skill-building, the reform of the nursing curriculum, and the increase in the visibility of
TASHKENT, UZBEKISTAN - CHICAGO, ILLINOIS PARTNERSHIP
nursing as a profession. An association of nurses has been established with the involvement of
TashMI II nursing leaders.
The Women's Wellness Center will provide an opportunity for demonstration of the expanding
roles of nurses. Along with the Medical Director, a Nurse Manager will have responsibilities
associated with administration of the Center. Nurses will also assume expanded roles in outreach
and prevention, patient education and counseling.
Physician Training: Over the past five years, over 30 physicians have participated in intensive
training programs in Chicago ranging from two weeks to six months. Training modules have been
conducted in neonatology, orthopedics, neurosurgery, cardiac diagnostic and surgical procedures,
obstetrics and gynecology, hospital administration, nursing management, and medical education.
Physicians have received instruction in modern techniques and practices with the expectation that
they would return to TashMI II and serve as trainers within their respective departments. Recently,
TashMI II has participated in outreach to other parts of Uzbekistan (e.g., Urgench).
UIC has now been host to two physicians from Uzbekistan who have been awarded training
fellowships for extended periods of time. One Uzbek neurosurgeon had a fellowship for a six-
month course of study. An obstetrician/gynecologist arrived at UIC in June of 1997 for a three-
month internship (with both a clinical and administrative focus in women's health) after spending
the previous twelve months at the Humphrey Institute of Public Affairs at the University of
Minnesota under a Fullbright scholarship program.
Future Plans for the Partnership
The partners plan to continue successful projects in the areas of neonatology and perinatal medicine,
women's health, hospital and clinic administration, nursing administration and nursing education.
Activities will focus on the implementation and development of the Women's Wellness Center and
the Neonatal Resuscitation Training Center at TashMI II. A commitment has also been made to
the development of a Neonatal Resuscitation Training Center in Urgench. As funding permits,
attention will also be given to other outreach and "train the trainer" programs in Urgench. A
Nursing Resource Center is also expected to open in Tashkent early next spring.
Although progress has been made in the upgrading of high-risk services for maternal and neonatal
patients, there remains a need for the continued development of the Center for Extra-Genital
Pathology (in the Maternity Hospital) as a referral center for high-risk care. Visitors from
Uzbekistan will continue to be oriented to concepts related to delivery of care within a perinatal
system.
The partners will work together to improve managerial skills in financial accounting, human
resource management, and patient records and data management systems. They will continue to
promote consolidation of departments and expansion of ambulatory care.
Advanced training for nurses will be provided in nursing management and in the clinical areas of
neonatal/perinatal care and women's health. The partners will continue to facilitate the
TASHKENT, UZBEKISTAN - CHICAGO, ILLINOIS PARTNERSHIP
development of on-site training programs based upon the expectation that those benefiting from
training will, in turn, serve as the trainers for others.
Partnership Contacts
Dharmapuri Vidyasagar, MD
Khamid Karimov, MD. PhD
Director of Neonatology
Rector
Co-Director, Perinatal Center
Second State Medical Institute
University of Illinois at Chicago
2 Farobi Street
Department of Pediatrics M/C 856
Tashkent-109 Uzbekistan 700109
840 S. Wood Street
Phone: (3712) 46-96-48;
Chicago, Illinois 60612
Fax: (3712) 44-26-03
Phone: (312) 996-4181
E-mail:[email protected]
Fax (312) 413-7901
E-mail: [email protected]
Richard Derman, MD, MPH
Fran Jaeger, DrPH
Director of Ambulatory Care
Administrator of Perinatal Center
University of Illinois at Chicago
Partnership Coordinator
Department of Obstetrics & Gynecology
UIC Perinatal Center M/C 808
820 S. Wood Street, M/C 808
820 S. Wood Street
Chicago, Illinois 60612-7313
Chicago, Illinois 60612-7313
Phone: (312) 413-5819
Phone: (312) 996-0818
Fax: (312) 996-4065
Fax: (312) 413-0263
E-mail: [email protected]
E-mail: [email protected]
Ravshan I. Azimov, MD, PhD
NIS Partnership Coordinator
e-mail: [email protected]
UKRAINE
Donetsk - - Orlando, Florida
Kiev - Coney Island, New York
Kiev - Philadelphia, Pennsylvania
L'viv - Buffalo, New York
L'viv - Detroit, Michigan
Odessa - Coney Island, New York
DONETSK, UKRAINE - ORLANDO, FLORIDA PARTNERSHIP
AIHA's Medical Partnership Program between the Orlando Regional Healthcare System in Orlando,
Florida. and the Donetsk Oblast Trauma Hospital in Donetsk, Ukraine, funded under a cooperative
agreement with the United States Agency for International Development (USAID). began in
September 1995.
The general areas of partnership focus are orthopedics and joint replacement, infection control,
biomedical engineering, computing communications, emergency medicine, and women's health.
Program Outcomes
Orthopedics/Joint Replacement: The US partners evaluated the capacity of the operating room for
conducting orthopedic surgery, observed surgical procedures and inventoried equipment needs. The
NIS partners have observed surgeries in joint replacement and have been trained in the use of
various types of orthopedic equipment. As a result. new techniques in joint replacement for the hip
and knee have been learned and seventy-two joint replacement operations have been performed.
Infection Control: The NIS partners observed infection control practices in both the operating room
and on patient care units. They were also trained in sterilization techniques for instruments and
supplies. According to a report submitted by the Donetsk Oblast Trauma Hospital, the average
length of stay at the hospital decreased from 30.6 days in 1995 to 27.8 days during the first six
months of 1996. During the same period the mortality rate decreased from 2.4 to 1.9, for 10,000
treated patients. As a result of a new regulation set forth by the Head Physician, two new positions
for epidemiologists were established at the hospital. Data has been gathered to establish baseline
status and procedures are in place to monitor these indicators on a continuous basis. The nursing
staff at the hospital has been very involved in implementing an effective system of infection control.
Future Plans for the Partnership
The partnership will continue to assess and evaluate infection control practices, including data
collection and analysis. The partners will establish and implement an employee training program
to reduce the risk of infection to hospital staff as well as patients. A comprehensive immunization
program will also be established for the region.
Clinical training will be conducted in the areas of surgery, rehabilitation/physical therapy, and
radiology. The partners will evaluate the current use, effectiveness, and supply of prosthetics in the
area of joint replacement, as well as physicians trained in this area. The role of the nurse in post-
operative care and infection control will continue to be expanded upon.
Training will be provided to staff on the usage of equipment, recommendations for preventative
maintenance, and procedures for repair. The partners will assess biomedical policies and
procedures, and the documentation of preventative maintenance of equipment.
An EMS curriculum, including documentation and monitoring of outcomes, for training of EMS
personnel will be introduced. Guidelines for communication between the hospital and EMS
personnel will be established. Partners will identify and establish the role of the hospital within a
DONETSK, UKRAINE - ORLANDO, FLORIDA PARTNERSHIP
citywide EMS system. An EMS Training Center will be established in November 1997. Instructors
for the Center were trained by their counterparts in Orlando.
Physicians and staff at the hospital have been trained on the use of the Internet for both medical
reference and education. The Local Area Network will be fully developed within the coming year.
The Women's Health Initiative will be undertaken in 1998 based on the specific needs of the
Donetsk region and patterned after other women's health programs in the NIS.
Partnership Contacts
Vladimir Klimovitskiy, MD
Catherine Canniff-Gilliam, RN
Head Physician
Vice President, Chief Information Officer
Donetsk Oblast Trauma Hospital
Orlando Regional Healthcare System
Artema Street. 106
1414 Kuhl Avenue
Donetsk 340051, UKRAINE
Orlando, Florida 32806
Phone: (622) 553-541
Phone: (407) 841-5233
Fax: (622) 551-141
Fax: (407) 841-0053
E-Mail: [email protected]
KIEV, UKRAINE - CONEY ISLAND, NEW YORK PARTNERSHIP
AIHA's Kiev EMS Training Center was opened on December 15, 1995. on the campus of the city's
Hospital of First Help (EMS Hospital). The Center is one of nine EMS Training Centers developed
by AIHA and its partnerships in the NIS to provide local capacity to train emergency first
responders. Emergency response was an area largely neglected in the former Soviet Union and one
which enjoys an especially high priority for the new governments now in light of the increased risks
for disasters which have resulted from the profound economic deterioration.
As in the case of all partnership activities, funding for the center comes from a variety of sources.
Substantial funding and in-kind contributions were made by the Ministry of Health and the City of
Kiev to refurbish and furnish the center classrooms and offices; USAID/AIHA funds were used to
equip the center with instructional materials and technologies and to pay for travel of instructional
staff and administrative costs: and thousands of expert training hours in the United States and in
Kiev are being contributed by Coney Island Hospital and New York City Fire Department.
To date, eighteen pre-hospital training courses have been conducted for a total of nearly 900 health
professionals trained by the Ukrainian faculty. The student population includes professors,
physicians, interns, feldshers and nurses. as well as other emergency service personnel. In addition,
members of the Antarctic Expedition have been trained by the Center's staff. In keeping with the
train-the-trainers methodology of the program, US representatives helped to conduct the early
courses, served as course monitors, and assisted with faculty development.
As a result of the efforts of the Training Center's leadership, in June of 1996 the Minister of Health
issued an order requiring all ambulances throughout Ukraine to be supplied with specialized
equipment. This equipment. which was introduced at the EMS Training Center, includes spinal
immobilization devices and extrication cervical collars. The Center has also conducted training of
the Presidential Security Staff and representatives of the Ministry of Internal Affairs. Plans for the
next twelve months include the presentation of seventeen various pre-hospital EMS and instructor
training courses for a total of 550 students. At the request of the Ministry of Internal Affairs, the
Partnership has developed a "First Responder" program.
As the interest and growth of the AIHA EMS Special Initiative, the Partnership has assumed the role
of a major training and educational facility for emergency and disaster medicine. In August of
1997, the US and Ukrainian partners presented a Train the Trainers course entitled: "Infection
Control for the Pre-Hospital Care Provider" to the faculty members of AIHA's EMS Training
Centers. In addition, the Partners will be conducting an Instructor Training Program for new
Instructors. The faculty members of the Kiev in concert with their US colleagues, will assume the
role of Instructor Trainers for the system of satellite EMS training centers throughout Ukraine. A
new course is being developed to address the medical management of a Catastrophic Casualty
Producing Incident, or Disaster. The curriculum will debut in mid-1998.
In June of 1997, the Partners met with senior representatives of the Ukraine Ministry of Health in
order to discuss reform of the EMS System in Ukraine. All parties pledged their assistance in
helping to create an efficient emergency medical service and national disaster medical system in this
nation of 55 million people.
KIEV, UKRAINE - CONEY ISLAND, NEW YORK PARTNERSHIP
Partnership Contacts
Georgiy Roischin, MD
William P. Walsh
Director General
Executive Director
National Emergency Medicine and
Coney Island Hospital
Disaster Medicine Training System
2601 Ocean Parkway
7 Bratislavska Street
Brooklyn, New York 11235
253166 Kiev, UKRAINE
Phone: (718) 616-4100
Phone: (380-44) 518-0496
Fax: (718) 616-4439
Fax: (380-44) 518-0496
E-Mail: [email protected]
E-Mail: [email protected]
Mikhail Natsiuk, MD
James W. Alexander
Director
Assistant Director, Community Health Center
EMS Training Center
Coney Island Hospital
7 Bratislavska Street
2201 Neptune Avenue
252156 Kiev, UKRAINE
Brooklyn, New York 11224
Phone: (380-44) 518-0496
Phone: (718) 946-3400
Fax: (380-44) 518-0496
Fax: (718) 996-5644
E-Mail: [email protected]
E-Mail: [email protected]
KIEV, UKRAINE - PHILADELPHIA, PENNSYLVANIA PARTNERSHIP
AIHA's Medical Partnership Program between the University of Pennsylvania Schools of Medicine
and Nursing. the Hospital of the University of Pennsylvania. and The Children's Hospital of
Philadelphia. and the Left Bank Center for Maternal and Child Health Care in Kiev. Ukraine.
funded under a cooperative agreement with the United States Agency for International Development
(USAID). has existed since October 1992.
The general areas of partnership focus are maternal and child health, including management of
pregnancy, prenatal evaluation. ultrasonography. and family planning: pediatric sonography,
cardiology, and gastroenterology: nursing education and practice; women's health: and breast
cancer screening and education.
Program Outcomes
Obstetrics/Gynecology: The Center for Maternal and Child Health Care (CMCHC) is recognized
as a center of excellence for obstetrical care and consequently attracts clients from the surrounding
districts of Kiev. Both the Ministry of Health and the City Health Administration have recognized
the reforms implemented by increasing budget allocations to the hospital for purchase of modern
equipment and consumables. The Center's reputation as a high-quality provider has attracted many
women from other districts to deliver their babies there. Indeed, while the municipal birth rate
decreased by six percent in 1994, CMCHC actually experienced a 1.6 percent increase in deliveries
since 1993. In 1997 the birth rate has continued at a rate of 3000 per year.
According to a mid-year report submitted by the CMCHC in 1996, the average length of stay for
all patients decreased from 7.9 days in 1995 to 7.2 days, in addition to strides made in specific
departments. The average length of stay (ALOS) in the obstetrics department for post-operative
treatment decreased from 7.1 days in 1995 to 5.2 days. In the gynecology department the ALOS
for post-operative treatment decreased from 6.6 days in 1995 to 6.1 days. In 1995 the Center
opened an outpatient unit for gynecological patients.
Quality of labor and delivery services has greatly improved as a result of training in neonatal
resuscitation and the introduction of labor and delivery relaxation techniques. The creation of a
School for Young Mothers, offering instruction in prenatal care, pain management techniques and
fetal development, will continue to effect better fetal and maternal outcomes in the delivery room.
In a drastic deviation from traditional clinical practice, husbands that attend the preparation for birth
classes with their wives receive permission to attend delivery and act as a labor coach. The newly
created Patient Education Center is staffed by two midwives and a psychologist who lectures to the
group on the advantages of attending a delivery class as well as including fathers in delivery
education and process. In 1996 sixty fathers participated in the program.
The success of the Philadelphia-Kiev Partnership attracted the attention of First Lady Hillary
Rodham Clinton. She visited the CMCHC in May 1995, to tour and witness its demonstrated
success in improving the health of mothers and babies in Kiev. During her visit, Mrs. Clinton
observed a birthing education class at the recently organized School for Young Mothers and talked
with obstetrician-instructors and expectant mothers.
KIEV, UKRAINE - PHILADELPHIA, PENNSYLVANIA PARTNERSHIP
Prenatal Evaluation and Ultrasonography: Partners established a Prenatal Evaluation Center in
Hospital No. 3 which contains consultation rooms and equipment for fetal monitoring and fetal
ultrasound. The formation of a ten-bed ambulatory day care unit for women with high-risk
pregnancies has given a significant boost to overall efficiency and productivity. The unit allows
patients to receive treatment for conditions such as anemia and hypertension on an outpatient basis.
In conjunction with other clinical and administrative innovations, the Center has been able to
achieve a decrease in the postpartum length of stay for normal deliveries from 7.4 to 4 days. Fetal
monitoring in the hospital's new Prenatal Evaluation Center has added to the decline in mortality
rates because of ultrasound diagnosis of fetal abnormalities.
Perinatal and Neonatal Care: As a direct result of improved techniques in ultrasonography, fetal
testing, neonatal resuscitation and labor and delivery services. the Center has reported a 62 percent
decrease in perinatal mortality since 1993. In 1997 the infant mortality rate was reported to be
9.6/1000. Intense training in neonatal resuscitation and consequent improved management of
neonatal asphyxia has resulted in a decline in infant mortality rates.
CMCHC statistics in 1996 document that the early neonatal mortality was reduced from 4.9 per
1000 in 1995 to 4.8 per 1000. The rate of infectious disease among newborns was nearly halved
from a rate of 2.5 per 1000 in 1995 to 1.4 per 1000 in the first half of 1996. The Center opened a
new Level II Neonatal Intensive Care Unit in 1995 and began performing artificial pulmonary
ventilation in a lasting ventilation regime, special infant management techniques using intubation
and artificial pulmonary ventilation, and phototherapy techniques for newborns with hemolytic
disease.
Family Planning: A polyclinic at the Center for Maternal and Child Health Care initiated a family
planning program offering a range of women's health services, health education and contraceptives
donated by the University of Pennsylvania. Together with contraceptive counseling, distribution
of contraceptive pills, donated by the University of Pennsylvania and Project Hope, to over 600
women contributed to a 30 percent decrease in abortions performed at the hospital in 1994. The
ratio of abortions to live births in 1997 is 1:1, continuing the downward trend from greater than 2
abortion: 1 live birth at the inception of the program.
Pediatric Sonography, Cardiology, and Gastroenterology: Diagnostic skills in the ultrasound
department continue to improve and be developed. The Center now has a fully equipped facility
for neurologic, cardiac, and abdominal studies. Work in this area with the US Partners led to the
diagnosis of a case of sub-acute bacterial endocarditis, which was successfully treated with
antibiotics. The endoscopy suite is also fully equipped and techniques continue to be improved
upon. The implementation of GI guidelines from the partners has led to a decrease in the number
of studies that are done on young children.
Nursing: Building on the experience of the Nursing Leadership Conference in Moscow, the
partners are working together to enhance the nursing profession and the role of nurse leaders. An
initial step in this process was made in May, 1995 when the Center hosted an organizational
meeting to facilitate the creation of the nursing associations within Ukraine. The associations' goals
will include expanding the scope and methods of nursing education; improving the level and quality
of nursing administration: creating collaborative relationships between nurses and other health care
KIEV, UKRAINE - PHILADELPHIA, PENNSYLVANIA PARTNERSHIP
providers: and defining the scope of nursing practice. The Nursing Association of Kiev was formed
in June 1995. A Nursing Learning Resource Center was opened in April 1997, which serves as a
resource for nurses at the Center as well as students in the areas of both education and training.
Future Plans for the Partnership
Additional training will be given to delivery room staff for immediate care of the newborn. A
continuous quality improvement program will be implemented in the delivery room in an attempt
to establish internal monitoring which may help to sustain those changes made in techniques and
functions of the delivery room.
The scope of the Perinatal Evaluation Center will be expanded upon to include the use of protocols
for the management of normal pregnancies and routine complications, such as pre-eclampsia and
premature labor.
New treatment methodologies for patients with asthma and cystic fibrosis will be addressed in order
to decrease hospitalization rates and length of stay and move toward outpatient treatment of these
diseases. The partners will also work in pulmonary physiotherapy and outpatient management of
cystic fibrosis. Protocols will also be developed to address appropriate treatment modalities and
improve pulmonary health for patients with these diseases.
The parent education center will be expanded allow for dissemination both within the Center, as
well as at other hospitals in the region. A curriculum will be developed, including study guides and
audio-visual materials. and additional staff will be trained.
The partnership will implement the Women's Health Initiative, which will focus on three areas:
family planning, diagnosis and treatment of sexually transmitted diseases, and adolescent health.
The adolescent health aspect will attempt to focus upon teen health issues including sexuality,
family planning, and sexually transmitted diseases.
The breast cancer program will focus on educating and screening women for breast cancer. The
major features of the program include community based screening, educational outreach for breast
self examination and mammography, patient support groups, and patient centered care. A liaison
between the Center and the local oncology center has been established which will help manage the
treatment of patients diagnosed with breast cancer.
KIEV, UKRAINE - PHILADELPHIA, PENNSYLVANIA PARTNERSHIP
Partnership Contacts
Victor Didichenko. MD
William Schwartz, MD
General Director
Professor of Pediatrics
Center for Maternal and Child Health Care
Room 2417 - General Pediatrics
26 P. Zaporozhtsta Street
Children's Hospital of Philadelphia
253125 Kiev 125
34th & Civic Center Boulevard.
UKRAINE
Philadelphia PA 19104
Phone: (44) 512-36-38
Phone: (215) 590-3347
Fax: (44) 512-36-38
Fax: (215) 590-4877
E-Mail: [email protected]
E-Mail: [email protected]
L'VIV, UKRAINE - BUFFALO, NEW YORK PARTNERSHIP
AIHA's Medical Partnership Program between Millard Fillmore Health Systems and the SUNY
Buffalo School of Medicine and Biomedical Sciences in Buffalo. New York, and L'viv Clinical
Railway Hospital and L'viv Perinatal Center in L'viv, Ukraine. funded under a cooperative
agreement with the United States Agency for International Development (USAID). has existed since
April 1993.
The partnership emphasizes obstetrics and gynecology, infection control. ophthalmology, resource
center development. hospital administration. and laparoscopic surgery.
Program Outcomes
Obstetrics and Gynecology/Surgery: Implementation of prenatal screening and diagnostic
ultrasound has enabled the partners to better identify high-risk pregnancies and, ultimately, improve
fetal outcomes at the L'viv Permatal Center. They have also introduced the utilization of the vaginal
probe with ultrasound for prenatal diagnosis. Training in the primary care of women has also been
conducted. combined with specific efforts in the reduction of low birth weight infants and their care.
Between 1992 and 1995 the number of complications due to infections decreased in both the
maternity and the gynecology units. In the maternity unit it has decreased by 2.8 times and in the
gynecology unit it has been reduced by a factor of 3.8.
The mid-year report in 1996 revealed a number of statistics regarding strides that have been made
in the Perinatal Center. The average length of stay in the maternity unit decreased from 13.6 days
in 1995 to 11.2 days in 1996. The average length of stay in the gynecology unit was reduced from
5.8 days in 1995 to 5.4 days in 1996. In addition, the length of stay for a woman after a normal
delivery was reduced to 3 days. Perinatal mortality rates were decreased from 27 percent in 1995
to 26 percent in 1996. Intra-natal mortality rates were reduced from 15.5 percent in 1995 to 14
percent in 1996. The mortality rate of full-term infants was also lowered in 1996 to 2 percent from
a rate of 3 percent in 1995.
The L'viv Perinatal Center has begun performing the following new diagnostic procedures:
hysteroscopy, amniocentesis. and ultrasound examination with the use of a transvaginal meter. The
following treatments and procedures have also been introduced at the Center: laparoscopy
cystectomy, laparoscopy tubectomy, LAVH, laparoscopic surgical sterilization, minilaparotomy,
and prolongation of pregnancy despite premature release of amniotic fluid.
The Perinatal Center has begun providing laboratory examinations on an out-patient basis prior to
surgery, and treating women with gynecological diseases. A short procedure unit was opened at
the Center, in addition to a neonatal intensive care unit and a prenatal diagnostics unit.
Infection Control: Both NIS partner hospitals have implemented infection control programs
including Universal Precautions, improved cleaning, disinfection and sterilization techniques, and
prophylactic vaccination of health care providers against Hepatitis B and diphtheria. As a result,
the incidence of nosocomial infections at L'viv Perinatal Center has been reduced by 15 percent.
The position of Infection Control Officer has been added at Railway Hospital. This individual has
responsibility for hospital-wide infection control and the quality improvement program. Nurses
continue to be trained in Body Substance Isolation and Universal Precautions. Statistics at Railway
L'viv, UKRAINE - BUFFALO, NEW YORK PARTNERSHIP
Hospital show that both hospital personnel contact with patients' blood and hospital infections
between patients have been significantly reduced. The overall length of stay at Railway Hospital
has been decreased by 2 days.
Ophthalmology: At Railway Hospital. extensive hands-on training in early detection of myopia
and cataracts has led to a 40 percent increase in early detection and an estimated 20 percent decrease
in vision related disabilities. Treatment was changed from intra-capsular to extra-capsular
techniques, and over 125 patients received extracapsular implants with correctly fitted lenses to
restore full vision. Training has continued in the areas of extra- and intra-capsular lens
implementation surgery as well as phaco-emulsification. To date over fifty phaco-emulsification
procedures have been performed. New diagnostic tools have helped to identify over 2600 patients
with cataracts and over 800 patients with glaucoma. Surgery has been indicated and performed for
ninety-two of the glaucoma patients.
Resource Center Development: Librarians from the L'viv Scientific Library have received training
in Buffalo to increase their knowledge of computers and the use of bibliographic materials. They
have studied the hospital library system and its support of patient care and have been trained in
special search techniques on new equipment that they now have in L'viv. They plan to implement
a computerized bibliographic system stored in two databases at the Resource Center. The partners
have successfully translated "Prologue in Obstetrics" and disseminated educational materials to a
vast audience. Reference materials and textbooks have been transferred to the L'viv partners for
establishment of a medical reference library.
Hospital Administration: Billing and collection procedures and cost containment strategies have
been implemented at both L'viv hospital sites. The role and responsibilities of the Infection Control
Officer were developed to include the management of infection control data and statistics.
In February 1996, a cost accounting department was opened at the Railway Hospital. The hospital
now provides services for which they receive payment. Revenues from these services total over
$5,000 per month. The hospital anticipates that within five years they will transition to a
completely fee-for-service institution.
Laparoscopic Surgery: Laparoscopic training has been conducted in three stages: research and
study of the techniques, observation of the techniques, and, lastly, using a laparoscopic trainer under
the supervision of a US trainer. Physicians have observed and studied the following surgeries:
laparoscopic cholecystectomy, appendectomy, herniorrhaphy, colon resection, and Nissen
fundoplication. A new laparoscopic surgery department was opened at Railway Hospital in
February, 1996; the department is staffed by physicians and nurses who were trained in Buffalo.
A new laparoscopic technique, double combined extirpation of uterine tissue, was introduced at the
Perinatal Center in 1996. Statistics that were received in June 1997 from Railway Hospital indicate
that 1603 laparoscopic GI procedures have been performed using the equipment and techniques
learned from US Partners. Eight GI endoscopists have also been trained and have begun performing
laparoscopic gynecologic surgeries at Railway Hospital.
L'viv, UKRAINE - BUFFALO, NEW YORK PARTNERSHIP
Future Plans for the Partnership
A comprehensive approach to women's health and breast cancer screening will be fully
implemented, enabling the L'viv partners to provide screening programs for breast, cervical, and
uterine carcinomas, as well as to offer appropriate treatment interventions. Mammography
procedures will be standardized and an educational outreach program will be developed, including
instruction in Breast Self Exam. Pap smear testing and staining will be standardized using the
Bethesda Classification method. Basic birth control services will be provided in an outpatient clinic.
Outpatient treatment of cervical dysplasia, including colposcopy and cryotherapy will be provided
on an outpatient basis.
An NICU will be developed at the Perinatal Center and personnel will be trained in the treatment
of premature newborns with respiratory illness. A birthing room and "Birthing Center" will be
created at the Perinatal Center.
The partners will develop a preventative maintenance program. Equipment will be evaluated for
potential maintenance. The partners will work together to assure the proper functioning of
laparoscopic, ophthalmologic and laboratory equipment.
The partnership will work in the area of nursing continuing education program by enhancing
collaboration on nursing school curriculum. They will also assist with the development of the
Nursing Learning Resource Center.
Training will be conducted in advanced laparoscopic techniques and gynecological laparoscopy at
both hospitals. Gastrointestinal and ENT laparoscopy will also be developed at Railway Hospital.
The computer network will be expanded and the potential for dial-in access from both hospitals will
be evaluated. Additional training in the use of biomedical databases will be provided.
L'VIV, UKRAINE - BUFFALO, NEW YORK PARTNERSHIP
Partnership Contacts
Severin Dyba, MD
Sanford Hoffman, MD
Head Physician
Partnership Coordinator
L'viv Clinical Railway Hospital
Millard Fillmore Health System
Ulitsa Ogienka, 5
Millard Fillmore Suburban Hospital
L'viv - 10, 290007
1540 Maple Road
UKRAINE
Williamsville, NY 14221
Phone/Fax: (322) 33-30-88
Phone: (716) 636-4297
E-Mail: [email protected]
Fax: (716) 568-3030
E-Mail: [email protected]
Ivan Popil. MD
Head Physician
L'viv Perinatal Center
G. Washington Street, 6
L'viv, Ukraine 290032
Phone: (322) 42-16-90/42-92-20
Fax: (322) 42-51-58
E-Mail: [email protected]
L'viv, UKRAINE - DETROIT, MICHIGAN PARTNERSHIP
AIHA's Medical Partnership Program between Henry Ford Health System in Detroit, Michigan, and
L'viv Oblast Clinical Hospital (LOCH) and the L'viv Medical Institute in L'viv, Ukraine, funded
through a cooperative agreement with the United States Agency for International Development
(USAID). has existed since April 1993.
The general areas of partnership focus are neonatology, urology, rheumatic fever, and emergency
care. Other areas of attention have included laparoscopic surgery, ophthalmology, otolaryngology,
operating room organization and operation, nursing education and function, and hospital
administration.
Program Outcomes
Neonatology: The partners have focused their efforts on establishing a Level III Neonatal Intensive
Care Unit to meet the needs of critically ill and pre-term infants being transported to LOCH from
throughout the city and oblast. This was accomplished by redesigning the 48-bed unit and
establishing eight intensive care beds complete with cardio-respiratory monitoring, capability for
providing mechanical ventilation, controlled intravenous therapy, central blood pressure monitoring
and supportive treatment. Development of a Neonatal Lecture Series by the US partners was the
foundation for education of the LOCH staff. A collaborative practice model for physicians and
nurses for care at the bedside was developed as well as one for Unit management. A Nurse
Educator position was developed, in addition to the Head Nurse role, to support the education and
role development of the bedside nurse. A Collaborative Practice Committee, which utilizes quality
management tools introduced by the US partners, meets monthly to solve Unit problems and
address practice related issues.
The partners, with the help of the members of the Ukrainian Village Corporation in Warren,
Michigan, who provided an infant transport isolette, have established a transport system for sick
infants in the oblast. The development of the transport system was significantly supported by the
L'viv Oblast Health Department which created new regulations regarding the transport of infants,
thereby ensuring that sick infants will be transported to LOCH early in life. Outreach education for
district hospital personnel has been established as physicians from LOCH are consulted on neonatal
care during transports. Physicians and nurses from district hospitals also come to LOCH for two
weeks of bedside training with the staff of the premature baby unit. The planning for a neonatal
follow up clinic is underway.
A database was created by physicians at LOCH to measure mortality and morbidity statistics as well
as Unit related activities, such as mechanical ventilation, admissions, and transports. A bedside
documentation system for physicians and nurses, modeled after the one at Henry Ford Hospital, is
currently in use at LOCH. In their yearly reports the hospital has noted a number of strides that
have been made in the area of neonatal care. The number of neonates admitted during their first
three days of life has increased from zero in 1992 to 74 in 1995. In-hospital mortality rates for pre-
term infants were reduced from 6.3 in 1992 to 3.0 per 100 cases for 1995. In April 1996, the unit
began providing 24-hour coverage to the NICU.
The partners hosted annual Neonatology Conferences in L'viv in 1996 and 1997. The first
addressed Primary Resuscitation of the Newborn and resulted in the Ministry of Health supporting
L'viv, UKRAINE - DETROIT, MICHIGAN PARTNERSHIP
the implementation of the Neonatal Resuscitation Program nationally, by way of a national
resolution. The resolution stated that the neonatal resuscitation training model developed by the
L'viv-Detroit partnership at LOCH would be used for replication nationwide. The 1997 Conference
addressed Current Critical Issues in Neonatal Care. Both conferences were attended by over 175
health professionals from all over Ukraine.
The partners began training physicians and nurses from LOCH in Neonatal Resuscitation
techniques. and subsequently have trained over 200 health care givers in L'viv and the L'viv Oblast.
The first Neonatal Resuscitation Training Center (NRTC) for Ukraine was opened at LOCH in
January 1997, and this model will be replicated in four other locations within Ukraine. The Deputy
Minister of Health of Ukraine has agreed that these NRTCs will be officially recognized by the
MOH. The US partners have trained 25 National Faculty for this national replication effort.
Rheumatic Fever: A L'viv Oblast-wide initiative to identify and develop protocols for the diagnosis
and treatment of rheumatic fever and its major sequalae, rheumatic heart disease, continues.
During the past year, the collection of demographic-based data concerning the location and
incidences of rheumatic fever outbreaks was analyzed and became the focus of plans for the
program. Several staff exchanges of physicians to L'viv and Detroit were conducted to develop a
coordinated program to address rheumatic fever in the L'viv Oblast. Staff involved included
personnel in the departments of infectious diseases, pathology, rheumatology, internal medicine,
cardiology, cardiac surgery and pediatrics.
A significant result of the data collection and analysis was the development of a Rheumatic Fever
Conference held in L'viv in November 1996. Attended by approximately 200 physicians from
throughout Ukraine, the conference included faculty from both Henry Ford Health System and
LOCH as well as Ukrainian health officials. A major thrust of the conference was the
encouragement of an increased use of prophylactic antibiotics, and a number of conference
attendees reported in informal sessions that they would be more aggressive in the use of primary
and secondary prophylaxis. A follow-up conference will be conducted in November 1997.
Urology: US partners have conducted training in transurethral resection (TURP) of the prostate and
bladder and in related infection control and nursing practices. Dissemination of this information has
resulted in the completion of over 200 transurethral surgeries at LOCH. Further, training and
donated equipment have allowed L'viv surgeons to successfully develop a urodynamics laboratory
at LOCH and perform laparoscopic cholecystectomies. These improvements have contributed to
a reduction in average length of stay from 20 days to 5 days while reducing associated patient pain
and trauma as well as hospital costs.
Surgeons are now performing endoscopic operations on prostatic adenoma and cystic cancers. The
average length of stay for patients with prostatic adenoma was reduced from 21 to 8 days; the
average length of stay for patients with cystic cancer was reduced from 27 to 6 days. In addition,
a transurethral operating room was opened. Surgeons have also begun endoscopic operations on
gallbladder and biliary duct diseases. The average length of stay for these patients was reduced 65
percent, from 16.3 to 5.7 days.
L'viv, UKRAINE - DETROIT, MICHIGAN PARTNERSHIP
Emergency Care: During the past year. exchanges to L'viv and Detroit focused on evaluating the
function of receiving acutely ill patients at LOCH and planning to implement change to improve the
process. Training was provided in critical care resuscitation, patient tracking and management,
physical layouts of an emergency receiving department, record keeping, and quality assurance. In
addition. the L'viv staff observed physician-nurse collaboration and the role of the nurse in a busy
emergency department and was exposed to a system of continuing medical and nursing education
preliminary to evaluating the current curriculum at LOCH.
Because acute toxicologic emergencies play a major role in emergency services at LOCH, as well
as in the US. a concentrated effort was made to provide training in that area both at Henry Ford
Hospital and at the Detroit Poison Control Center. A copy of a computerized data base system
(Poisindex) was provided to the LOCH staff, as well as five computer monitors to help in
developing a regional toxicology center at LOCH.
Future Plans for the Partnership
In neonatology, the partnership will create a Developmental Assessment Clinic to follow the
progress of infants cared for in the Unit and will conduct a third Neonatology Conference in the
Spring of 1998. Partnership staff from both Detroit and L'viv will participate in the training of
faculty for the Neonatal Resuscitation Centers to be established throughout Ukraine. A new
ambulance, which will be purchased with donated funds, will be delivered to LOCH in Fall or early
Spring.
Urology exchanges will continue training in transurethral procedures for both surgical and nursing
staffs. Training will be provided in the vaportrode approach to TURP and the services provided by
the donated urodynamics laboratory will be monitored.
Progress in diagnosing and treating rheumatic fever will continue to be monitored through analysis
of the developing database, and preparations will be completed for the 1997 rheumatic fever
conference in L'viv.
A plan for the creation of a system of emergency care at LOCH, including the development of a
toxicology center, will be developed and monitored.
L'viv, UKRAINE - DETROIT, MICHIGAN PARTNERSHIP
Partnership Contacts
Borys Kryvko. MD
Alan Case
Acting Head Physician
Assistant Vice President
L'viv Oblast Clinical Hospital
Henry Ford Health System
UL Chernigivska, 7
One Ford Place
290010 L'viv-10, Ukraine
Detroit, Michigan 48202-34505
Phone: (0322) 75-50-21
Phone: (313) 876-8485
Fax: (0322) 75-78-15
Fax: (313) 874-6037
E-Mail: [email protected]
E-Mail: [email protected]
Mvroslava Struk. MD
Partnership Coordinator
L'viv Oblast Clinical Hospital
UL Chernigivska, 7
290010 L'viv-10 Ukraine
Phone: (0322) 75-50-21
Fax: (0322) 75-78-15
E-Mail: [email protected]
ODESSA, UKRAINE - CONEY ISLAND, NEW YORK PARTNERSHIP
AIHA's Medical Partnership Program between Coney Island Hospital in New York, and Odessa
Oblast Hospital in Odessa, Ukraine, funded under a cooperative agreement with the United States
Agency for International Development (USAID), has existed since October 1992.
The partnership emphasizes surgery. infection control, neonatology, nursing. dentistry, hospital
administration, women's health. and breast cancer.
Program Outcomes
Surgery: Hands-on training at Coney Island Hospital in thoracic, vascular, ophthalmologic and
orthopedic surgery have provided Ukrainian physicians with the opportunity to employ new
methods in every day practice and disseminate them to their colleagues in the Odessa Oblast. In
the five years of the partnership's collaboration approximately 2,000 laparoscopic procedures were
completed by the surgeons at Odessa Oblast Hospital(OOH). Six surgeons from OOH have become
experts in laparoscopy and laparoscopic cholecystectomy is now performed as a standard procedure
in 73 percent of patients with cholecystitis. As a result of all the improved surgical techniques, there
has been a reduction in average length of stay for cholecystectomies from 11 days to 3.8 days.
Through the partnership training three thoracic surgeons have gained expertise in the performance
of thoracic operations. The OOH was the first hospital in Ukraine to perform laparoscopic
vagatomy. This experience and knowledge is being disseminated to a number of regional hospitals.
The partnership has sponsored three Annual All-Ukrainian Surgical Conferences in Odessa. These
conferences have become an important source for the dissemination of knowledge and advanced
experience on a nation-wide level. Every year these conferences attract from 120 to 160 leading
surgeons from all over Ukraine. The latest conference in May 1997 was dedicated to the economic
benefits of laparoscopic surgery.
A new professional society, the Ukrainian Association of Laparoscopic Specialists, was formed in
Spring 1997. The Association will serve to provide education in laparoscopic procedures to all
regional hospitals. There are currently 102 members, representing 16 regions of Ukraine. The
chairman of the Association is a physician at the Odessa Oblast Hospital who has received extensive
training in laparoscopic surgery at Coney Island Hospital.
Infection Control: New infection control procedures, including changes in hand-washing protocol,
pre-operative showers, surgical skin preparation and other universal precautions, have decreased
the rate of post-surgical infection by half. The overall length of stay in the hospital has been
reduced by two days. The nursing staff continues to take a leading role in the implementation of
the infection control program. The department of surgery at the hospital now has an infection
control committee, which meets monthly to discuss infection-related issues. The position of
hospital epidemiologist was created in May 1996. Odessa Oblast Hospital (OOH) has also initiated
a comprehensive program to protect hospital personnel from blood borne infections.
The achievements of the partnerships in the area of infection control influenced the Ministry of
Health of Ukraine and US Infection Control Experts to chose OOH as a site for conducting an
infection control survey. The survey is part of a program to develop a model hospital protocol in
ODESSA, UKRAINE - CONEY ISLAND, NEW YORK PARTNERSHIP
the are of infection control. In July 1997 five epidemiologists, representing the Ministry of Health,
were trained in infection control protocols for two weeks at Coney Island Hospital.
WHONET: Odessa Oblast Hospital is one of the AIHA partner hospitals that are pilot sites for the
new WHONET program. This program is part of AIHA's Infection Control Initiative. Its goal is
to introduce current methods of quality control for microbiological tests; to introduce current
methods of antimicrobial resistance testing; and to establish a system of antimicrobial susceptibility
monitoring, using the WHONET program, developed by the World Health Organization.
Microbiology lab staff from Odessa Oblast Hospital have received equipment and supplies that
allow quality testing of antimicrobial resistance and monitoring of the results. They have received
training in current methods of antimicrobial resistance testing and in using WHONET.
Over the next year, WHONET participants will develop and implement mechanisms to control the
use of broad spectrum antimicrobial agents. Based on WHONET data. and with assistance from
their American partner and from the Society of Healthcare Epidemiology of America, each
participating NIS hospital will design protocols for empirical and targeted antimicrobial therapy for
major infections.
Neonatology: Initiation of training in neonatal resuscitation and neonatal intensive care has resulted
in improved fetal outcomes, specifically in reduced infant mortality, at Odessa Oblast Hospital.
Many advances have been made in medical practices, including newer treatments of various
diseases and most importantly, complete education in the area of neonatal resuscitation. Four
physicians have already been trained as certified instructors in neonatal resuscitation. The data
collection mechanisms which were developed to collect information on nosocomial infections have
assisted in the reduction of infection rates in the nursery and neonatal intensive care unit..
Nursing: The Partnership Nursing Conference, Leadership in Nursing, which was sponsored by
AIHA and the Odessa Oblast Trade Union of Medical Workers, was held in Odessa in June 1996.
In attendance were over one hundred and fifty nurses from twenty-six regions of Ukraine. The
conference focused upon revising the role of nurses in infection control, treatment, and
management. In September 1996 a Nursing Learning Resource center was opening at Odessa
Oblast Hospital. The Center has served to encourage independent learning, to enhance traditional
teaching methods, and to disseminate the advance experience gained through the partnership
collaboration. The Center continues to help promote the development of nurses in the areas of
practice, curriculum, and professional skills.
Dentistry: The concept of preventive care, including diagnostic x-rays, routine periodontal
screenings, and periodic examinations, which was introduced by the US Partners, are now being
utilized at Odessa Oblast Hospital and disseminated to nearby clinics. Through lectures and clinical
training, the Ukrainian partners are able to assist in clinical procedures at the dental clinic, review
radiological exposure. and develop new diagnostic techniques. Universal precaution, as it applies
in dentistry, and a dental management system have also been implemented.
Hospital Administration: The head accountant, head economist and assistant head doctor for
organizational systems for the Odessa Oblast Hospital spent short-term residencies in New York
ODESSA, UKRAINE - CONEY ISLAND, NEW YORK PARTNERSHIP
working with the administration of Coney Island Hospital to improve inventory, staffing, accounting
procedures, and quality control in the Odessa region. The director of primary care has implemented
a number of administrative and market-reform changes since visiting Coney Island Hospital.
Odessa now markets in the local media a private, evening, fee-for-service clinic. In addition, nurse
rotation has begun. allowing for broader cross-training and better use of human resources.
Future Plans for the Partnership
The partners will continue to disseminate expertise in techniques and methods in surgery, including
urology. orthopedics, nursing, anesthesiology, and infection control. The knowledge base of the
operating room staff will be enhanced with regard to all aspects of pre-operative, peri-operative, and
post-operative patient care. The partners will hold another hands-on surgical conference for the
region. The level of care provided in the Surgical Intensive Care Unit will continue to improve.
The Women's Health Center in Odessa is scheduled to open early in 1998 at the Odessa Oblast
Hospital (OOH). The Center will provide clinical and educational services and to address the health
needs of women throughout their lives. The OOH maintains ongoing communication with twenty-
six hospitals and two prenatal clinics in the region.. The Center will provide a centralized approach
to women's needs through a multi-disciplinary team consisting of obstetrician/gynecologists. family
practitioners, nurses, midwives, health educators, and a psychologist. The role of the Ob/Gyns will
be to be the primary care giver for patients at the Center. Special emphasis will be placed upon the
preventative aspect of women's health, starting from adolescence to post-menopause.
The partnership is rapidly developing plans for the Breast Cancer Center to be opened early in 1998.
The partners have already collaborated in conferences, study tours, and hands-on training in the area
of breast cancer education, screening, and early diagnosis.
Reduction of infant and neonatal mortality will continue through continuous improvement of
techniques in neonatal resuscitation and medical management of infants requiring intensive care.
This will be supplemented by the opening of a Neonatal Resuscitation Training Center at the Odessa
Oblast Hospital early in 1998.
Partnership Contacts
William Walsh
Vasily Gogulenko, MD
Executive Director
Head Physician
Coney Island Hospital
Odessa Oblast Hospital
2601 Ocean Parkway
Ak. Zabolotnogo Street, 26
Brooklyn, NY 11232
270117 Odessa, UKRAINE
Phone: (718) 616-4100
Phone: (482) 55-01-01
Fax: (718) 616-4439
Fax: (482) 55-1024
E-Mail: [email protected]
E-Mail: [email protected]
RUSSIA
Dubna - La Crosse, Wisconsin
Moscow - Austin, Texas
Moscow - Boston, Massachusetts
Moscow - Chicago, Illinois
Moscow - Norfolk, Virginia
Moscow - Pittsburgh, Pennsylvania
Murmansk - Jacksonville, Florida
St. Petersburg - Atlanta, Georgia
St. Petersburg - Louisville, Kentucky
Stavropol - lowa
Vladivostok - Richmond, Virginia
DUBNA, RUSSIA - LA CROSSE, WISCONSIN PARTNERSHIP
AIHA's Medical Partnership Program between the cities of La Crosse, Wisconsin, and Dubna, Russia,
funded under a cooperative agreement with the United States Agency for International Development
(USAID), has existed since December 1992. Hospital No. 9. Central City Hospital, and the Bolshaya
Volga Hospital, which houses the Diabetes School and the Children's Rehabilitation Center. are the
Russian partners. Lutheran Health System. Franciscan Health System, Gundersen Clinic, Skemp
Clinic and the La Crosse Visiting Nurses Association represent the American side of the program.
The general areas of partnership focus are home care and hospice programs, cardiac rehabilitation,
diabetes education, alcohol rehabilitation and education, orthotics. renal dialysis and women's health.
Program Outcomes
Home Care and Hospice Programs: More than 300 elderly are currently part of the home health
program whose focus is to reduce health sector costs and improve quality of care. This has been
accomplished by reducing inpatient lengths of stay, reorienting non-acute care to home settings and
increasing the number and the educational level of home care workers. As a result, budget savings
of 150 million rubles have been realized over each of the past two years. The Moscow Oblast cities
of Klim, Electrostal, and Taldom have become involved in preliminary steps for replication of this
model. In addition, a hospice program which was established in August 1994 continues to grow each
year. A regional hospice seminar was held in 1996 to disseminate information about steps to develop
a comprehensive hospice care service for the Moscow Region.
Cardiac Rehabilitation: Partnership collaboration on cardiac rehabilitation has resulted in dramatic
reduction in length of stay for uncomplicated myocardial infarctions. The average length of stay has
been reduced from 30 days to approximately 14-16 days. In addition to this advance, nurses are now
using American Heart Association brochures and materials to conduct inpatient teaching. These
materials have been translated and distributed throughout Dubna. Training through community health
fairs has continued in the areas of risk factor modification, community education, and curriculum
development in cardiac risk factor management.
Diabetes Education: The partnership's Diabetes School has educated more than 600 patients in
diabetes self-management since September 1993. As a result, average insulin dose levels have
declined 30 percent for Type I and 24.4 percent for Type II patients, and the average length of stay
for hospitalized diabetics has fallen from 33 days in 1992 to 20 days in 1995. These clinical outcomes
have led to cost savings of approximately 188 million rubles.
The Diabetes School model includes a multi-disciplinary approach. Educational sessions offered
within the Diabetes School include six three-hour sessions for patients and their families on a number
of topics: diet and diabetes, the accurate use of glucometers, physical exercise, treatment of diabetics
with insulin, hypoglycemia and hyperglycemic and podiatric and ophthalmologic problems of the
diabetic.
These activities have led to a collaborative agreement between the La Crosse, Wisconsin - Dubna,
Russia Partnership, AIHA, the Russian Ministry of Health, and Eli Lilly to utilize the existing Diabetes
School as a central training center. To date, five replication sites in the Moscow Oblast, and within
Moscow city limits have been selected and trained at the Dubna School. The sites in Moscow Oblast
DUBNA, RUSSIA - LA CROSSE, WISCONSIN PARTNERSHIP
include: Balasicha, Krasnogorsk and Dmitrov. The Moscow City sites are Medical Diagnostic Center
No. 2 and Polyclinic No. 139. Teams of patient educators led by the Chief Endocrinologist from each
site have received training from Dubna and La Crosse diabetes professionals. This initiative is
expected to serve as a model for similar programs throughout Russia in coming years.
Alcohol Rehabilitation and Education: Due to the partnership's efforts, Alcoholics Anonymous
(AA) and Al-Anon groups have been in existence in Dubna for over two years, and this model has
been successfully replicated in Dmitrov, Zaprudnia, Sergiev Posad. Taldom and Klin. with the support
of a grant from World Learning. More than 1600 individuals meet each month in AA and Al-Anon
groups throughout the replication sites. Television call-in programs. newspaper advertising and
community forums on alcoholism have maintained AA attendance at about 30 participants per
meeting. Alcohol counselors and community specialists in each of those cities have established
treatment centers and developed resource centers for literature dissemination. Two centers have
developed detoxification centers. Each center is engaged in prevention strategies in schools and in the
community at large.
Orthotics: The partners have collaborated to facilitate the establishment of an Orthotics Center in
Dubna. including the development of a fabrication process. Professionals from Dubna have been
trained in the identification of patient needs, in the fabrication and fitting of orthotics, as well as the
management of an Orthotics Lab. Therapists have been trained to work with both adults and children
in the fitting of orthotics. They have also learned how best to identify appropriate follow up care for
orthotics patients. The center has been designated a regional prosthetic center by the Moscow Oblast
Health Administration.
Women's Health: A comprehensive Women's Wellness Center is expected to open in Dubna by
December 1997, as part of AIHA's Women's Health Initiative. The center will offer comprehensive
services to women of all ages in the areas of childbirth education, reproductive health, disease
prevention and health promotion, nutrition, breast feeding, education, newborn infant care, sick infant
care and follow up care.
With the help of contraceptive counseling, educational materials, and an accessible supply of oral
contraceptives, family planning clinics in Dubna have had a dramatic affect on abortion rates in the
Dubna area. The number of abortions at Central Clinical Hospital was reduced from 431 in 1994 to
351 in 1995; the ratio of births to abortions was reduced from 1:2 to 1:1.6 over the same period. At
Hospital #9 abortions were reduced from 575 in 1994 to 323 in 1995; the ratio of births to abortions
was reduced from 1:2.2 to 1:1.1. Overall the abortion rate is declining, the number of women using
contraception is increasing, and the birth rate is increasing.
Renal Dialysis: Through the efforts of the partnership program and the Dubna City Health
Administration, a firm infrastructure has been established to support the expansion of this program.
The result is a two-station Renal Dialysis Center in Central City Hospital. The unit has been in
operation since November 1996.
DUBNA, RUSSIA - LA CROSSE, WISCONSIN PARTNERSHIP
Future Plans for the Partnership
Future plans for the partnership include:
To increase the number of CPR instructors in Dubna and surrounding communities by 10%.
To increase the number of personnel trained in CPR in the Dubna area by 15%.
To distribute at least 130 copes of the Russian CPR Manual for training assistance.
To identify a process to integrate home care services of hospitals, polyclinics, charity services and
the hospice.
Through additional training of health care providers, to enhance care provided to the elderly of
Dubna.
To enhance the clinical use of orthoses in the physical rehabilitation area.
To identify goals and objectives and design a community-based alcoholism prevention program
for at-risk youth in Dubna.
To establish a ten-week comprehensive, school-based alcoholism prevention program for grades
4-6.
To continue the self-management education of diabetics in Dubna and in each replication site.
Partnership Contacts
Yuri Komendantov
Sandra McCormick
Deputy Mayor
Vice President
La Crosse/Dubna Health Sciences
Lutheran Hospital
Resource Center
1910 South Avenue
Sovetskaya 11
La Crosse, Wisconsin 54601
141980 Dubna (Moscow Region) Russia
Phone: (608) 785-0530
Phone: (09621) 4-03-90
Fax: (608) 791-6334
E-Mail: [email protected]
E-Mail: [email protected]
Moscow, RUSSIA - AUSTIN, TEXAS PARTNERSHIP
AIHA's Moscow EMS Training Center was opened October 23. 1995. at the Institute of Continuing
Education of the Federal Directorate for Biomedical Problems and Disaster Medicine. The Training
Center is partnered with the City of Austin Emergency Medical Services Department and is
supported by the Ministry of Health and Medical Industries of the Russian Federation.
Program Outcomes
Since its inception, the center has conducted training courses for more than 445 health professionals,
including physicians, nurses, feldshers, and other emergency service personnel. The initial training
courses were presented jointly by US and Russian partners. Presently. US representatives serve as
course monitors and assist with further faculty development.
The partners worked together to develop a modified 48-hour first responder course with special
emphasis on radioactive emergencies. This course will be presented in locations throughout Russia
during the Fall of 1997.
The partners also created a public service video, to be aired on national television, aimed at
educating citizens to properly respond to medical situations they might encounter.
Future Plans for the Partnership
Future plans include the presentation of 15 courses annually for approximately 525 health
professionals. Personnel trained will include representatives from the medical facilities of the
Federal Directorate for Biomedical Problems and Disaster Medicine; the City of Moscow
Department of Health Care; and related chemical, nuclear, and space industries
Partnership Contacts
Vladimir Reva, MD
Sue Edwards
Director
Director
Federal Directorate for Biomedical
City of Austin EMS
Problems and Disaster Medicine
15 Waller Street
30 Volokolamskoe Highway
RBJ Health Center
Moscow 123182 Russia
Austin, TX 78702
Phone: (095) 190-33-26
Phone: (512) 469-2050
Fax: (095) 190-07-25
Fax: (512) 482-9407
Moscow, RUSSIA - BOSTON, MASSACHUSETTS PARTNERSHIP
AIHA's Medical Partnership Program between Brigham and Women's Hospital of Boston,
Massachusetts, and Pirogov First Municipal Hospital of Moscow, Russia, funded under a
cooperative agreement with the United States Agency for International Development (USAID), has
existed since October of 1992.
The general areas of partnership focus are infection control, nursing education. quality management,
hospital administration and finance and general surgery.
Program Outcomes
Infection Control: Pirogov Hospital has been selected by the Ministry of Health as a model site for
the development of hospital infection control techniques. The partners have organized a ten-
member Infection Prevention/Quality Assurance Committee which monitors post-operative
infections. establishes universal precautions and regulates operating room equipment. The
committee enacted major facility enhancements in the operating room. including ultraviolet lights,
new floors and secure doors.
The Head Specialist in the Division of Infectious Diseases Prevention for the Ministry of Health
(MOH) of the Russian Federation met with the Infection Control Committee at Brigham and
observed US infection control practices in order to prepare for the MOH/AIHA Infection Control
Workshop in Moscow in June 1994. The workshop enabled the Ministry of Health to review
implementation plans for Regulatory Order #220.
The partnership's First International Nursing Conference, in October 1994, was entitled
"Nosocomial Infections: Prevention and Control." It introduced the audience to principles of aseptic
technique, assessment of infection, nutritional health and infection prevention. infection surveillance
and other issues. The conference syllabus was distributed to attendees for dissemination and to use
as a learning tool.
From July 23-29, 1995, AIHA's Infection Control Task Force conducted an intensive infection
control survey of Pirogov Hospital. This survey consisted of three components: interviews with
personnel; observation of facilities, equipment. supplies and practices; and a prevalence survey of
active nosocomial infections, utilization of invasive devices and procedures and antimicrobial
prescription. A detailed written assessment of the survey was submitted to the hospital to use as
a measurement guide in improving its infection control practices. In addition, the US partners
devised a surgical wound classification guide for use by the Pirogov Infection Prevention-Quality
Assurance Committee.
The partnership developed an infection control assessment document, which includes over 70
recommendations for NIS hospitals to decrease infection rates. This document has been reproduced
in Russian and English.
During partnership exchanges focusing on infection control, members of the BWH Infection Control
Committee have conducted a series of lectures and seminars on Tuberculosis, Hepatitis A, B, Non
Moscow, RUSSIA - BOSTON, MASSACHUSETTS PARTNERSHIP
AB and HIV. These presentations addressed the current status of these diseases in Russia and
worldwide, and they also discussed their potential impact in the future. All of the lectures have
been translated into Russian for dissemination.
Continuing Nursing Education: In October 1994, the partnership held their first International
Nursing Conference in Russia for over 250 nurses from Moscow and ten republics of the former
Soviet Union. The event increased awareness of the integral role of nurses in patient care delivery,
specifically in the prevention and control of nosocomial infections.
On November 30 and December 1. 1995. the partnership hosted nurses and hospital administrators
from each AIHA hospital partnership at their second international nursing conference. entitled
"Professional Issues in Nursing." This conference emphasized the need to increase the clinical and
management role of the nurses in NIS medical institutions. On December 5 and 6, 1996, the
partnership hosted their third such conference, which focused on "Interventions in Trauma."
In May 1997. the partnership held a teleconference between Boston and Moscow, entitled "Nursing
Management." The conference was well attended in Moscow, by Chief Nurses from Pirogov and
by faculty and students from the Graduate Nursing Program at the Moscow Medical Academy. The
teleconference addressed: methods of nursing care delivery, evaluation as a tool for nurse managers,
coaching, teamwork, and other topics related to nursing management.
Nurses from Pirogov have participated in multiple exchanges with Brigham and Women's Hospital.
During the course of these exchanges, they have focused on methods of nursing care delivery in the
United States, and they have been able to participate in conferences organized for BWH nurses.
Hospital Administration and Finance: Administrators from Pirogov have focused on issues of
quality management, management planning and financial management.
In the field of financial management, the partners have focused on insurance policies and cost-
accounting. In response to their decreased share of the state healthcare budget, Pirogov is expanding
its revenue base to non-Muscovite fee-for-service clientele through a variety of mechanisms which
could eventually include managed care.
Administrators from Pirogov have become familiar with capitation-based systems of payment, and
with the system at BWH in particular. They have also focused on contracts and on funds-allocation
for employee wages.
Surgery: Pirogov physicians and nurses have renovated and reorganized the Emergency Room to
include a special dispatching area staffed by feldshers, who are responsible for managing patient
flow. These dispatchers register patients based on diagnosis, to enable emergency physicians to
separate acute and non-acute trauma patients and, thus to provide more effective treatment.
The partnership sponsored a conference entitled "Contemporary Problems in Surgery" in Moscow
in June 1993 for over 600 NIS clinicians. Presentations included the following topics: laparoscopy,
Moscow, RUSSIA - BOSTON, MASSACHUSETTS PARTNERSHIP
infection control, the role of nurses in surgery and cost-effectiveness in evaluating surgical
procedures.
Future Plans for the Partnership
The partners plan to continue successful projects in infection control, nursing education and hospital
administration. Pirogov hospital will continue as a model site for the development of hospital
infection control techniques for the Ministry of Health. Furthermore. the partners will continue to
implement concepts of quality assurance and utilization review.
The Infection Control team at BWH and Pirogov is planning to create an Infection Control Website,
in order to better disseminate the most current information in this area.
The partnership conducted an interactive teleconference on September 12, 1997, discussing two case
studies of acute myocardial infarction.
On December 4 and 5. 1997, the partnership will host it's Fifth International Conference, entitled
"Emergency Care of III and Injured Patients."
Partnership Contacts
Andrei Lishansky, MD
Elena Catizone, Program Coordinator
Pirogov First Municipal Hospital
Russian Exchange Program
Leninsky Prospekt, Dom 8
Richardson Fuller Building
117049 Moscow
221 Longwood Avenue
RUSSIA
Boston MA 02115
Phone: (095) 952-3868
Phone: (617) 732-8332
E-Mail: [email protected]
Fax: (617) 264-6856
E-Mail: [email protected]
Moscow, RUSSIA - CHICAGO, ILLINOIS PARTNERSHIP
The Chicago - Moscow partnership. linking the Medical Center of the General Management
Department of the President of the Russian Federation in Moscow with Premier, Inc., in Chicago,
officially graduated from AIHA's partnership program in April 1996. The graduation date
coincided with the Grand Opening of the newly renovated International Patient Department at
Moscow's 1400-bed Central Clinical Hospital.
During the past three years. the partners have addressed such issues as maternal health, diagnostic
and interventional cardiology. nursing education and practice, medical education, ambulatory care,
outpatient surgery, medical insurance. quality indicators, food and nutrition services, healthcare
administration, human resource management, blood banking, intravenous therapy practices,
cardiovascular surgery, endoprosthetics. clinical case management and customer service. Using the
resources of Premier affiliates such as Mount Sinai Hospital and Beth Israel Medical Center (New
York), Strong Memorial Hospital/University of Rochester (Rochester), The Cleveland Clinic
Foundation (Cleveland). Millard Fillmore Health System (Buffalo), and Mount Sinai Hospital
Medical Center (Chicago), the partners have had frequent exchanges to and from Moscow. Three
major. multidisciplinary conferences were conducted onsite in Moscow; these programs were open
to participants from other partnership programs.
As an affiliate of Premier, Central Clinical Hospital is enrolled in the Maryland Hospital Association
Quality Indicators Program. Recipient of an Abt Grant, the QI team presented a poster at the
International Quality Indicators Meeting in Jerusalem in May 1996. Representatives of Central
Clinical Hospital will participate in the International Congress on Performance Measurement and
Improvement in health Care in Chicago during November 1997.
Post-graduation, the NIS partners have continued to impact and participate in AIHA-sponsored
regional activities, including local conferences and educational symposia. Two abstracts were
presented at the 1997 Nursing Conference in Kiev, Ukraine; two speakers will contribute to the
1997 Annual Partnership Conference in Atlanta. The partners have enjoyed an outstanding working
relationship; they credit AIHA with facilitating this relationship and supporting program initiatives.
Partnership Contacts
Marina Ugryumova, MD
Sharon Weinstein, R.N., CRNI, MS
Chief Physician, International Patient Dept.
Director, Office of International Affairs
Central Clinical Hospital
Premier, Inc.
15 Marshala Timoshenka Street
3 Westbrook Corporate Center, 9th Floor
Moscow, Russian Federation 121356
Westchester, Illinois 60154
Phone: (7-095) 414-0686
Phone: (708) 409-3793
Fax: (7-095) 414-0710
Fax: (708) 409-3499
E-Mail: [email protected]
E-Mail: [email protected]
Moscow, RUSSIA - NORFOLK, VIRGINIA PARTNERSHIP
Building on the initiatives of the neonatal resuscitation initiative. in 1995 AIHA joined with the
USAID funded partnership between the Children's Hospital of the King's Daughters in Norfolk,
Virginia and the Ministry of Health (MOH) and the Institute of Pediatrics and Children's Surgery
in Moscow. Russia to establish a core group of Russian physicians and nurses skilled in neonatal
resuscitation and the basics of immediate newborn care. This will be accomplished by conducting
week-long training courses with the Russian MOH under the auspices of the Neonatal Resuscitation
Training Center. which was opened in May 1997.
Program Outcomes
Thus far, the US partners have conducted seven courses in neonatal resuscitation and the basics of
neonatal care for medical professionals in Moscow Oblast, two courses in Samara, and one course
in Tver. Approximately 370 Russian health care providers have been certified in the American
Heart Association/American Academy of Pediatrics Neonatal Resuscitation Program. A revised
clinical protocol on delivery room assessment and newborn care has been distributed to all regions
of Russia by the MOH.
A neurodevelopmental clinic has been established at Hospital No. 13, in Moscow for follow-up of
high risk premature infants. Approximately 300 patients have been followed serially by the clinic.
The CAT/CLAMS neurodevelopmental assessment tool of visual, language, and cognitive
development has been translated into Russian. Training videos for neurodevelopmental evaluation
of premature infants have also been created. A manuscript is in preparation entitled:
Neurodevelopmental Pediatrics in Russia: The Follow-Up of High Risk Premature Infants in
Moscow. Russia.
An AIHA sponsored Learning Resource Center has been established at the Institute of Pediatrics
and Children's Surgery. The computer center allows connection with Internet and the transmission
of e-mail, thereby expanding upon the availability of current medical information and enhancing
communications and consultation opportunities.
Future Plans for the Partnership
The long term goals of this partnership include improving neonatal health care in Russia by assisting
the MOH in creating a cadre of physicians, nurses, and midwives skilled in neonatal resuscitation
and in the basics of immediate newborn care and who are capable of sustaining an effective neonatal
outreach education program throughout Russia. The partnership will facilitate neonatal care policy
reform by assisting the MOH in revising existing policies and regulations and in developing new
clinical protocols for newborn care. The partners also aim to decrease infant morbidity by
establishing a coordinated and comprehensive neurodevelopmental follow-up program for infants.
Other related objectives include the promotion of the model Regional Neonatal Resuscitation
Training Center that is charged with training instructors for other training cites and hospitals
throughout Russia. The partners plan to revise existing protocols and develop policies and
procedures for normal newborn care and for the clinical management of common neonatal diseases.
The Learning Resource Center will continue to be developed in order to expand access to the current
medical literature and to allow for world-wide consultations with other health care providers.
Moscow, RUSSIA - NORFOLK, VIRGINIA PARTNERSHIP
Lastly. the partnership will establish a coordinated and comprehensive neurodevelopmental follow-
up program for infants in Moscow Hospital # 13 and a Neurodevelopmental Pediatrics Department
at the Moscow Institute of Pediatrics and Children's Surgery.
Partnership Contacts
Glen Green, MD
Olga Belova, MD
Neonatal Medicine
Partnership Coordinator
Children's Hospital of the King's Daughters
Institute of Pediatrics & Children's Surgery
601 Children's Lane
2 Taldomskaia Street
Norfolk. Virginia 23507
Moscow 127412, RUSSIA
Phone: (757) 668-7456
Phone: (095) 274-7207
Fax: (757) 668-9255
Fax: (095) 483-3335
E-Mail: [email protected]
E-Mail: [email protected]
Moscow, RUSSIA - PITTSBURGH, PENNSYLVANIA PARTNERSHIP
AIHA's Medical Partnership Program between Magee-Women's Hospital, Pittsburgh,
Pennsylvania, and Savior's Hospital for Peace and Charity and the Main Medical Administration
of Moscow, Russia funded under a cooperative agreement with the United States Agency for
International Development (USAID). has existed since December 1992.
The general areas of partnership focus are maternal and child health. family planning, consumer and
community education, and hospital administration.
Program Outcomes
Maternal and Child Health: In July 1993, the partners created a Woman and Family Education
Center, which offers classes in prenatal care. family planning, labor and birth preparation for parents
and siblings. The center also provides general women's health classes designed for adolescents. Six
Russian childbirth educators, trained and registered with the International Childbirth Educators
Association (ICEA), staff the Center. The Center serves an average of 400 Russian women per
week from Moscow and two outlying rural areas.
The Moscow Main Medical Administration donated the ruble equivalent of $500,000 in support of
a renovated birth house with Western medical standards and a model of obstetric care. US partners
shipped two 40-foot containers. filled with equipment and supplies. to Savior's Hospital to assist in
the renovation. The shipment, valued at $94,800, is a result of in-kind donations by Magee-
Women's Hospital and private companies in the Pittsburgh area. In addition, Johnson & Johnson
will supply the Birth House with discounted medical supplies for delivery and obstetrical services.
With the renovated Birth and improved obstetric care, the partnership's goal is to deliver 3,000
infants and train 350 Russian obstetricians annually.
First Ladies Hillary Rodham Clinton and Naina Yeltsin visited Savior's Hospital in January 1994.
The First Ladies toured the pediatric ward and attended a childbirth education class at the Savior's
Hospital. They also participated in a round-table discussion with the partnership's leaders and
representatives from AIHA and USAID.
In conjunction with the University of Pittsburgh School of Medicine, the Moscow Main Medical
Administration and the Russian National Academy of Obstetrics and Gynecology, the partnership
sponsored the First Annual 1994 Moscow Update in Obstetrics and Gynecology. American and
Russian experts presented on medical advances in pre-term labor, sexually transmitted diseases
(STDs), pre-eclampsia, menopause, pelvic inflammatory disease and antenatal assessment.
Additional seminars have been offered by the partners in collaboration with the Main Medical
Administration of Moscow. Approximately 250 physicians and midwives from nine AIHA
partnerships attended the dissemination conference entitled "Partners in Birth: The Role of Labor
Support in the Medical Management of Labor" on February 2-3, 1994.
Magee Womancare International received a grant award in 1994 for $540,000 from World Learning
to establish twenty Woman and Family Education Centers in Russia. Over the course of 24 months,
the partners built a network of independent women's health education centers throughout Russia.
They trained over 70 health professional trainers from 24 regions of Russia in consumer education,
Moscow, RUSSIA - PITTSBURGH, PENNSYLVANIA PARTNERSHIP
train-the-trainers methods. education center design and management. fundraising and community
organization. As a result of this grand. the first professional Russian association of childbirth
educators was established with members in 27 regions of the Russian Federation.
In collaboration with First Lady Naina Yeltsin, the Russian Ministry of Health and Medical
Industry, the Woman and Family Education Center, and Magee Womancare International,
ASPO/LAMAZE held its first annual certification conference for Russian childbirth educators in
September 1995. Over 300 Russian health care professionals were trained in the Lamaze method
of prepared childbirth and in the health curriculum of the Woman and Family Education Centers
throughout Russia.
Savior's Chief of Surgery, in collaboration with Magee cardiologists, designed treatment protocols
for women with cardiological disorders during prenatal and post-natal periods. In addition, he
worked with Magee ambulatory care administrators on plans for the future Savior's Ambulatory
Care Center for Women.
Family Planning: In May 1994, the partners opened the Woman and Family Planning Clinic which
offers low-cost, high-quality family planning services. It is the first comprehensive family planning
program in the eastern region of Moscow and one of the first clinics in Russia to include pap smears,
sexually-transmitted disease testing and preventive health counseling in a standardized model of
women's health care. In its first four months of operation, more than 2,000 women used the
services offered. Due to increased demand. the Center is now expanding and anticipates seeing
approximately 700 clients per month. USAID granted the Magee-Savior's partnership $400,000 to
replicate the Magee-Savior's Family Planning Clinic in 18 regions of the Russian Federation.
The Soros Foundation granted the partnership over $160,000 to establish eighteen women's health
clinics in eighteen regions of Russia. Building upon the successful model implemented in Moscow,
these clinics were established by July 1997. This network of women's clinics will provide Russia
with a community health services model of family planning. In addition, health education training
for adolescents was offered through the established Education Centers and in collaboration with the
Soros Foundation's Regional Health Education Program.
The partnership has completed an epidemiological study to record baseline data and statistics from
the Woman and Family Education Center, the Woman and Family Planning Clinic and four
Moscow birth houses.
Consumer and Community Education: The partnership has printed and distributed over 10,000
pregnancy-guide calendars, family planning materials, contraception and women's health brochures
and breast self-exam cards. Video productions in Russian include "You and Your New Baby,"
"Puberty," "Partnership in Birth," "A Time to Grow," and "Its Up to You: Adolescent Sexuality."
From February 27-March 3, 1995, CNN International aired a series on women in Russia that
featured the partnership's Woman and Family Planning Clinic and Woman and Family Education
Center.
Moscow, RUSSIA - PITTSBURGH, PENNSYLVANIA PARTNERSHIP
On April 14. 1995, the Magee-Savior's partners hosted Moscow adolescents and their parents for
"Teen Day." an event launching the partnership's new adolescent clinic program. Adolescents are
encouraged to visit the Woman and Family Planning Clinic on a regular basis during special hours
to consult with the clinic's adolescent instructor.
Created by the partnership. the Woman and Family Foundation at Savior's is the first non-
government fundraising arm affiliated with a Russian hospital. In cooperation with this foundation,
the Woman and Family Education Center has launched a local fundraising campaign which has
raised over $50,000 through special events. grants and hospital services.
Over the past three years, the Magee-Savior's partnership has worked with various Russian and
international organizations to sponsor an annual community event. The Womancare Wellness
Festival (formerly the Celebration of Women). Most recently in March 1997 the Wellness Festival
brought in nearly 2,000 women form Moscow and the surrounding regions to participate in wellness
information sessions, a healthy lifestyles exhibit fair. With sponsorship from Avon Beauty
Products. Johnson & Johnson and Upjohn Pharmaceuticals. the festival gave women an opportunity
to obtain new information, receive free health screenings and grow both personally and
professionally.
Hospital Administration: Selected as a training site by Management Sciences for Health, Magee
has hosted over 400 Russian health care executives for training in hospital financial management.
To date more than 300 Russian professionals have been trained in basic infection control techniques,
policies and procedures for hospital workplace safety and management, including the orientation
and training of non-medical hospital staff. the writing of job descriptions, employee contracts and
performance appraisals, and budgeting for cost centers.
Future Plans for the Partnership
The Magee-Savior's partnership will sponsor the Third World Conference on Childbirth Education
in October 1997 in Budapest, Hungary. This year's conference will bring health professionals from
throughout the US, NIS and Central and Eastern Europe for the future global development of
women's health education.
As part of AIHA's Women's Health Initiative, Magee-Savior's will enhance the services offered
at the Savior's Family Planning clinic to include comprehensive menopause and older women's
health programs. The program will include an informational resource center on breast health as well
as screening for hormonal replacement therapy. In addition, the partnership plans on producing
a video and additional educational materials in this area of women's health.
Magee-Saviors will initiate a new program with the Avon Beauty Products company to produce
infomercials on women's health issues. With a $100,000 grant from the Avon Foundation, Magee,
Savior's and Avon will produce ten infomercials on issues such as family planning, adolescent
health, pregnancy, breast cancer and menopause. The infomercials will be aired in various cities
throughout Russia.
Moscow, RUSSIA - PITTSBURGH, PENNSYLVANIA PARTNERSHIP
Partnership Contacts
Tanya Ozor
Alexander Goldberg. MD
Coordinator. Savior's Hospital Project
President and Chief Physician
Magee Women's Hospital
Savior's Hospital
300 Halket Street
Moscow Municipal Hospital No. 70
Pittsburgh, PA 15213
17. Federativny Prospekt
Phone: (412) 641-1189
Moscow, 111399 RUSSIA
Fax: (412) 641-1221
Phone: (7095) 304-49-39
E-Mail: [email protected]
Fax: (7095) 303-97-69
E-Mail: [email protected]
MURMANSK, RUSSIA - JACKSONVILLE, FLORIDA PARTNERSHIP
AIHA's Medical Partnership Program between the cities of Jacksonville, Florida, and Murmansk.
Russia, funded under a cooperative agreement with the United States Agency for International
Development (USAID). has existed since October 1992. Murmansk Regional Hospital and
Murmansk City Ambulance Hospital are the Russian partners. From 1992 through June 1996. St.
Vincent's Medical Center and Memorial Hospital of Jacksonville represented the American side of
the program. Effective July 1. 1996. coordinating responsibility for this partnership. on the
American side, has been transferred to the Jacksonville Sister Cities Association. Sister Cities will
draw on the expertise of health care professionals from the greater Jacksonville area. On the basis
of this change, the partnership has been extended for one year.
The general areas of partnership focus are laparoscopic surgery, quality indicators. hospital
administration, infection control (STDs and HIV/AIDS), emergency medical services and women's
health.
Program Outcomes
Emergency Medical Services: From March 23 - 28, 1995. the Jacksonville-Murmansk partners
sponsored two workshops on pre-hospital emergency care. The first workshop, a modified
American Heart Association Pediatric Advanced Life Support Course, provided strategies for early
recognition of infants/children at risk for respiratory failure and/or cardiopulmonary arrest. At this
workshop the participants practiced airway management, vascular access and basic life support
techniques. The second workshop, "Trauma, Resuscitation and Stabilization," presented the
fundamentals of pre-hospital trauma management of acute care patients. Approximately 100
professionals were trained at each of these workshops.
In September 1995, a six-person delegation traveled to Jacksonville to receive additional training
in emergency preparedness.
The partners installed an intercom system at Murmansk Regional Hospital to assist in intra-
institutional communication and to improve situation response time.
Women's Health: In September 1994, the partnership initiated a prenatal vitamin study including
100 patients in Maternity Homes No. 2 and No. 3. This project was designed to improve the
nutrition of mothers and reduce maternal and neonatal morbidity and mortality rates. OB/GYN
physicians and nurses from St. Vincent's Medical Center and the former Memorial Hospital of
Jacksonville have worked with their counterparts in Murmansk to improve the treatment of women
with high-risk pregnancies.
A training program was also developed to educate women in Murmansk about diagnosis and
treatment of breast cancer. The program included instruction in breast self-examination.
Through the partnership, an advanced training program for diagnosis and treatment of sexually
transmitted diseases (STDs) was developed to train Murmansk health care professionals. In
September 1995, supplementary lectures on STDs and infertility were presented to Murmansk
physicians and nurses.
MURMANSK, RUSSIA - JACKSONVILLE, FLORIDA PARTNERSHIP
Infection Control: In December 1996. the director of the Murmansk HIV/AIDS Clinic and
Laboratory traveled to Jacksonville to receive advanced training in education, prevention, diagnosis,
treatment and outreach programs for HIV/AIDS. Planned Parenthood of N.E. Florida has become
actively involved in providing additional training in education and prevention of STDs and
HIV/AIDS. The executive director traveled to Murmansk in March of 1997, delivering lectures to
over 150 nursing students, high school students, school psychologists. midwives and other
healthcare professionals.
Quality Indicators, Hospital Administration and Finance: Through a partnership exchange, four
senior health care administrators from Murmansk Regional Hospital and Murmansk City
Ambulance Hospital were trained in key aspects of quality assurance and utilization management
at St. Vincent's Medical Center and the former Memorial Hospital of Jacksonville. These senior
health care administrators returned to Murmansk and implemented these administrative practices.
As a result. the partners have seen improvement in the areas of financial management,
documentation, medical records administration and general hospital administration.
In September 1995, a four-person delegation from Jacksonville visited five Murmansk medical
institutions to review quality assurance and quality improvement projects. The delegation found that
the institutions have begun to implement quality improvement systems despite financial constraints.
The US team worked with the administrators to develop incentives to motivate physicians to
incorporate quality improvement systems in their practices.
The partners are continuing efforts in this area. In December 1996 a senior administrator from
Murmansk Regional Hospital and the director of the Murmansk Insurance Fund received advanced
training in medical insurance reimbursement issues from Jacksonville area healthcare providers,
HMOs and insurance companies.
Due to partnership efforts, the average length of patient stay following surgery at City Ambulance
Hospital has decreased from 14-15 days to 9-10 days. This chance reflects the maximum utilization
of hospital resources and a subsequent reduction in hospital costs.
Laparoscopy: The partnership sponsored an international medical conference in Murmansk with
more than 300 health care professionals in attendance. A group of fifteen physicians. nurses and
administrators provided concurrent lectures and practica in laparoscopy, ACLS, neurology, nursing
and hospital administration.
In April 1996, two surgeons and a gastroenterologist from Columbia/Memorial Hospital of
Jacksonville conducted a one-week, interactive, train-the-trainer course in laparoscopic and
endoscopic diagnosis and treatment for their colleagues in Murmansk.
In November 1996, two surgeons and an anesthesiologist from Columbia/Memorial assisted their
Russian colleagues in a one-week, interactive course, focusing on special anesthesia procedures for
laparoscopic surgery and new techniques for herniorrhaphies and cholecystectomies. Surgeons,
nurses and an anesthesiologist from Murmansk have traveled to Jacksonville for continued,
advanced, hands-on training.
MURMANSK, RUSSIA - JACKSONVILLE, FLORIDA PARTNERSHIP
In early 1997, Murmansk surgeons assisted their US partners in surgery, marking the first time
AIHA partners have performed surgery in the US.
Since 1993. surgeons at Murmansk City Ambulance Hospital have performed approximately 300
laparoscopic cholecystectomies with minimal complications.
Future Plans for the Partnership
The partners have developed a comprehensive workplan for this program year. Building on past
work. they will focus on the areas of Orthopedic Laparoscopic, Pediatric and Cardiovascular
Surgery, Infection Control (STDs and HIV/AIDS) and Women's Health.
Partnership Contacts
Julie Buckingham
Dr. Alexander Pisarenko, Director
Jacksonville Sister Cities Association
Murmansk City Public Health Department
4049 Woodcock Drive, Suite 200
Profsoyuznaya, 20, Suite 418
Jacksonville, FL 32207
183038 Murmansk, RUSSIA
Phone: (904) 399-5548
Phone/Fax: (7-815) 255-5335
Fax: (904) 391-1004
Fax: (7-789-10452 (Norwegian Line)
E-Mail: [email protected]
E-Mail: [email protected]
ST. PETERSBURG, RUSSIA - ATLANTA, GEORGIA PARTNERSHIP
AIHA's Medical Partnership Program between Georgia Baptist lealthcare System, Atlanta, Georgia
and St. Petersburg Medical University in the name of Pavlov. minded by the United States Agency
for International Development (USAID). has existed since April 1993.
The general areas of partnership focus are obstetrics and gynecology, radiology. ophthalmology,
medical education, nursing education and hospital administration and finance.
Program Outcomes
Obstetrics and Gynecology: The Second International Symposism on Obstetrics and Gynecology
was hosted at Pavlov in June 1994. Demonstrations and lectures addressed the management of
complex obstetrical patients. endoscopic procedures and re onstructive techniques following
oncological surgery. 400 nurses and physicians attended from the NIS. the United States. Germany
and Austria.
In April 1997. the partners sponsored another Symposium on obstetrics and Gynecology, in St.
Petersburg. focusing on the use of fetal monitors, donated by the Atlanta partners, and on the
surgical techniques or hysterectomy and laparoscopy. Another symposium is planned for October
18-25. 1997.
Radiology: The partnership has sponsored a number of exchanges in the field of medical imaging.
In winter 1995. a radiologist from Pavlov visited Georgia Baptist to begin preliminary training on
the operation of a CT scanner and interpretation of imagery. III spring 1995, a radiologist from
Georgia Baptist provided further training in St. Petersburg. During his visit, he installed the Winrad
teleradiology system which enables radiologists in Atlanta and St. Petersburg to study imagery
together to facilitate collaborative diagnosis and training. The radiologists in St. Petersburg also
hope to use this teleradiology system to study and compare imagery with other hospitals in Russia.
Medical Education: The partnership has sponsored a number of international symposia in St.
Petersburg on ophthalmology, laparoscopy and endoscopy. At each symposium, new procedures
and technology are demonstrated to NIS physicians and nurses. In spring 1995, a physician from
Atlanta traveled to St. Petersburg to deliver a microscope donated by Georgia Baptist for vitreous-
retinal surgery. While in St. Petersburg, he assembled the microscope, provided direction regarding
its use and maintenance and observed a successful operation by Russian doctors using the
microscope. Over 1000 laparoscopic procedures. including 60 gynecological procedures, have been
performed at Pavlov.
During winter 1996, the partners focused their efforts on the areas of urology and ophthalmology.
Two partnership representatives and two members of the Atlanta business community traveled to
St. Petersburg Medical University to explore options for further development of the hospital's
ophthalmology department. A two-week educational and training program was held in Atlanta,
exposing surgeons from St. Petersburg Medical University to radical prostatectomy surgery and
treatment procedures for male infertility at both Georgia Baptist and Southeast Fertility Institute.
As part of the education exchange, one urologist from St. Petersburg was invited to present a paper
on Bilharzia of the urinary tract at Grand Rounds at Emory University.
ST. PETERSBURG, RUSSIA - ATLANTA, GEORGIA PARTNERSHIP
Training in the areas of ophthalmology and urology has actively continued, with partnership
exchanges in both areas in early 1997.
Nursing Education: The partners developed a new curriculum for the College of Nursing at Pavlov
to enhance the clinical knowledge base and practicum. The new curriculum emphasizes clinical,
psychological and pathophysiological skills. as well as English language training. Following
successful completion of the courses. graduates will serve as head nurses and participate in post-
graduate education programs for nurse managers in St. Petersburg.
To supplement efforts to further nursing education, Georgia Baptist obtained funding from Emory
University and the local education community to support educational exchanges for nursing
students. Already three groups of US students have traveled to the NIS and three student
delegations from St. Petersburg have traveled to the US.
In May 1996. a delegate from Atlanta traveled to St. Petersburg to review progress in nursing reform
and continuing education. The Dean of the School of Nursing expressed the need to incorporate
additional courses focusing on patient education and interpersonal skills into the nursing curricula
to ensure better patient care. The partnership will work to determine whether the courses should
be included in the regular or post-graduate nursing program to best address the needs of the hospital
before developing and implementing the new course curriculum. A focus on psychosocial aspects
of nursing will continue to be a major component of the partnership agenda.
In February 1997, a group of St. Petersburg nurse-educators visited Atlanta. followed by an April
visit by Atlanta nurses to St. Petersburg. The focuses of these visits were evaluating and revising
the nursing education curriculum in St. Petersburg and exploring the possibility of developing a joint
course.
Hospital Administration and Finance: In September 1995, administrators from Georgia Baptist
held a seminar on hospital administration and finance at Pavlov. The seminar focused on
developing a strategic business plan and budget for a hospital and introduced participants to product
line management. pricing and costs of service. Through this and other partnership exchanges,
administrators from Pavlov have become familiar with the overall financial and business operations
of Georgia Baptist and developed a strategic business plan and budget for their hospital.
In April 1997, a delegation from Atlanta traveled to St. Petersburg in order explore possibilities for
the partnership in fund-raising and foundation development.
Future Plans for the Partnership
The partners plan to continue current projects that have proven to be successful in obstetrics and
gynecology, radiology, medical education, ophthalmology, nursing education and hospital
administration and finance.
A nursing learning resource center (NLRC) will open at the College of Nursing in November 1997.
A delegation of nurse leaders from Atlanta will provide on-site training in the use of the center and
participate in the grand opening activities.
ST. PETERSBURG, RUSSIA - ATLANTA, GEORGIA PARTNERSHIP
On-site nursing education in Atlanta will focus on developing an understanding of fetal reactivity,
fetal decelerations, early fetal decelerations and variable fetal decelerations.
Laparoscopic surgery, including an emphasis on intra-abdominal suturing will continue.
Partnership Contacts
Larissa Kochorova, MD
Charles Hancock, MD
General Director
Vice President of Medical Affairs
Delor Medical Center
Georgia Baptist Medical Center
Pavlov Medical Institute
303 Parkway Drive. NE
L. Tolstoy Str. 6/8
Atlanta, GA 30312
197022 St. Petersburg, RUSSIA
Phone: (404) 265-4214
Phone: (812) 234-0989
Fax: (404) 265-3903
Fax: (812) 234-2749
E-Mail: [email protected]
E-Mail: [email protected]
ST. PETERSBURG, RUSSIA - LOUISVILLE, KENTUCKY PARTNERSHIP
AIHA's Medical Partnership Program between Jewish Hospital Health Care Services (JHHS) of
Louisville, Kentucky and Medical Center of St. Petersburg in the name of Sokolov (formerly
Hospital No. 122), funded under a cooperative agreement with the United States Agency for
International Development (USAID). has existed since April 1993.
The general areas of partnership focus are hospital administration and finance, medical education,
nursing education and emergency medicine.
Program Outcomes
Hospital Administration and Finance: Sokolov has taken a number of steps towards privatization.
With the assistance of the finance specialists at Jewish Hospital and Clark Memorial Hospital, the
St. Petersburg partner developed a corporate reorganization plan with subsidiaries and defined
relationships to a holding company. Administrators at Sokolov also completed an expanded
marketing program and opened a hospital gift shop to increase revenue. Another example of this
progress was the partnership's efforts to establish a micro-hospital unit, which offers Western style
health care delivery on a fee-for-service basis. The profits made by the micro-hospital unit support
other programs throughout the hospital.
Administrators from Sokolov have reviewed and studied cost accounting systems in place at Jewish
Hospital and Clark Memorial Hospital in order to reformulate and expand Sokolov[s account
system to capture real costs of surgical procedures and evaluate cost effectiveness of current
services. A performance evaluation system has been developed. complete with evaluation ratings,
salary incentives, and a re-organization program to increase cost effectiveness and outcomes.
In addition, a special curriculum in Economics and Business management has been developed
jointly by Jewish Hospital, the University of Louisville and Sokolov. Eight representatives from
Sokolov participated in Part One of this curriculum, in Louisville, in November 1996, and part two
was conducted in St. Petersburg in February 1997.
Jewish Hospital hosted two US Department of Commerce Special American Business Training
Program (SABIT) interns. Rimma Grigorieva, MD, Vice President of Sokolov participated in a six-
month administrative fellowship in the areas of finance, outpatient services, quality assurance and
patient care services. Irina Bakhtina, MD, Dean of the Post-Graduate School of Nursing in St.
Petersburg, recently completed a SABIT internship focusing on administration of nursing education
programs.
The hospital recently became a foreign affiliate of Premier Inc.
Nursing Education: One of the partnership's major objectives has been to improve the post-
graduate education of nurses at Sokolov. Through the partnership, a six-month post-graduate
nursing course in clinical practice and management was established. This program has been
successful in increasing the responsibilities of nurses at Sokolov in patient care and management.
Over the past four years, there have been numerous exchanges of nurses from Sokolov and from
Jewish Hospital and Clark Memorial Hospital. During the course of these exchanges Sokolov
ST. PETERSBURG, RUSSIA - LOUISVILLE, KENTUCKY PARTNERSHIP
ses have received extensive hands-on training in the Western model of nursing care. They have
1 exposed to the fields of marketing, management and quality assurance.
The US and NIS partners co-chair AIHA's Nursing Task Force. Dr. Bakhtina, director of the Post-
Graduate Nursing School at Sokolov, was appointed chairperson of the Society of Educators of
Nurses. a multidisciplinary group of professionals who share an interest in nursing education. She
was invited to speak at the May 1997 All-Russian Conference of Nurses, and to develop a
questionnaire for conference participants, in order to formulate a general strategic plan for the
development of nursing in the Russian Federation.
Sokolov's nurses are actively participating in AIHA's series of Nursing Videoconferences.
Women's Health Initiative: As part of AIHA's Women's Health Initiative the partners have begun
work to create a Women's Wellness Center as an affiliate to one of their partnership institutions.
In addition to addressing unmet health needs of women, the Center will serve as a highly visible
model for comprehensively addressing and managing the health care needs of women through an
effective programmatic mix of health promotion, education, early diagnosis, treatment and follow
up. Clinic and resource management, the utilization of nurses as educators and administrators,
patient-centered education and service, and the development of sustainable financing for the Center
will be program priorities.
The center's scope of services will include family planning, diagnosis and treatment of sexually
transmitted diseases, menopause and breast health. The center will open in fall 1997.
dical Education: In 1994, the US partners conducted an intensive practicum on-site in St.
Petersburg on general and reconstructive surgery and anesthesiology. Through the partnership's
educational programs, Sokolov has expanded its service base by adding cardiovascular surgery,
orthopedics and endoscopy.
1994 Goodwill Games: Sokolov was chosen as the medical support base for all visiting journalists
and dignitaries during the 1994 Goodwill Games. The partners developed the clinical and
administrative basis for an international polyclinic for the participants of the games and the general
St. Petersburg community. At the Goodwill Games, US participants assisted their NIS partners in
the management of the outpatient clinic and, during this two-week period, cared for patients from
the United States, Bulgaria, Afghanistan, Finland, Canada and Russia. Stomatology emerged as
a primary clinical care area following the Goodwill Games and is an on-going clinical agenda for
the partnership.
Infection Control: In January 1997, Sokolov was the third AIHA partner hospital to undergo an
infection control hospital survey. The survey was conducted by a team of US physicians and
infection control practitioners, including a representative from Centers for Disease Control.
Future staff of an Infection Control Training Center in Moscow, as well as Sokolov infection
control staff observed the survey. The team used a model survey protocol developed for the
NIS by AIHA's infection control task force, based on the International Hospital Infection
Prevention and Quality Assessment Program (INQUAL).
ST. PETERSBURG, RUSSIA - LOUISVILLE, KENTUCKY PARTNERSHIP
The survey team is prepared a report, giving specific recommendations that address all aspects
of a hospital based infection control program including organizational issues, surveillance
activities. policies and procedures. facilities. patient care practices, environmental cleaning and
waste. In addition. this and other survey results have been used to develop case studies for the
Basic Infection Control Manual: to introduce the model survey to NIS ministries of health for
adaptation and replication: and to assist the ministries in modifying national infection control
regulations.
WHONET: Sokolov is one of the AIHA partner hospitals, which are participating in the new
WHONET program. This program is part of AIHA's Infection Control Initiative. Its goal is to
introduce current methods of quality control for microbiological tests; to introduce current methods
of antimicrobial resistance testing: and to establish a system of antimicrobial susceptibility
monitoring, using the WHONET program, developed by WHO.
Microbiology lab staff from Sokolov have received equipment and supplies that allow quality
testing of antimicrobial resistance and monitoring of the results. They have received training in
current methods of antimicrobial resistance testing and in using WHONET.
Over the next year, WHONET participants will develop and implement mechanisms to control the
use of broad-spectrum antimicrobial agents. Based on WHONET data, and with assistance from
their American partner and from the Society of Healthcare Epidemiology of America, each
participating NIS hospital will design protocols for empirical and targeted antimicrobial therapy for
major infections.
Future Plans for the Partnership
The partners plan to continue current projects that have proven to be successful in hospital
administration and finance, nursing education, medical education and stomatology services. In
addition. women's health has become a major partnership focus, culminating in the upcoming
opening of a women's health center at Sokolov.
Administrators from JHHS will work with administrators from Sokolov to expand the cost
accounting system; analyze current services for cost effectiveness and consider their continuation,
expansion, reduction or elimination; determine new programs or business lines; and develop a
continuous quality improvement program.
Nurse educators from Louisville and St. Petersburg will continue clinical evaluation and practice
for nurses completing Sokolov's six-month post-graduate nursing course. The newly revamped
nursing curriculum will be initiated and evaluated.
Nursing administrators at Sokolov are currently developing a curriculum for a masters of Science
in Nursing program. They are in the process of discussing these plans with the Ministry of Health
of the Russian Federation, in order to get approval.
Dental professionals from Louisville will assist their Russian partners to improve outcomes.
ST. PETERSBURG, RUSSIA - LOUISVILLE, KENTUCKY PARTNERSHIP
Sokolov will be the site of a Nursing Learning Resource Center. The area for the center has been
selected and a renovation plan has been developed. The opening has been scheduled for early
November 1997.
Partnership Contacts
Irina Bakhtina. MD
Jane Younger, RN
Director
Chief Operating Officer
Post Graduate School of Nursing
Clark Memorial Hospital
Medical Center in the Name of Sokolov
1220 Missouri Avenue
Prospekt Kulturi, 4
Jeffersonville, IN 47130
St. Petersburg. 194291
Phone: (812) 283-2147
RUSSIA
Fax: (812) 283-2688
Phone: (812) 559-9685
E-Mail: [email protected]
Fax: (812) 559-9673
E-Mail: [email protected]
(via Anatoly Belousov)
STAVROPOL, RUSSIA - IOWA PARTNERSHIP
AIHA's Medical Partnership Program between the State of Iowa and Stavropol Krai, Russia, funded
under a cooperative agreement with the United States Agency for International Development
(USAID). has existed since May 1993. The Regional Ministry of Health. Stavropol Regional
Hospital (SRH). and Stavropol City Hospital No. 2. the Oncology Center and the Women' Health
Center in Essentuki are the leading Russian partners. The Iowa Hospital Education and Research
Foundation (IHERF), the foundation of the Association of Iowa Hospitals and Health Systems,
represents the American side of the program. Participating hospitals include: Iowa Methodist
Medical Center and Iowa Lutheran Hospital in Des Moines; Mercy Medical Center in Cedar Rapids,
University of lowa Hospitals and Clinics in Iowa City, Mercy Medical Center in Des Moines,
People's Memorial Hospital of Buchanan County in Independence. Marshalltown Medical and
Surgical Center of Marshalltown. Grinnell Regional Medical Center of Grinnell and Muscatine
General Hospital of Muscatine.
The general areas of partnership focus are hospital administration. infection control, surgery,
emergency medical services. pediatric hematology. orthopedics. nursing education, women' health
and biomedical engineering.
Program Outcomes
Infection Control: Infection control has been a major programmatic focus of the partnership since
its inception. Over 30 physicians and nurses from have participated in seminars and training
sessions on infection control during partnership exchanges to Iowa. They have also participated in
grand rounds, infection control committee meetings and surgery. Over 300 physicians and nurses
have participated in educational programs and seminars in Stavropol Krai, conducted by specialists
from both the US and Russian sides of the partnership. Two surgical teams from Stavropol were
trained in infection control techniques in the operating room and post-operative recovery area.
Extensive discussions occurred outlining the administrative structure of hospitals in the Stavropol
Krai. Based upon this understanding, a position description for an infection control nurse was
drafted and positions were created at Hospital No. 2 and the Stavropol Regional Hospital.
Observations during 1996 and 1997 indicate that improvements in technique have been adopted in
the OR and recovery areas. This resulted in a decreased length of stay for surgical patients.
Exchanges of specialists will continue and will focus on more advanced techniques and on
educational programs for the medical and nursing staffs, in order to disseminate these techniques
more widely.
Surgery: The partners have created a Model Surgical Unit based on Western standards, at the
Stavropol Regional Hospital, which will serve as a center for replication throughout the Krai. The
unit has implemented a strict operating room dress code as well as protocols for hand-washing,
environmental cleansing, instrument sterilization and prevention of cross-contamination, thereby
effectively linking the infection control and surgery initiatives.
Several exchange visits were devoted to assessing the status of the cardiac surgery program at the
regional hospital in Pyatigorsk, and training and orientation have been conducted for surgeons,
anesthesiologists and nurses at the University of Iowa Hospitals and Clinics. A plan was developed
to create an open-heart surgery program at Pyatigorsk. Because crucial resources and infrastructure
STAVROPOL, RUSSIA - IOWA PARTNERSHIP
upgrades were not available, the establishment of that program has been delayed until such
resources can be identified.
Emergency Medical Services: Thirty Russian physicians and nurses have participated in train-the-
trainer seminars in Iowa in basic and advanced life support techniques. lowa physicians and nurses
have conducted seminars in resuscitation and emergency medicine in Stavropol and Essentuki.
Paramedics provided instruction on extrication and transportation techniques to clinicians and to
police and fire department personnel. These training programs represent a significant advancement
in first provider emergency care in Stavropol Krai.
Orthopedics: After three exchange visits by orthopedic surgeons and the sharing of surgical and
infection control techniques, the Russian partner asked that specialists from Iowa visit Stavropol to
evaluate the current program of production of artificial limbs and assess the feasibility of producing
more advanced prostheses. In April 1996. an orthopedic surgeon and a prosthetist went to
Stavropol, visited the orthopedic surgical departments of the hospitals, met with senior
administrative officials in the Health and Social Protection ministries. and visited the facility at
which artificial limbs are produced. The US representatives developed two alternative plans in
response to this request from the Russian partner. The first proposal would require some minor
equipment upgrades at the factory, the retraining of some key staff, and periodic exchange visits
to maintain quality. The result would be a lower cost, higher quality artificial limb. The second
proposal would create an entirely new facility with new equipment and newly trained staff. It
would also produce the new, lower cost, higher quality artificial limb. Both partners are studying
the financial feasibility of these proposals.
Pediatric Hematology: Three teams of physicians and nurses from the Stavropol Children' S
Hospital visited the University of Iowa Hospitals and Clinics, and were trained in new treatment
techniques for leukemia and other children's cancers. Physicians from Iowa visited Stavropol,
presented lectures and seminars, and worked directly with their colleagues in developing
enhancements to the current treatment protocols.
Women' S Health: In September 1995, the partners began a maternal and child health program that
focused on three activities: developing a perinatal care program; reduction of complications through
enhanced infection control procedures during delivery; conducting training for physicians and nurses
in neonatal resuscitation. Three exchanges were conducted to establish these programs. In 1996,
the scope of this program was broadened to include comprehensive women' S health services. A
site in Essentuki was selected, an on-site assessment conducted and three exchange visits conducted
to develop this set of program activities.
Nursing Reform: From the outset of the project, the reform of nursing was a key activity that was
to be accomplished through education. Nursing was involved in all project components and nurses
participated in virtually all exchanges. In 1995, the partners agreed that a more general approach
to nursing education would be preferable to targeted action within program areas, such as women' S
health or infection control. Exchanges were conducted with the faculty of the Department of
Continuous Nursing Education for Stavropol Krai, which is located at the Oncology Center. Faculty
from Stavropol visited nursing schools in Iowa, observed continuing nursing education programs
in hospitals, and shadowed nursing staff on the hospital floor. Iowa delegations to Stavropol
STAVROPOL, RUSSIA - IOWA PARTNERSHIP
conducted seminars and lectures for the medical and surgical nurses receiving continuing education
at the Oncology Center. A partnership team designed enhancements to the curriculum, including
patient and physician psychology. that were taught jointly by the US and Russian partners and then
were incorporated into the standard curriculum. Agreement was reached to add a nurse educator to
the faculty of the department. and a job description was developed.
Future Plans for the Partnership
During the period May 1. 1997 through September 30, 1998, the Partnership will focus on three
areas of activity: nursing education, infection control and women' S health.
Nursing Education: The partners will establish nursing associations in the cities of Stavropol and
Essentuki. A Nursing Learning Resource Center (NLRC) will be established. staff identified and
training of the staff completed to enable use of the NLRC by nursing staff throughout the city and
the Krai. Increased access and use of the Internet by nursing staff will also be accomplished by
occasional visits paid by the participants.
Infection Control: The partners will identify a hospital epidemiologist and infection control nurse
at Hospital No. 2 in Stavropol. Both of these individuals will receive supplemental education and
training in infection control and teaching techniques. These two individuals and other clinicians
from the partnership will develop a model hospital-wide infection control plan, which would be
pilot tested at Hospital No. 2 in Stavropol. The Stavropol Medical Academy will include these new
infection control practices and the model plan into the nursing curriculum. Declines in nosocomial
infection rates will be documented. Plans will be developed to maintain communication and
information-sharing electronically.
Women' Health: In Essentuki, the number of abortions will be reduced and the usage of
contraceptives increased. Educational programs designed to provide information regarding healthier
lifestyles, prenatal education, childbirth. teenage sexuality, nutrition, breast feeding and breast self-
examination will be developed and taught to the public. As a result of interactions between
physicians in the partnership, the number of transfusions given post-operatively in childbirth will
be reduced. A business plan will be jointly developed that establishes a financially viable women' S
health center. Marketing of the center will begin with a special public relations event, a Health and
Wellness Fair. Plans will be developed for ongoing communication through electronic means.
Partnership Contacts
Philip Latessa
Antonia Dunchenko, MD
President
Deputy Director
Iowa Education and Research Foundation
Stavropol Krai Regional Hospital
100 East Grand Avenue, Room 100
Semachko Street 1
Des Moines, IA 50309
355030 Stavropol, RUSSIA
Phone: (515) 288-1955
Phone: (8652) 26-13-81
Fax: (515) 282-0454
Fax: (8652) 26-42-18
E-Mail: [email protected]
E-Mail: [email protected]
VLADIVOSTOK, RUSSIA - RICHMOND, VIRGINIA PARTNERSHIP
AIHA's Medical Partnership Program between the cities of Vladivostok, Russia, and Richmond,
Virginia, funded under a cooperative agreement with the United States Agency for International
Development (USAID), was formed in March 1993. The Russian partners are City Clinical Hospital
No. 2. a teaching and referral hospital, and Vladivostok State Medical Institute. The US partner is
the Medical College of Virginia (MCV), the fourth largest university-affiliated hospital in he US.
The general areas of partnership focus have been emergency medical services, nursing education
reform and hospital administration and finance. Recently intensive work has also been done in
implementation of new surgical procedures and establishing Infection Control Training Center.
Program Outcomes
Emergency Medical Services: Vladivostok has been selected as one of seven Emergency Medical
Services Training Center sites in the NIS. Over seventy 100-hour courses have been conducted
since the Center opened in October 1994. with over 700 emergency medical professionals
(physicians, feldshers, nurses, and other rescue personnel) trained thus far in didactic and practical
skills. The first-responder training course covers a wide range of topics, including airway, breathing
and circulation management; spinal immobilization; and trauma management. Since the ninth
training course, the Russian partners have conducted 100 percent of the instruction.
In addition to these training courses for health professionals, the partners have expanded training
in basic EMS to policemen and fire fighters. They have also begun an outreach program to teach
first aid and CPR to secondary school students. A videotape has been created of the students as
they participate in a mock earthquake/disaster drill. The partners have provided this training video
as a model educational tool for other EMS Training Centers and use it to attract medical students.
Instructors from the Vladivostok EMS Training Center participated in an EMS Train-the-Trainers
course in Richmond, Virginia from July 31-August 11, 1995. The course focused on continuing
education in emergency medicine and first-responder protocols, including a review of principles of
adult learning, case-based learning, the use of videos as audio visual aids, sessions on disaster
planning and equipment maintenance and repair. In addition, the center directors received training
in administration and data management.
Hospital equipment and supplies from a decommissioned Department of Defense trauma hospital
in Japan, valued at $5 million, were donated to Municipal Clinical Hospital No. 2 in late summer
1995.
In October 1996, the Vladivostok EMS Training Center hosted an international EMS conference for
health professionals from the US, Russia, Ukraine, Moldova, Kazakstan, Turkmenistan, Georgia,
and Armenia. This conference focused on the topic of disaster management, including issues in
program planning, education and training, and communications. In 1997 the Vladivostok EMS
Training Center continued consultations helping new Training Centers in Moscow and in Ashgabat.
In 1997 a new model of Emergency Services was established in rural areas of Primorskiy Krai, in
the town of Partizansk. A special team of paramedics from the town were trained in Vladivostok,
VLADIVOSTOK, RUSSIA - RICHMOND, VIRGINIA PARTNERSHIP
special computer programming for dispatcher's services and database on the Emergency Services'
activity was provided and equipment was donated by the Richmond Ambulance Authority.
At the same time Emergency Department of the Hospital #2 has also provided a lot of educational
training for the physicians of the Region: 142 physicians attended different seminars and
conferences in 1997 and 245 third-year medical students attended 15-hours course "Intensive Care
Patients and their subsequent Rehabilitation".
Nursing Reform: Nurses at Vladivostok Municipal Clinical Hospital No. 2 have created a
committee to coordinate educational seminars for nursing staff. These presentations are modeled
on skills development seminars which were conducted by the US partners for nurses in Municipal
Clinical Hospital No. 2, the nursing school and nearby hospitals. Topics have included the
management of patient emergencies. the concept of accountability and the development of "unit
educators" or "procedure nurses" to train colleagues in infection control procedures and the
standardization of clinical practice.
In April 1997 Vladivostok City Hospital #2 opened its Nursing Learning Resource Center. The
purpose of the Center is to provide continuing education to currently practicing nurses, to train
newly employed nurses, and to provide assistance to medical students of the local university. A
number of questionnaires and test of nurses' current level of experience have been developed. The
results of these questionnaires have helped in the development of the Center's curriculum. The
center's educational seminars and trainings are being taught by experienced nurses in close
collaboration with physicians and members of Infection Control Committee.
Hospital Administration and Finance: Building on partnership efforts begun in 1994, Abt
Associates; ZdravReform project in June 1995 awarded a grant to the partners to develop a cost
accounting and financial planning system at Municipal Clinical Hospital No. 2. The partners have
developed methods to capture the costs of care in order to develop payment rates that reflect the true
cost of efficiently delivered services. This information system will facilitate transactions with the
Territorial Mandatory Health Insurance Fund and can be replicated in other health care facilities
throughout the Primorskiy Krai.
Hospital administration met and provided seminars for all department heads and head nurses with
the purpose of improving their managerial skills and enhancing the quality of overall management
of the hospital. Hospital administration actively participated in re-certification process for county
medical administrators and presented at the meeting of county physician-experts. Hospital CEO
shared his experience in financial management with the county administrators.
Infection Control program: Inpatient facilities of the hospital have organized an Infection Control
Committee to implement new infection control policies. A number of training programs for hospital
staff have been prepared, including "Prevention of Urinary Tract Infections", "Prevention of Post-
Operative Infections", "Proper Technique of Performing Blood Transfusions and Prevention of
Blood Infections".
264 members of the hospital staff attended continuous education sessions dedicated to infection
control procedures in inpatient wards. Hospital epidemiologists have provided a course of lectures
VLADIVOSTOK, RUSSIA - RICHMOND, VIRGINIA PARTNERSHIP
on infection prevention in surgical units. The following five programs were prepared to be used in
training: "Clean Hands", "Prevention of Spread of Infections among Hospital Staff", "Prevention
of HIV Infection and Parental Transmission of Hepatitis", "Methods of Sterilization and
Disinfecting of Endoscopic Tools", "Modern Disinfection".
A database containing information on infection outbreaks within the hospital has been installed and
prepared for connection with a computer program Epilnfo. Development of a program explaining
proper use of antibiotics for preventative and curative purposes is also in progress. Hospital
physician-microbiologists are also involved in the Infection Control Program and plan to develop
a unit of bacteriological control within the Program.
In January 1997, Hospital No. 2 was the fourth AIHA partner hospital to undergo an infection
control hospital survey. The survey was conducted by a team of US physicians and infection control
practitioners. using a model survey protocol developed for the NIS by AIHA's infection control task
force, based on the International Hospital Infection Prevention and Quality Assessment Program
(INQUAL).
The survey team has written a complete report, giving specific recommendations that address all
aspects of a hospital based infection control program including organizational issues, surveillance
activities, policies and procedures, facilities, patient care practices, environmental cleaning and
waste. In addition, this and other survey results have been used to develop case studies for the
Basic Infection Control Manual; to introduce the model survey to NIS ministries of health for
adaptation and replication; and to assist the ministries in modifying national infection control
regulations.
WHONET: Hospital No. 2 is one of the AIHA partner hospitals that are pilot sites for the new
WHONET program. This program is part of AIHA's Infection Control Initiative. Its goal is to
introduce current methods of quality control for microbiological tests; to introduce current methods
of antimicrobial resistance testing; and to establish a system of antimicrobial susceptibility
monitoring, using the WHONET program, developed by the World Health Organization.
Microbiology lab staff from Hospital No. 2 have received equipment and supplies that allow quality
testing of antimicrobial resistance and monitoring of the results. They have received training in
current methods of antimicrobial resistance testing and in using WHONET.
Over the next year, WHONET participants will develop and implement mechanisms to control the
use of broad spectrum antimicrobial agents. Based on WHONET data, and with assistance from
their American partner and from the Society of Healthcare Epidemiology of America, each
participating NIS hospital will design protocols for empirical and targeted antimicrobial therapy for
major infections.
"VLADIVOSTOK, RUSSIA - RICHMOND, VIRGINIA PARTNERSHIP
Future Plans for the Partnership
The EMS Training Center will continue to reach out to regional rescue personnel to provide training
in first aid and CPR. The partners also plan to introduce a special advanced training course for
paramedics, which will be operational by May 1997. In addition. a curriculum for dispatch and
communications personnel will be developed in cooperation with Medical Priority Consultants.
The Partnership will be working on the development and implementation of a drug utilization
system. They are in the process of developing a pharmaceutical reference manual and a drug master
list. The partners plan to implement a standards of quality care. develop and implement a program
of monitoring side-effects and develop a continuously running program of drug use evaluation.
Partnership Contacts
Sergei Novikov, MD
Carl R. Fischer
Chief Physician
Executive Director
City Clinical Hospital No. 2
Medical College of Virginia Hospitals
57 Russkaya Street
Virginia Commonwealth University
Vladivostok, 690105
Post Office Box 980510
Russian Federation
Richmond, VA 23298-0510
Phone: (4232) 32-62-77
Phone: (804) 828-4682
Fax: (4232) 32-49-86
Fax: (804) 828-0170
E-Mail: [email protected]
E-Mail: [email protected]
KYRGYZSTAN
Bishkek - Kansas City, Kansas
BISHKEK, KYRGYZSTAN - KANSAS CITY, KANSAS PARTNERSHIP
AIHA's Medical Partnership Program between the Kyrgyzstan and the University of Kansas
Medical Center (KUMC), funded under a cooperative agreement with the United States Agency for
International Development (USAID) was formed in October 1992. In addition to the Kyrgyzstan
Ministry of Health, the Kyrgyz partners are the Institute of Oncology and Radiology, the Institute
of Obstetrics and Pediatrics and, since 1996, the Institute of Cardiology and Internal Medicine.
Since the inception of the partnership, over 100 Kyrgyz physicians and nurses have visited KUMC,
while over 70 US physicians, nurses and health administrators have traveled to Kyrgyzstan.
The general areas of focus for the partnership have been nurse education, introduction of family
medicine, management training, pediatric oncology, laparoscopic surgery, prosthetics and orthotics,
neonatology, respiratory disease, emergency and burn care. and continuing education.
Program Outcomes
Health Care Reform: In collaboration with the Ministry of Health, the partnership has focused on
three main components of health care reform in Kyrgyzstan. These include nursing education,
introduction of family practitioners/family medicine, and management training for nurses and health
care administrators.
In order to reduce overhead costs and generate revenue, the Institute of Oncology and Radiology
has decreased its number of beds by closing a hospital wing, renovating the facility and re-opening
it as a hotel for relatives of patients. A private rehabilitation hospital in Bishkek was founded after
studying the American health care system during a partnership visit.
Nursing Reform: The priority given to nurse education and the development of management skills
represents a pioneering attempt by the partners and the Kyrgyzstan Ministry of Health to upgrade
health care delivery in the country by elevating the skills of nursing professionals. Senior nurses
from throughout Kyrgyzstan have participated in intensive one- and two-month training programs
at KUMC focusing on skills development and hospital administration. The partners developed the
"Kyrgyzstan Nursing Administration Course," emphasizing management skills for nurse
administrators. The nurses receive a general overview of the structure and function of the US health
care system, especially the role of the nurse, nursing education, nurses' clinical skills, and the
administrative structure of nursing in the hospital. The visiting nurses accompany nurse managers
on the floors, visit nursing skills labs, and are introduced to the work of the Home Health Nurse,
who provides health care in a home setting. In addition, they attend lectures on standards of patient
care, infection control, and prevention.
New nurse administrator/manager positions have been created by the Ministry of Health and filled
by these nurses in their respective institutions. Nurses have been hired in each oblast of the
Republic to the newly-created position of senior nurse-administrator with a salary comparable to
that of chief physicians. In addition, nurses have been invited to KUMC to participate in a train-the-
trainers courses designed to prepare them to teach other nurses at the Bishkek School of Nursing.
KUMC has donated equipment for five nursing laboratories at the School for this purpose.
In May 1995, the partners hosted a conference in Bishkek for chief nurses from each of the Central
Asian Republics (CAR). Over 120 nurses participated in the CAR Leadership in Nursing" seminar,
which specifically addressed management and administrative issues pertaining to the region. A
BISHKEK, KYRGYZSTAN - KANSAS CITY, KANSAS PARTNERSHIP
second nursing conference took place in Bishkek during September 1997. This conference was
preceded by a "train-the-trainers" seminar for nurse educators at the Bishkek School of Nursing,
using a new nursing textbook developed by the partners.
Neonatology: The partnership program has also focused on neonatal resuscitation of full-term
normal weight infants. A series of seminars were conducted by KUMC specialists on thermal
regulation, intubation, and general diagnostics. The program started in partnership hospitals in
Bishkek; however, responding to requests from the Ministry of Health, the program has been
expanded to include neonatologists from all over Bishkek. The US teams also traveled to Osh and
repeated the training seminars in that city. Over 110 physicians from ten of the twelve birthing units
in the Kyrgyz Republic were trained in a series of "train-the-trainers" courses to become instructors
in neonatal resuscitation. Translated textbooks on neonatology were distributed to the participants
to increase their knowledge base. The training in neonatal resuscitation conducted at multiple sites
around Kyrgyzstan is having a significant impact on reducing morbidity and mortality. KUMC staff
project infant deaths have been reduced by thirty percent as a result of the training across the
republic.
Respiratory Diseases: The Partnership program has also focussed upon Respiratory Diseases. Three
teams of Kyrgyz physicians traveled to KUMC to observe the American treatment of asthma and
bronchial infections. Three pulmonologists traveled to Bishkek to conduct seminars and give
lectures. Of interest to the American physicians were salt chambers and native herbs used in
treatment of bronchial diseases in Kyrgyzstan.
Management Training: Partnership efforts, augmented by AIHA/AUPHA management training
workshops, have given health care managers from Bishkek the opportunity to participate in a series
of training seminars in diverse areas, such as grantsmanship, informed decision-making and
financial management.
In an effort to establish model blood banks in Bishkek, partners have worked toward improving the
administrative skills of blood bank directors. Their training will lead to greater efficacy and
management of blood banking, including infection control. Specialists from US community blood
banks traveled to Bishkek and Jalal Abad in December 1995 to assess the work of blood banks in
Kyrgyzstan. The specialists made recommendations on donor recruitment, materials management,
and standard operating procedures. They also donated and installed a computer with word
processing, database and accounting software to Regional Blood Bank in Bishkek.
Pediatric Cancer Registry: Through several exchange visits, the KUMC and Kyrgyz partners have
established an academic exchange program and a national pediatric cancer registry in Bishkek,
which has allowed the partners to collect accurate cancer morbidity and mortality rates in
Kyrgyzstan. In addition, the partners have begun to conduct a comprehensive cancer screening and
treatment project in the township of Malli-Say, which in 1993 was struck by an earthquake which
reopened an abandoned mine and uncovered uranium waste. At the request of partners at the
Institute of Oncology and Radiology, KUMC diagnostic teams examined residents for radiation-
related illness, collected data, and treated patients. Together, the partners are analyzing the data
to assist in the long-term treatment of victims of this disaster.
BISHKEK, KYRGYZSTAN - KANSAS CITY, KANSAS PARTNERSHIP
Laparoscopic Surgery: Surgeons from Kansas City demonstrated laparoscopic techniques at a
conference of surgeons in Central Asia. They performed six operations at the Institute of Oncology
and Radiology. using equipment donated by KUMC. In addition they presented two lectures: one
for operating room nurses on the maintenance of laparoscopic equipment, the other for
anesthesiologists on the use of resuscitation equipment.
Prosthetics/Orthotics: At the request of the Ministry of Health, the partnership took steps towards
the establishment of a center for clinical training and production in prosthetics and orthopedics. One
prosthetist and one orthotist traveled to Bishkek in the Fall of 1995 to review local prosthetic and
orthopedic services and to study current medical practices related to prosthetic care. In addition,
they visited the Bishkek prosthetic plant to evaluate the equipment and technology available. The
specialists made recommendations to enhance education and improve the prosthetic rehabilitation
of patients.
Catastrophic Emergency Care and Burn Care: Following a very successful two week program
on emergency and burn care, the ministry asked the partners to repeat the seminar and expand the
program to include the city of Osh and the firefighters and first responders in both cities. A team
of physician, nurse, two therapists and an emergency technician traveled to Bishkek and Osh to
teach two seminars and set up a comprehensive burn department at Hospital No. 4 in Bishkek and
the Oblast Hospital in Osh. All supplies to set up these departments were donated by 20 hospitals
in Kansas, cleaned and packaged by the firefighters and shipped by container from the State
Department to Kyrgyzstan. The departments will be set up in such a way that they can function
independently in the future.
Future Plans for the Partnership
Nursing reform through practical skills development will continue to be a major area of partnership
focus. Plans are underway to upgrade the existing nursing skills laboratories, introduced to
hospitals with partnership assistance. Discussions have also begun regarding the establishment of
a masters degree program for nurses at the Medical Academy. They will also be conducting a
seminar to train nurses to teach nurses.
The Partnership also plans to continue in it's efforts of supporting Catastrophic Emergency Care and
Burn Care. They will continue to work on the two comprehensive burn care centers in Osh and
Bishkek together with educating first responders. This program represents a nationwide effort in
Kyrgyzstan and a statewide effort in Kansas.
BISHKEK, KYRGYZSTAN - KANSAS CITY, KANSAS PARTNERSHIP
Partnership Contacts
Zakir Kamarli, MD
Frederick Holmes, MD
Former Director
Professor of Medicine
Institute of Oncology and Radiology
University of Kansas Medical Center
92 Akhunbaeva Street
3901 Rainbow Boulevard
Bishkek, 720064 Kyrgyzstan
Kansas City, KS 66103
Phone: (3312) 477-450
Phone: (913) 588-6005
Fax: (3312) 479-191
Fax: (913) 588-3994
E-Mail: [email protected]
E-Mail: [email protected]
Duishe Kudajarov, MD
Louise Redford, RN
Director
Project Coordinator
Institute of Obstetrics and Pediatrics
KUMC-Kyrgyzstan Hospital Partnership
1 Togolok Moldo Street
University of Kansas Medical Center
720040 Bishkek, Kyrgyzstan
3901 Rainbow Boulevard
Phone: (3312) 224-423
Kansas City, KS 66103
Fax: (3312) 264-275
Phone: (913) 588-1490
E-Mail: [email protected]
Fax: (913) 588-4736
E-Mail: [email protected]
KAZAKSTAN
Almaty - Tucson, Arizona
Semipalatinsk - Houston, Texas
ALMATY, KAZAKSTAN - TUCSON, ARIZONA PARTNERSHIP
The primary partners in Almaty are the Institute for Pediatrics and Children's Surgery, the primary
pediatric referral center in the Republic. and the Almaty City Emergency Hospital, an adult acute
care hospital. Other institutions include the Almaty City Perinatal Center, the Emergency Medicine
Training Center, the Almaty Medical College, and the Almaty Women's Wellness Center. The US
partners include eight hospitals in Tucson, with Tucson Medical Center serving as the organizing
partner of a coalition which includes University Medical Center and the Arizona Health Sciences
Center, Columbia Northwest and El Dorado Hospitals, Carondelet Health Care of America (St.
Mary's and St. Joseph's Hospitals), the Veterans' Affairs Medical Center, and Tucson General
Hospital. Pima County Health Department and the Kino Community Hospital also participate in
training activities. This partnership builds upon an existing Sister City relationship between Almaty
and Tucson.
The general arcas of partnership focus have been physician training in specialty areas, establishment
of programs in toxicology, perinatology, leukemia and respiratory disease, infection control, nursing
education, emergency medical services, and health care administration and management reform.
Learning resource centers have been established by AIHA at the Institute for Pediatrics and
Children's Surgery, the City Emergency Hospital, and the Almaty Medical College.
Program Outcomes
Infection Control: The Almaty City Health Administration has taken an active role in the reform
of in-service training for nurses in infection control. Responding to an Almaty City Health
Administration request, the U.S. partners conducted a train-the-trainers course in July 1994 for the
faculty of the Republican School for Continuing Education and Allied Health on basic infection
control techniques, including hand washing, proper handling of linens, and sterilization of surgical
instruments. As a result, a number of similar training programs on infection control have been
launched throughout the Republic, and approximately 300 nurses throughout Kazakstan have been
trained. The City Health Administration has also created the new position of Head Nurse for
Infection Control at all 11 Almaty hospitals.
Recently, the partners implemented surveillance-modeled infection control demonstration projects
in the Institute for Pediatrics and Children's Surgery, the Emergency Hospital and the Perinatal
Center. Using the Memorandum of Understanding as a source of authorization, the Minister of
Health issued special rules for infection control practices for the participating hospitals. Based on
the results of preliminary data, the Deputy Minister of Health has asked the Tucson partners to
assist with the implementation of an oblast wide pilot study. The demonstration project will utilize
a CDC based surveillance reporting system. When this project is complete, the partners will work
on a republic-wide revision of infection control laws and regulations.
Nursing Reform: Working in collaboration with the partners, the Almaty Medical College has
developed and implemented a revised and expanded nursing curriculum that provides for basic
nurse education as well as expanded clinical practice and administrative/managerial training. The
curriculum was approved by the Ministries of Health and Education. In addition, the Ministry of
Labor has approved new job classifications for graduates of the program. At the end of each year
of nursing training, students can enter a certified nursing position in a public hospital. Fourth-year
graduates will now enter the work force at a higher pay level, equal to that of a graduate of the six-
ALMATY, KAZAKSTAN - TUCSON, ARIZONA PARTNERSHIP
year physician education program. Two classes of baccalaureate nurses have graduated from the
program.
The Almaty Medical College also has established a night school for senior nurses who wish to
enhance their clinical training or expand their role in administration and management. Meeting four
nights a week. these senior nurses can complete years three and four of the new nursing curriculum
in two and one-half years. The partner hospitals in Almaty are supporting the program by providing
sites for practical and clinical training. Over forty senior nurses graduated from the program in July
1997. These nurses will become the major force behind nursing reform. The Soros Foundation has
provided a grant to the college to purchase computers and teaching aids.
The role of nurses has changed significantly within the partnership hospitals as physicians are
finding that the new roles for nurses complement physician practice. The Institute of Pediatrics and
Children's Surgery recently created a new nurse educator position for nurse orientation and training,
and have established a training and orientation program for their new nursing employees. The
partner hospitals are establishing demonstration units with nurse managers. The City Perinatal
Center initiated the first demonstration unit, with a nurse managed post-partum recovery unit in
which nurses from each level are working.
EMS Center: Almaty has been designated as one of seven AIHA-sponsored EMS Training Center
sites in the NIS. Over thirty-five 80-hour courses have been conducted since the Almaty center
opened on October 1, 1994, with over 1000 ambulance team members trained thus far (including
physicians, nurses and feldshers), as well as 225 medical students and 30 rescue team personnel.
EMS Training Center faculty also traveled to partnership hospitals in Semipalatinsk, where they
conducted a basic training course for 90 EMS specialists. The training course teaches didactic and
practical skills on topics such as airway, breathing and circulation management; spinal
immobilization; and trauma management. The impact of the training has been confirmed by field
reports of life-saving methods being used in extrication and airway management by ambulance
personnel, including drivers.
NIS faculty members were trained as instructors in "train-the-trainer" programs, and are responsible
for ongoing instruction with minimal technical assistance by U.S. faculty. In addition to sessions
on center administration and data management, the faculty training course provided continuing
education for the director and instructors on emergency medicine and first responder protocols,
disaster planning, and training equipment maintenance and repair. Participants also were instructed
on principles of adult learning, case-based learning, and utilization of videos in developing audio-
visual aids. Foreign companies have paid tuition to the center to train their employees, and the
center is accumulating funds to help support its transition to independence from AIHA funding.
Faculty members at the Almaty EMS Training Center have developed and presented two practical
skills lessons on Kazak national television. In addition, the Director of the EMS Training Center
has appeared several times on national television to discuss the activities, goals and objectives of
the center.
A curriculum for hospital physicians in receiving departments has been developed to improve the
coordination of care between ambulance teams and in-hospital personnel. The first course was
ALMATY, KAZAKSTAN - TUCSON, ARIZONA PARTNERSHIP
taught to physicians from the Emergency Surgery Department at the Emergency Hospital in Fall
1995. In collaboration with the Almaty Medical University, senior medical students were provided
training in EMS and faculty members are also being trained.
Model Perinatal Center: The Ministry of Health and the City Health Administration have
supported the partners in their initiative to establish a Model Perinatal Center to demonstrate clinical
and educational services to improve pregnancy outcomes. The Tucson partners have provided
training. consultation, medications. supplies and equipment. The Center performs an average of
22 deliveries per day in a family-centered delivery unit on a fee-for-service basis. Revenues
generated by the private units are used to augment programs throughout the clinic. In addition,
medical staff have introduced family planning services within the past year that have been
welcomed by patients.
The center staff has successfully implemented "rooming in" for babies with their mothers. reduced
lengths of stay for both vaginal and cesarean deliveries, and has supported a breast-feeding program
in which over 90 percent of the mothers are participating.
Neonatology: The US partners conducted a training-of-trainers course in neonatal resuscitation in
Fall 1994. The Department of Neonatology of the Almaty Institute for Continuing Education of
Physicians (located in the Perinatal Center) then assumed responsibility for teaching the course.
Over 100 neonatologists and obstetricians from across Kazakstan have participated in the training
sessions.
Toxicology Information Center: In collaboration with the City Health Administration, the U.S.
partners have helped to establish a Toxicology Information Center at the Emergency Hospital.
Physicians from across Kazakstan can contact the center in case of emergency 24-hours a day to
receive qualified consultation on first aid for poisoning and drug overdose. In addition, the center
is integrated into the city emergency system, with established communications between the center
and ambulance teams and receiving departments. The physician director of the Center underwent
three months of training at the Arizona Poison and Drug Information Center. The U.S. partners
continue to provide 24-hour clinical consultation via e-mail in complex cases. The Center has been
equipped by the U.S. partners with a computer donated by Intel and the PoisIndex database donated
by Micromedex and updated quarterly. The City Health Administration refurbished facilities for
the Center and will staff and operate it as a national referral center for poison and drug overdose
information. The Soros Foundation has provided a grant to the center to support community
education and encourage citizens to call the center when they have questions or problems about the
toxic exposures. poisonings or drug overdoses.
The Toxicology Information Center and the Emergency Medicine Training Center co- sponsored
a national conference on the management of emergency toxicology cases in the spring of 1997. Two
specialists from Tucson participated as faculty. The two centers have also cooperated in a program
to introduce the treatment of drug overdoses with Naloxen. The drug was distributed to ambulance
teams, who have successfully administered it on site and saved lives and reduced hospital
admissions.
ALMATY, KAZAKSTAN - TUCSON, ARIZONA PARTNERSHIP
Physician Training: Since the partnership program began, six physicians have completed three-
month training programs in Tucson in the areas of cardiology, hematology-oncology, pulmonology,
pediatric intensive care, toxicology and emergency medicine. The physicians had the opportunity
to develop new skills and techniques and familiarize themselves with procedures and equipment
in their areas of specialty. In addition. they developed peer relationships with their U.S. colleagues
to facilitate the continued exchange of information and improve access to the latest developments
through electronic mail and facsimile. Other physicians have participated in training programs of
10 to 30 days in a variety of specialty areas.
Extensive collaborative efforts in the treatment of leukemia, gastroenterology, bleeding disorders
and respiratory diseases have evolved between the Children's Research Center at the Arizona
Health Sciences Center and the Institute of Pediatrics and Children's Surgery resulting in improved
pediatric care and reduced hospital stays.
Center for Endoscopic Surgery at the Almaty City Emergency Hospital: Through donations from
Johnson and Johnson and Olympus, equipment and supplies were provided to the Almaty City
Emergency Hospital, whose surgeons were trained in laparoscopic surgery techniques. Over 500
laparoscopic surgeries were performed in the first year of the Endoscopic Surgery Center. Improved
patient outcomes and reduced lengths of stay have resulted in increased demand for this surgical
technique. The center has trained surgeons from other partner hospitals and one of the surgeons is
setting up a new program in another hospital in the city.
Future Plans for the Partnership
Institute for Pediatrics and Children's Surgery: The Director of the University of Arizona
Children's Research Center will seek funding from the National Institutes of Health to support an
applied clinical research program in pediatric gastroenterology. The institute will be the site for
the implementation of a telemedicine program to support continued collaboration in the areas of
respiratory disease, leukemia and bleeding disorders, and gastroenterology. Once this program has
been successfully implemented, the telemedicine program will be expanded to include other partner
hospitals.
Almaty City Emergency Hospital: The Toxicology Center will be supported in its efforts to
increase calls from the public as well as physicians and to provide a community education program.
The implementation of case review and standardization of responses to calls will also be a focus of
partner collaboration.
The surgeons in the laparoscopic program will be trained to perform surgeries on patients with
complex gastroenterogical problems.
Almaty City Perinatal Center: Support will be given to the center to assist it in becoming
designated a "WHO Baby Friendly Hospital." A learning resource center is to be established at
there. The Tucson partners have donated equipment and supplies to upgrade the laboratory and the
surgical department, and the center expects to double the size of the privatization unit this year.
ALMATY, KAZAKSTAN - TUCSON, ARIZONA PARTNERSHIP
Almaty Women's Wellness Center: The Center will have a Grand Opening Ceremony in
November 1997. The center staff will continue to receive clinical training as well as the technical
assistance required to enable it to become a self-sustaining clinic. Educational programs will be
developed to include community outreach and educational programs for women of all ages,
including teens and menopausal women.
Infection Control: The partners expect to collaborate on the implementation of a republic wide
surveillance infection control program based on revised legislation and supported by a training
program for all SES and hospital staff.
The focus of the program activities in the future will be on bringing projects to closure and seeking
funding from sources outside USAID and AIHA to fund continued collaborative efforts in clinical
training and applied clinical research.
Partnership Contacts
Emily Jenkins, JD
Erik M. Musin, MD
Project Director
Head of the Department for the
Tucson-Almaty Health Care Coalition
Organization of Health Care
5301 E. Grant Road
Ministry of Health
Tucson Medical Center
Almaty, 480003 Kazakstan
Tucson. Arizona 85712
Phone: (520) 324-1784
Phone: (3272) 33-16-90
Fax: (520) 795-5689
E-mail: [email protected]
SEMIPALATINSK, KAZAKSTAN - HOUSTON, TEXAS PARTNERSHIP
The Medical Partnership Program between the cities of Houston, Texas, and Semipalatinsk,
Kazakstan, funded under a cooperative agreement with the United States Agency for International
Development (USAID), was established in February 1995. The Semipalatinsk Regional
Administration and six local hospitals in Semipalatinsk participate in the partnership. The Regional
Oncology Dispensary, the Regional Clinical Hospital, the Regional Children's Hospital, The
Emergency First Aid Hospital, the Regional Diagnostic treatment Center in Kurchatov, the
Semipalatinsk Gynecological Hospital. and the Semipalatinsk Medical Academy provide care for
the population of Semipalatinsk and Kurchatov.
The partnership is led on the US side by The Methodist Hospital (TMH) and Baylor College of
Medicine. TMC is an internationally renowned facility, which provides primary, secondary and
tertiary care services to the Houston metropolitan area and the state of Texas, and is the primary
teaching facility for Baylor College of Medicine. Other participating institutions on the US side
include Texan Children's Hospital, Veterans Affairs Medical Center, and Harris County Hospital
District. In addition, Baylor scientists are deeply involved in several collaborative research projects
and scientific exchange programs in Russia, Ukraine and Belarus focusing on health effects of
exposure to radiation resulting from the Chemobyl power plant accident.
The general areas of focus for these partners are cancer screening and tumor registry, infection
control. nursing education, health care reform, maternal/child health, women's health, disaster
management, clinical pathology, and public health education of the population.
Program Outcomes
Cancer Registry: A major focus of the partnership is assisting with the elimination of the effects
of nuclear radiation on the people of Semipalatinsk. Until 1989, the Semipalatinsk region was home
to the Soviet Union's Nuclear Test Site. Increased incidences of cancer, infant mortality, birth
defects, and early aging syndrome have been attributed to the nuclear testing program. The
programmatic focus of the partnership is responding to the critical needs of the population through
a broad-based set of initiatives in cancer screening and registry.
A cancer registry center for Semipalatinsk and the region is being established through the training
of oncologists and a cancer registrar at TMH's Cancer Registry Center, and exposing trainees to
computerized office automation and data management in a hospital environment. Further more, the
partners plan to develop a cancer prevention program for physicians and public health educators by
introducing them to cancer screening programs as part of the patient's regular examination and with
programs related to cancer education and prevention.
The partners also plan to identify reagents needed for screening and will train physicians in
treatment and follow-up of early stage cancer diagnosed by the screening methods. In July of 1997,
for Houston specialists traveled to Semipalatinsk to lead a Cancer Registration Conference, with the
goals of improving histology/morphology coding, quality control, and data analysis. The
partnership is also in the process of developing and implementing cancer registry software, which
will assist in the coding and screening process.
SEMIPALATINSK, KAZAKSTAN - HOUSTON, TEXAS PARTNERSHIP
Health Care Reform: In collaboration with city and oblast level health care officials, the partners
plan to develop a model for health care reform in the Semipalatinsk region with specific attention
to the possible impact of privatization. To date, twelve health care leaders from the oblast have
participated in workshops on financial management/cost accounting, decision-making and effective
grant proposal writing through partnership efforts augmented by AIHA/AUPHA management
training. The Head Physician and the Head Economist of the Semipalatinsk Ophthalmology Center
participated in the sessions and are currently using their training to manage the Center's newly
established fee-for-service department.
Infection Control: The partners plan to establish infection control programs in each of the
partnership hospitals by providing training in current infection control methods for physicians and
nurse educators from Semipalatinsk. As a result of recent partnership exchanges. a representative
from Semipalatinsk had the opportunity to train extensively with TMH's Infection Control
Committee, focusing on prevention of nosocomial infections, the importance of intra-hospital
epidemiological studies and support services.
Maternal and Child Health: In collaboration with key Semipalatinsk health care officials, the
partners have developed a plan to reduce infant mortality by improving prenatal, neonatal and infant
care in Semipalatinsk and remote areas by training partners in neonatal resuscitation, principles of
immunization. nutrition counseling, and other aspects of maternal and child health care as part of
prenatal and postnatal health.
In October 1996, the director of the Semipalatinsk Gynecological Hospital participated in a four
week long training program in Houston, concentrating specifically on surgery and quality/infection
control.
In February 1997, a group of four pediatricians, including the Director of the Semipalatinsk
Regional Children's Hospital, participated in extensive training sessions at Texas Children's
Hospital specializing in leukemia treatment.
Nursing Reform: A primary objective of the partners is to develop nursing leadership and improve
nursing functions in the partnership hospitals. As a part of the continuing effort to reform the role
of nurses in Kazakstan, six nurses from various regional hospitals in Semipalatinsk traveled to the
US for a four-week visit beginning in July 1996. The nurses participated in training sessions with
TMH inpatient nursing staff, attended patient education activities, and met appropriate faculty.
In October 1996, nurses from Houston and Semipalatinsk attended a biannual conference for
Continuing Nursing Education in Semipalatinsk. The conference emphasized the need to increase
the role of nurses in patient care and health care administration in the NIS. A second annual
conference is expected in September 1997.
Semipalatinsk nurses have succeeded in establishing a Semipalatinsk Nursing Association, with
2,000 members to date. They interact and correspond with other international associations,
including the Association of Operating Room Nurses in the United States.
SEMIPALATINSK, KAZAKSTAN - HOUSTON, TEXAS PARTNERSHIP
Emergency Medicine/Disaster Planning: An additional component of the partnership's efforts
will focus on the establishment of a disaster management and emergency medical care program with
an outreach component to surrounding areas. In order to initiate the process, the directors from the
Emergency First Aid Hospital and the Kurchatov Regional Diagnostic Center traveled to TMH to
study ER and disaster management procedures, safety education and evacuation procedures. They
met with Houston area officials responsible for emergency services and civil defense. In May of
1997, the Director from City Emergency Medical Services of Semipalatinsk, as well as the Faculty
Head of the Disaster Medicine Department of the Semipalatinsk Medical Academy traveled to
Houston for a four-week long training program in their specialties.
Other Activities
In November 1996 scientists from the United States and Kazakstan convened in Kurchatov,
Kazakstan for a Workshop on Health Effects of Environmental Radiation Exposure in Kazakstan.
Representatives from the US side included the Armed Forces Radiobiology Research Institute,
Department of Energy, National Cancer Institute, Centers for Disease Control and Prevention, and
NASA. Kazak Participants included the Minister of Science and Technology, representatives from
the Ministry of Ecology and the Environment and the Ministry of Health. The president of the
National Nuclear Center in Kurchatov organized and co-convened the workshop. The objectives
of the workshop were to standardize data collection and analysis, prioritize a research agenda,
evaluate preliminary research findings, explore the feasibility of conducting cross-cultural
collaborative research within the current infrastructure, and identify potential collaborators and
institutions. A follow-up workshop is tentatively scheduled for November of 1997.
The Houston-Semipalatinsk Partnership has also been successful in leveraging funding and support
from additional sources, including General Board of Global Ministries, Santa Fe Pacific Gold,
Department of Defense, AmeriCares, Counterpart, NIEHS, and Kodak.
Partnership Contacts
Armin Weinberg, PhD, Director
Bakhyt Tumenova, MD
Center for Cancer Control Research
Head of the Department of Social Services
Baylor College of Medicine
Semipalatinsk City Administration
6560 Fannin Street, Suite 924
8 International Street
Houston, TX 77030
Semipalatinsk, Kazakstan
Phone: (713) 798-4614
Phone: (3222) 66-06-56
Fax: (713) 798-3990
Fax: (3222) 62-35-73
E-Mail: [email protected]
E-Mail: [email protected]
Clinton Presidential Records
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J
WOMENS
HEALTH
eases. We have several joint projects, which,
First Ladies Speak Out on
when fulfilled, will improve the situation.
Women's Health
If you could alleviate one health challenge
confronting women in your country, what
would you choose?
OMMONHEALTH asked First Ladies in the NIS and CEE
C
Currently, our foundation pays a great
to talk about women's health in their nations and
deal of attention to the education and up-
bringing of children and teenagers. They
their work in health promotion for families. The First
are our future. our hope. The future of the
Ladies of Kazakstan and Latvia submitted written an-
country depends much upon how we
manage to teach our children to preserve
swers to a set of questions. Future issues of COM-
their health while they are young.
I would like to start more consistent
MONHEALTH will include interviews with other First Ladies.
and systematic work with teenagers, with
and reproductive system cancers.
young girls and younger children. It is very
Unfortunately. there is a growth of
important to make them enthusiastic
sexually transmitted disease as well.
about good health, which is so important
In several rural regions there are
for a life full of value. I want to show them
practically no healthy women;
the dangers of smoking, alcoholism and
many of them suffer from anemia.
drug addiction. It is necessary to explain to
This is because of unfavorable eco-
the young people in an attractive way the
logical conditions left as an inher-
rules of private hygiene and safe sex (if it
itance from the past. (See articles
is not possible to avoid it before marriage).
on Semipalatinsk, p. 25-29 of this
I hope for the collaboration in this field
issue.)
with AIHA, which has experience in pub-
licizing of healthy lifestyles among the
How are you using your role as
population.
First Lady to advocate women's
Kazakstan has an enormous amount of
Sara Nazarbaeva, First Lady of Kazakstan.
health issues?
territory and a low density of population.
SARA NAZARBAEVA, FIRST LADY OF KAZAKSTAN
That is why the inhabitants of distant rur-
We have established the charity foun-
al regions do not have any modern infor-
What are the most important health issues
dation Bobek (Baby) for the children of
mation about healthy lifestyles and about
facing women in your nation?
Kazakstan, and I serve as its president. Its
their responsibility to preserve their own
work is directed toward the children, and
health and that of their children. In these
Kazakstan is moving toward a market
hence toward the families and the moms of
conditions, it is very important to orga-
economy. It is well known that everything
these families. It is very important for
nize with the help of mass media a wide-
that is new suffers "growing pains." In such
women to know how to support their own
scale public education program.
times, life is especially difficult for women.
and their children's health and how to pro-
They are working in factories on equal foot-
vide good nutrition for their families.
AINA ULMANE, FIRST LADY OF LATVIA
ing with men. They also must take care of
Our foundation is closely collaborat-
in families and children. There is no time to
ing with the Republican Center of Moth-
What are the most important health issues
nk about one's health, although there are
ers' and Children's Health Care, whose pri-
facing women in your nation?
many problems, such as the extremely high
mary mission is the care of pregnant
level of abortions, and an increase in breast
women and those with gynecological dis-
Women's health and health problems
COMMONHEALTH
FAIL 1996
1221
Photo by Barry Kinsella
WOMENS
HEALTH
"I have always emphasized that the family is responsible for the health of the next generation.
Children's health, and thus the health of the next generation, depends largely on the mother's health."
reflect the current situation in our health
How are you using your role as First Lady to
situation in Latvia, and, following her rec-
care system and the impact of the envi-
advocate women's health issues?
ommendations, AIHA considered coop-
ronment and economic conditions on
erative opportunities with Latvia. In lune
health. Hospitals are short of funds, and
I think that issues of women's health, like
1995, a partnership agreement between
a large number of vulnerable people can-
general health issues, must be solved with
three Latvian and three St. Louis hospitals
not afford the high cost of health care.
combined efforts - the state, physicians and
was signed in the White House, with Mrs.
People are also lost 111 the ever-changing
women themselves must contribute to seek-
Clinton's and my participation.
labyrinths of the health care system
ing solutions. However, as the first lady tends
This program pays particular attention
they are not sure where and to whom to
to be the focus of public attention, her opin-
to the health care issues of women, chil-
turn. As a result, people seldom visit doc-
ion and presence add a certain weight to this
dren and the elderly. I believe that women's
tors; according to an opinion poll, no
health is closely linked with children's
respondents had visited a health care
health issues. A mother's health has an
institution within the last two weeks
impact on her child's health, both phys-
to seek preventive care. only to treat
ically and spiritually, and a mother has
an actual health problem. Taking re-
a responsibility to educate her child
sponsibility and understanding their
about healthy behaviors.
own health is not valued. This, unfor-
I am doing my utmost to attract the
tunately, refers in large part to women.
media's attention regarding the joint
It is painful to note that would-be
efforts of these medical personnel, so
mothers are becoming less responsi-
that they do not remain neglected by
ble. Women enter pregnancy unpre-
society at large.
pared and in ill health. and diagnosis is
often delaved. We have a large number
If you could alleviate one health challenge
of would-be mothers who have high-
confronting women in your country, what
Aina Ulmane, First Lady of Latvia.
risk pregnancies, and there are many
would you choose?
complicated births that result in maternal
issue. Although she is not able to directly in-
deaths.
fluence solutions to a particular problem,
It would be really difficult for me to se-
We have an inexcusably high number
her opinion is taken into account.
lect a particular health problem as each of
of pregnancies that are artificially inter-
During visits and meetings of high-lev-
them are important, and I believe that a
rupted; according to statistics, there are
el statesmen and officials, their spouses
solution to one particular problem will
114 abortions for every 100 live births.
have special itineraries, often focused on
not bring adequate results.
This, in combination with sexually trans-
children and health care issues. As a most
I have always emphasized that the fami-
mitted diseases, results in serious com-
successful example of this I would like to
ly is responsible for the health of the next
plications and even in barrenness in
mention the cooperative program between
generation. Children's health. and thus the
women.
the Latvian and St. Louis, Missouri hos-
health of the next generation, depends large-
The main problem lies in a careless
pitals. The program was initiated in July
ly on the mother's health. Thus, parents in
lifestyle, facilitated by the social and eco-
1994 when US President Bill Clinton and
each family, thinking about the future of
nomic situation, inferior nutrition, gaps in
Mrs. Clinton visited Latvia. Within the
our nation, must acknowledge the value of
education, as well as an insufficient na-
framework of this visit, Mrs. Clinton was
their children's health and teach them re-
tional framework for preventive measures.
presented with a review of the health care
sponsibility for their own health.
Photo by Eun-Joo Chang
1231
COMMONHEALTH
FALL 1996
WOMENS
S
HEALTH
L'viv's Smallest Success Story
BY SUDHAKAR EZHUTHACHAN, MD, H. AND CHRISTINE NEWMAN, MS, RNC
he infants are tiny enough to fit in the palm a nurse's hand, with hearts barely the size
1
of a walnut and underdeveloped lungs struggling for oxygen. But with the help of the
American partners at the Henry Ford Health System (HFHS) in Detroit, Michigan,
these babies at the L'viv Oblast Clinical Hospital (LOCH) in L'viv, Ukraine now have
a fighting chance.
"Little things really do count."
tologist with the Ministry of
said LOCH neonatologist Zori-
Health. Good management of
ana Salabay, referring to the im-
low birth weight babies at part-
provements made in neonatal
nership hospitals in Eviv pro-
techniques that have helped save
duced some early positive results,
the lives of hundreds of prema-
added Sulima.
'ure infants.
For example, last year 70 per-
From increased training of
cent of the 80 newborns in criti-
doctors and nurses to the use of
cal condition brought to the
mechanical ventilators, the Eviv-
NICU at LOCH within their first
Detroit partnership has improved
three days of life survived. In
the level of infant care, not only at
1995, the NICU had a 45 percent
the Premature Baby and Neona-
survival rate for transported in-
tal Intensive Care Units (NICU)
fants weighing under one kilo-
within LOCH, but to infants
gram, compared to a 25 percent
A nurse holds the tiny hand of a premature infant at LOCH.
throughout the oblast. The part-
survival rate at regional birth
nership created a successful framework for care by adapting the
houses. The use of modern approaches to improve newborn care at
principles of regionalization a system of care based on the lev-
LOCH has decreased length of stay from 32.1 days in 1993 to 29.8
el of risk for the baby - used in the United States since the 1950s
days in 1995.
but new to Ukraine. Very ill babies from throughout the region
Prior to 1993, L'viv Oblast did not have a neonatal intensive
now come to LOCH for treatment.
care unit. Partners selected neonatology as the most critical area
In 1993, infant mortality in Ukraine was 13.5 per 1,000 live
of focus for the partnership to respond to the high infant mortal-
births, compared with 8.2 per 1,000 live births in the United States,
ity level in Ukraine. The partnership's four-part model addresses all
and 4.4 per 1,000 live births in Japan - the lowest in the world.
the responsibilities of a Level III (the most intensive) regional
However, unlike in the United States and Japan, the data from
neonatal center as outlined in the "Guidelines of Perinatal Care,"
Ukraine do not include infants weighing less than 1.000 grams -
published by the American Academy of Pediatrics and the Ameri-
meaning that the mortality rate is higher than the statistics indicate.
can College of Obstetricians and Gynecologists, including clinical
"We are fighting for every child's life." explained Head of the
service, education, quality assurance and unit management.
Eviv Oblast Health Administration Mykhola Khobzei.
An important initial step in the creation of the unit was the de-
The high infant mortality rate, coupled with declining birth
velopment of the Collaborative Practice Committee, comprised
rates, have made improved care for premature babies a priority for
of unit nurses and physicians to oversee issues as they relate to pa-
the Ukraine Ministry of Health, said Elena Sulima, MD, chief neona-
tient and staff concerns and analyze outcomes. Members of the
Photo by Sudhakar Ezhuthachan
151
COMMONHEALIH
FALL 1996
WOMEN
S
HEALTH
committee were educated on principles
seven days were transported to LOCH. In
Education: The Key to Success
of quality management and encouraged
most instances, however, they arrived very
The most important component of L'-
to use them to run their monthly meet-
sick and cold (with a body temperature
viv's model and the key to establishing a
ings, identify priority issues and analyze
less than 35 degrees Celsius), and in some
high-quality Level III neonatal unit is edu-
results.
instances, efforts to keep the infants warm
cation. Educational efforts included the der
with hot water bottles resulted in exten-
velopment of a neonatal curriculum and
Technical Advances in Care
clinical bedside training for physi-
In 1995. an eight-bed intensive
cians and nurses. Consisting of 40
care area was established at the Pre-
lectures and instruction outlines,
mature Baby Unit, and was equipped
slides and audio-visual equipment
with equipment donated from the
donated by HFHS, the curriculum
health care community in south-
provided a template for continuing
eastern Michigan, local equipment
education efforts within the region.
vendors and colleagues within the
Practical bedside training in intuba-
Henry Ford Health System.
tion, chest tube insertion, umbilical
Advances in technology intro-
catheter insertion and suturing was
duced in the neonatal unit at LOCH
an essential part of the curriculum. A
included mechanical ventilation,
library of western medical and nurs-
regulated oxygen delivery, continu-
ing literature - books and journals
ous positive airway pressure through
donated by HFHS employees, Toron-
the nose. cardio-respiratory and
to Children's Hospital and several
oxygen saturation monitoring, con-
others - also was established at
trolled infusion therapy, photother-
LOCH. Similarly, teaching videos, a
apy (including use of a biliblanket
television and a video cassette
to keep the baby warm), and ap-
recorder were donated by US part-
propriate dosing and administra-
ners to assist with meeting the staff's
tion of antibiotics. Guidelines for
educational needs. Over 160 health
clinical practice were developed and
care providers from LOCH have
translated into Ukrainian. and are
been trained in neonatal resuscita-
available as a pocket-sized reference
A mural in Kiev's Obstetrical and Gynecological Hospital No. 3 promotes
tion techniques. Supplemental,
for unit staff.
happy, healthy babies.
Ukrainian-language course material
Introduction of mechanical ven-
was also produced for staff with the
tilation was not without problems, how-
sive burns. Hypothermia is still a frequent
aid of Malteiser Humanitarian Aid Orga-
ever; use of mechanical ventilators drained
problem since most infants are transport-
nization.
existing meager oxygen supply, and voltage
ed by car.
"L'viv neonatologists are the first who
differences made transformers essential.
A regional infant transport program,
have applied the new approaches to the care
With increasing experience on the use of
is key to effectively transporting sick in-
of the newborn," explained Nina Goida,
this technology, the average duration of
fants to LOCH. A donation from Detroit's
MD, head of the Department of Maternal
ventilation has increased over time, and
Ukrainian community last winter helped
and Child Health Care at the Ukrainian
ventilated infants have been surviving in
with the purchase of an infant transporter,
Ministry of Health.
greater numbers.
which now can carry critically ill newborns
Speaking at the May 1996 regional con-
One of the main issues identified by
to the LOCH referral center from distant
ference on neonatal resuscitation and re-
the partnership is the inability to ensure
birth houses and hospitals (see COMMON-
gionalization, Goida encouraged neona-
at sick infants reach the regional center
HEALTH, Winter 1996). Reliable ambulance
tologists to develop programs modeled after
111 a timely fashion. Typically, only those
support is needed, however, to ensure that
the LOCH program, which has introduced
critically ill infants who lived longer than
this effort continues uninterrupted.
"a practical level of skills" to neonatologists
COMMONHEALTH
FALL 1996
161
Photo courtesy of Vivian Lowenstein
WOMEN
S
HEALTH
ity to measure urine concen-
Morbidity and mortality data collection in
Regionalization of Care
tration, and blood gas analysis
Ukraine is currently not consistent with that
- changes which necessitated
of western nations.
Level I
Uncomplicated care
major alterations in patient care
Recently, a policy change in the Eviv
Level II
Care of moderately ill
documentation.
Oblast required that all infants who die, in-
Level III
High-risk care
Dmvtro Dobriansky, MD, a
cluding those less than 1,000 grams, be eval-
neonatologist at I.OCH, and
uated by a pathologist. This modification will
Level III Referral Centers
Level III care + neonatal
Andrew Tooziak, MD, a post-
allow data comparisons with western nations.
transport and regional
graduate student at the L'viv
Computers donated to the partnership
outreach education
Medical Institute and LOCH,
have aided the staff in developing a program
designed a bedside flowsheet to
that provides them an extensive database on
and "affected declines in early neonatal mor-
document patient data in the NICU, mod-
many aspects of patient care. Staff physicians
tality" at the LOCH Premature Baby Unit.
cling it after the one used at Henry Ford
enter data into the computer on all patients at
These early positive outcomes prompted the
Hospital. The information documented by
the time of discharge. Using this data, trends
Ministry to work with AIHA to introduce
the nurses is readily available to the physi-
can be identified in the newly instituted prac-
the LOCH Neonatal Resuscitation Program
cians, who also use the flowsheet to write
tice of mechanical ventilation and care mod-
throughout Ukraine, Goida concluded.
daily orders. This has greatly improved both
ified if needed. The computer support has fa-
LOCH physicians and nurses realized that
communication and collaboration between
cilitated regular communication through
in order for clinical care to improve, the ex-
physicians and nurses, contributing signifi-
e-mail with colleagues in L'viv. This allows us
isting role of the bedside nurse would have to
cantly to better patient care.
to have an ongoing dialogue about issues and
be altered. A nurse educator position was
Education of support service staff in ra-
aid in problem solving in a very expeditious
created within the unit to help ensure sus-
diology, pharmacy and microbiology also
and cost-effective manner.
tainable improvements 111 care and provide
addressed specific needs of sick infants, be-
Though partner efforts have resulted
ongoing education to nurses. The unit's first
cause if these staff do not function at peak ef-
in improvements in care, critical problems
nurse educator, Olha Vlad, participated in
ficiency, the critical care provided to these
remain that threaten the ability to sustain
an intensive, one-month training program at
infants could be jeopardized.
the changes and successes achieved. The
HFHS and continues to provide ongoing
Outreach efforts to neonatologists and
need for a steady stream of supplies, more
education and support to nurses in the
nurses in the Lviv region culminated in the
equipment and last but not least the
NICU in Eviv.
creation of two- to four-week training pro-
attitude of continuously challenging old.
And the outcomes of these courses are
grams in patient management and bedside
ineffective practices cannot be underesti-
significant, noted Salabav. "We accomplish
care. Physicians and nurses from district
mated. We continue to be amazed at the
more in our unit thanks to the expanded
hospitals in western Ukraine visit LOCH for
dedication and commitment of our col-
role of our nurses."
training. In addition, their realization that
leagues despite an unending series of ob-
Nurses in the unit now provide bedside
small babies had a chance to survive at
stacles. We have learned that collabora-
care to small, sick infants on ventilators, and
LOCH has resulted in earlier transport of
tion, not only between the partners, but
are responsible for routine monitoring of
small and sick infants.
with other departments, organizations and
vital signs, interpretation of monitor and
Parent education is an essential compo-
the community, is vital to ensure that qual-
bedside laboratory data. listening to breath-
nent of the neonatal education program.
ity care can be provided even to the tiniest,
ing through a stethoscope, endotracheal suc-
This includes conducting ongoing classes
most fragile patients at LOCH.
noning to clean the trachea, initiating IV
for parents and providing informational
therapy, and monitoring central blood pres-
brochures on important issues related to
Sudhakar Ezhuthachan. MD. DCH, and Christine
sure. Nurses in NICU also perform basic
their infant's care.
Newman. MS. RNC. are US partners from the Hen-
!!' Ford Health System. Department of Pediatries.
bedside laboratory testing, including mi-
Division of Neonatology and the Department of
crosedementation rates to determine if a
Evaluation of Program Outcomes
Nursing (Detroit, Michigan). Dmytro Dobriansky,
baby has an infection, hematocrit to deter-
Collection of accurate data is the only
MD, assistant professor at 1. viv Medical Institute
and a neonatologist at LOCH, provided numerical
mine hemoglobin count. urine specific grav-
way to evaluate any program or change.
data.
1171
COMMONHEALTH
FALL 1996
WOMENS
S
HEALTH
Innovations in Care
ily-centered prenatal education, screening,
and counseling services to expectant moth-
ers. Midwives at the center have been trained
at the Tashkent Women's
to conduct Lamaze classes about childbirth
techniques for expectant mothers and their
Health Center
birthing partners, who because of religious
and cultural reasons are often a female rel-
ative or friend rather than the father. Pro-
motion of family-centered childbirth at
BY/OANXI NEUBER
TASHMI II is a significant accomplishment,
where traditional beliefs formerly discour-
hildren will soon comprise more than 50 percent of
aged birth partners from being present dur-
C
ing childbirth, said the center's director and
the Uzbek population, according to Uzbek Ministry of
obstetrician Alla Pogorelova, who has
Health statistics. This high birth rate, coupled with
trained with University of Illinois at Chica-
go (UIC) partners in obstetrics, high-risk
the fact that Uzbekistan has one of the highest ma-
maternal care and gynecology.
ternal mortality rates in the former Soviet Union
One area where partners have had a
great impact is educational training in
estimated at 46 per 100,000 live
neonatal and perinatal care.
births - is placing increasing de-
Tashkent partners collaborate with
mands on the country's already
colleagues from Chicago to learn ef-
strained health care system.
fective, low-tech ways to manage
The changing demographic pat-
and care for high-risk mothers and
terns in Uzbekistan prompted the
infants. Vidyasagar said that part-
Second Tashkent Medical Institute
nership training programs at TASH-
(TASHMI 11) to create one of the
MI II that target low-tech neonatal
country's first women's health cen-
resuscitation techniques, have con-
ters. in collaboration with the AIHA
tributed to the decline in infant
Tashkent-Chicago partnership pro-
mortality at TASHMI II, from 27
gram in April 1996.
Alla Pogorelova (left) and Guitera Hashimova show the family planning
per 1,000 live births (1,000 to 1,499
materials at the Women's Health Center.
"We see the importance of pro-
grams) in 1992 to 15 per 1,000 live
moting a health care system based
tionally were either non-existent, or were
births in 1995.
on primary care," Hamid Karimov, MD, rec-
situated in buildings far from each other.
"The positive results in maternal and
for of TASHMI Il said. "And women's health
For example, women deliver in their own
child health at TASHMI II are a result of
is a necessary component of that system."
private rooms. After delivery, women are
the partnerships' collaborative program in
This innovative women's health center
transferred to a four-bed unit in the center
neonatal and perinatal care," Vidyasagar
provides comprehensive "cradle to grave"
with their babies to promote greater moth-
said. "This program has been very effective
care for women in the region. It includes a
er-child bonding. This new "rooming in"
in improving the care of mothers and their
maternity center, a neonatal care unit, and
technique is also improving the level of
newborns."
an ambulatory women's health clinic for
breast-feeding in Uzbekistan, which is only
The ambulatory women's health clinic
women with medical, gynecological or ob-
10 to 15 percent, according to US partner
is a "more effective system than the referral
stetrical problems.
Dharmapuri Vidyasagar, MD, director of
system of the past," Pogorelova said. Women
In a departure from traditional practice,
the Division of Neonatology at the Univer-
who opt to come to the clinic for a medical
the center consolidates women's health ser-
sity of Illinois at Chicago.
consultation are not required to have a spe-
vices in one building - services that tradi-
The maternity center also provides fam-
cial referral from their polyclinic, and may
Photo by Joanne Neuber
1111
COMMONHEALTH
FALL 1996
WOMEN
S
HEALTH
visit the clinic throughout the day or
ily planning education classroom at the clin-
these programs, noted Pogorelova.
evening. she said.
10 was created with the help of many inter-
The most important outcome of the cen-
Patient visits at the clinic have doubled
national health organizations to promote
ter may not be measured in hard data, but
since it was opened last year due to a change
increased awareness of contraceptive alter-
rather as the "change in the way we view
in pre-natal services practices to include
natives, including IUDs, condoms and oral
women's health," Pogorelova said. Earlier,
4
greater patient education, according to
contraceptives. Women are also encouraged
certain women's health issues like birth con-
Pogorelova. "There is more open discussion
to consult with their physicians on possible
trol alternatives and family planning were
between physicians and women of family
social and economic issues that may affect
"simply not discussed" in traditional Mus-
planning alternatives," she said.
the number of children they have, explains
lim society she said. "Now we can openly
The clinic also provides ongoing, free
Pogorelova. Partner clinical training of doc-
discuss important and necessary women's
family planning services to women. A fam-
tor/nurse teams at TASHMI II complements
health issues."
Mother and Child
ROM capability and a planned Internet connection. For new par-
ents, the center offers educational materials on topics such as
breast feeding and care of the newborn. Two full-time staffers,
Health Information Center
provided by the Health for All Foundation (with support from the
Soros Foundation), will coordinate educational seminars for new
Opens in Albania
parents, to be held in the center's large meeting room. This room
will also be available for workshops and seminars organized by the
hospital's physicians and nurses.
ew parents and health professionals now have their own re-
N
Various officials attended the opening, including: Teodor Tod-
source center at the Maternity Hospital in Tirana, Albania,
he, MD, general director for hospitals at the Albanian Ministry of
thanks to the sup-
Health; Deedee Blane, US-
port of AIHA and Albania's
HEALTH
AID Representative to AI-
Health for All Foundation.
COMPLETE state of
physical. mental
bania; Cam Pippitt and
social well-
A reception and ribbon-
being and not
mercly 1hc
Silva Mitro of USAID;
ASENCE of
cutting were held July 5
scase
"
Comity
Zhani Treska, MD, direc-
to mark the formal open-
tor of the Maternity Hos-
ing of the hospital's
pital; Tatjana Daci, direc-
Mother and Child Health
tor of the Health for All
Information Center, with
Foundation; Bill Walsh,
a ministry of health rep-
chief operating officer of
resentative, USAID offi-
Jacobi Medical Center;
cials, hospital staff and
and Charles Brecher, pro-
AIHA staff members in at-
fessor of public adminis-
tendance.
tration at New York Uni-
The center houses a li-
versity, representing
brary with medical books
AIHA's health management
and professional journals
Left to right: Zhani Treska, MD, director of University Maternity Hospital in Tirana, Albania;
education partnership be-
for physicians and nurs-
Teodor Todhe, MD, of the Albanian Ministry of Health; and Anduena Vako, manager of the hospi-
tween Albania and New
es (largely in-kind dona-
tal's Mother and Child Health Information Center, join in the center's ribbon-cutting ceremony.
York.
tions from AIHA partner
The center will also serve as an office for AIHA's new in-coun-
Jacobi Medical Center in Bronx, New York), and a computer with CD-
try coordinator for Albania, Judy Biletnikoff.
COMMONHEALTH
FALL
1996
1121
Photo by Eun-Joo Chang
WOMEN
S
HEALTH
Health Status of Women
in CEE and the NIS
he rapid political, economic and social
1
changes occurring in the countries of central
and eastern Europe (CEE) and the new inde-
pendent states (NIS) of the former USSR have
created conditions that fundamentally affect
the population. These changes have lead to
to the life situation, to conditions
social and economic hardship and, in some
of work and to patterns of be-
cases, to war. The result is a widening gap
havior. all of which tend to vary in
in health between the eastern and western
gender-specific ways.
halves of Europe, a serious inequity. A clos-
er look at CEE and the NIS reveals that
Life Expectancy
Nurila Narina of Bishkek, Kyrgyzstan, gave birth to twins at the In-
while women bear more of the burdens im-
Data comparing life ex-
stitute of Obstetrics and Pediatrics last February. The Institute has
posed by change, they also comprise an in-
pectancy at birth provide an
improved neonatal mortality, from 8.1 percent in 1994 to 7.5 percent
in 1995.
valuable, largely untapped resource for im-
overview of differences in sur-
proving their communities and their health.
vival for the female population of CEE and
main causes of overall mortality for males
It must be emphasized that the infor-
the NIS in relation to European Union (EU)
and females (cardiovascular disease and
mation available on women's health is quite
averages. In 1993, the average life expectan-
cancer under the age of 65) give rise to con-
limited. In the past, the collection of gender-
cy for women in the NIS was six years less
cern. Particularly worrisome are the death
specific data was uncommon globally. Only
than the average for women in the EU. The
rates for cardiovascular disease for females.
in recent times have the fundamental dif-
difference for women in CEE was five years.
The lowest female rate in CEE and the NIS
ferences in the health of men and women
Within CEE and the NIS, there is a seven-
- Lithuania at 72.95 per 100,000 is
been formally recognized. Further, a great
year average difference between the coun-
more than one and a half times the Euro-
deal of the available data is uncertain. Not
tries with the lowest and highest figures,
pean average of 47 per 100,000 and more
only do the systems of data collection vary
from 69.3 years in Turkmenistan to 76.5
than twice the EU average. Subregional vari-
greatly in quality and comprehensiveness,
years in the Republic of Georgia.
ations in cardiovascular mortality are par-
the types of data collected and the meth-
In the 1980s, life expectancy in CEE and
ticularly large - Turkmenistan has 165
ods of analysis are often quite limited.
the NIS showed a very gradual increase.
deaths per 100,000 women, while Estonia
Most of the diseases that are major threats
But for most of the countries, life ex-
has 81. While mortality from cardiovascu-
to the health of populations in CEF and the
pectancy fell from 1990 to 1993. Life CX-
lar disease (mainly ischemic heart disease
NIS develop over long periods of time. Causal
pectancy at birth in the Russian Federation
and cerebrovascular disease) in females has
factors interact with other influences in com-
decreased from 74.4 years to 72. Latvia fell
been decreasing since 1980 in western Eu-
plex ways. Many health problems are related
from 74.5 to 73.3 years.
rope, no progress was made in CEE and the
NIS.
Excerpted from "Investing in Women's Health: Cen-
Cardiovascular Disease and Cancer
The gap in cancer mortality rates for
tral and Eastern Europe." World Health Organiza-
tion, 1995 and WHO's "1995 Highlights on Women's
Diverging trends between CEE and the
females is less dramatic than that for car-
Health in Europe."
NIS and the rest of the region in the two
diovascular diseases, but growing larger.
Photo by Joanne Neuber
171
COMMONHEALTH
FALL 1996
WOMEN
S
HEALTH
ceptives, limited availability and-cost re-
Female Life Expectancy at Birth. 1993-94
move them as viable options for many peo-
Years
80.19
ple. In a 1993 survey of St. Petersburg
80
women, almost 34 percent said they use no
75.25
74.3
75
contraception. A 1994 Centers for Disease
72
71.2
Control study in Romania found that the
70
most prevalent method of contraception is
66.5
withdrawal (34 percent) followed by the
65
60
Source: WHO
calendar method (8 percent). Only 14.5
percent of the women studied used "mod-
EU
CEE
Hungary
NIS
Russia
Turkmenistan
ern contraception" such as birth control
pills or intrauterine devices (IUDs).
CEE and the NIS have not enjoyed the
Maternal Mortality
Abortion remains the most frequently
consistent decline in mortality from can-
Maternal mortality rates in the NIS are
used means of family planning. In many
cer in females under 65 that has been
about twice those in CEE and about four
CEE and NIS nations, the rate is as high as
found in other countries of the region
times the'average for the region. Maternal
one abortion for each live birth. Data from
since 1995.
mortality in Romania and Albania fell dra-
1992 show three abortions for each live
The standardized death rate for female
matically after the legalization of abortion
birth in Romania. In St. Petersburg, the ra-
lung cancer in CEE is similar to the EU av-
in 1989. Nevertheless, abortion remains a
tio rose from 2:1 in 1990 to 2.48:1 in 1992.
erage of 6.48 deaths per 100,000 women
major cause of maternal mortality in both
Estonia's rate rose from 1.13:1 in 1990 to
under 65. As in the western countries of
countries.
1.5:1 in 1994. But in several Central Asian
region, the rate in CEE rose in the
In 1990, the maternal mortality rate in
nations, the ratio of abortions to live births
60s. Female lung cancer rates in the NIS,
Tajikistan was 42 per 100,000 live births;
is dipping slightly: In Kyrgyzstan, the ratio
however, were low and stable, with 3 deaths
two years later it leapt to 83. In Georgia,
dropped from .606:1 in 1990 to .588 in
per 100,000 in Tajikistan and 5 per 100,000
the rate rose from 20.5 in 1990 to 50 in
1994. In Kazakstan, the ratio was .975:1 in
in Russia in 1991, possibly because of a low-
1992. A portion of the increases is probably
1990 and .88:1 in 1994.
er smoking rate among women.
due to better reporting systems, but real in-
Mortality from cancer of the breast, in
creases in maternal mortality arise from
Lifestyles
contrast to most other major causes of
deteriorating socioeconomic conditions,
Where information is available, the evi-
death among women. is lower in CEE and
limited access to safe and effective health
dence shows that the prevalence of smoking
the NIS than the rest of the region. The EU
services and other factors. Still, it is impor-
is still far lower for women than for men.
average is 20 deaths per 100,000 women
tant to note that at the same time, several
The relatively greater rates of death attrib-
under 65, but the CEE average is 16 and
nations report decreases in maternal mor-
uted to smoking among men as compared
the NIS average is 14.5. It appears, howev-
tality, such as Kyrgyzstan, whose rate went
to women reflect the usually lower smoking
er, that breast cancer may more often reach
from 73 in 1990 to 43 in 1994.
prevalence among women. In Albania for ex-
an advanced stage before being detected.
Only in Georgia, Kyrgyzstan and Kazak-
ample, 7 percent of women smoke, whereas
Estonia has reported that 30 to 40 percent
stan, where most birth-related deaths are
50 percent of men smoke. In Belarus, 37 per-
of all new cases of breast cancer are ad-
due to hemorrhage, is abortion not the pri-
cent of deaths of males ages 35 to 69 are at-
vanced.
mary cause of female deaths associated with
tributed to smoking; only I percent of
The rates for cervical cancer are among
pregnancy and birth.
women in that age group died of causes re-
the highest in Europe: 7 per 100,000, com-
lated to smoking. However, it is feared that
pared with the EU average of 2.3. The NIS
Family Planning
the targeting of young people, particularly
average is slightly lower than that of CEE.
Because of the reliance on abortion,
young women, in tobacco advertising will
cal cancer is decreasing in the rest of
awareness of family planning alternatives
lead to higher smoking rates among women.
ope, mainly as a result of effective early
remains quite limited. Although most coun-
While little is known about the rate of
detection and treatment.
tries report a growing interest in contra-
See Health Status, page 24
COMMONHEALTH
FALL 1996
Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
K
15 Between tradition and modernity:
the dilemma facing contemporary
262
Shirin Akiner
Central Asian women
by newly fashioned languages and Western-style literatures and
histories. Universal compulsory education was introduced, at first at
primary level, later extended to secondary level; medical and social
SHIRIN AKINER
welfare networks were established, as a result of which health
standards were greatly improved and average life expectancy raised by
several years. Society was secularised: Islamic legal and educational
institutions were abolished and Islamic beliefs and practices almost
obliterated. Western-style cultural amenities such as museums, art
galleries, opera and ballet companies and theatres took the place of
Introduction
traditional forms of artistic expression, thereby altering the social,
cultural and intellectual environment. These and the many other
By the end of the nineteenth century a huge part of Asia had been
changes that were set in motion at this time were ideologically driven
brought under Russian rule - in terms of surface area, a territory far
and underwritten by major allocations of human and financial
larger than that encompassed by modern India. The indigenous
resources from the central government. This degree of official support
population was almost entirely Muslim, of the Sunni sect. In the north
(accompanied, from time to time, by ruthless coercion) enabled
(approximately equivalent to the territory of present-day Kazakhstan
substantial progress to be achieved within a remarkably short period.
and Kyrgyzstan) and the south-west (present-day Turkmenistan), the
It was against this background of dynamic transformation that the
local peoples followed a nomadic or semi-nomadic way of life.
campaign for female emancipation - or more precisely, for gender
Religion here tended to be syncretic, only superficially Islamicised. In
equality before the law, in the home, in education and at work - was
the oasis-river belt of Transoxiana (present-day Uzbekistan and
launched. Thus, the struggle to redefine women's rights did not take
western Tadzhikistan), there was an ancient urban culture. The cities
place in a vacuum, but as part of a larger process, and was strength-
in this region had long been famous as centres of Muslim scholarship.
ened and amplified by other reforms that were implemented concur-
There were hundreds of madrassah (religious colleges) and thousands
rently. The basic aims were underpinned by a variety of practical
of (male) students of Islamic law. The focal point of the social as well
measures that gave substance to these new rights and opportunities for
as the religious life of the community was the mosque, at least one of
women. These might appear to have been optimum conditions in
which was to be found in every hamlet or town ward. Folk traditions
which to bring about a radical change in the position of Central Asian
and customs were inextricably intermingled with Islamic practices. At
women. Yet this was only partially achieved: despite the very real
the popular level these were reinforced by the authority and prestige of
improvement in facilities and range of choices, and the greater
representatives of the mystic orders - Sufi adepts, wandering dervishes
visibility of Central Asian women in public life, in the private sphere
(kalendar) and local holy men (ishan) - who were frequently credited
older patterns of behaviour continued to dominate gender relations.
with possessing supernatural powers of healing and soothsaying.
Soviet-style modernity was accepted by the indigenous population, but
Under Soviet rule, Central Asia underwent an intensive process of
subtly transformed (or subverted) so as to accommodate traditional
modernisation. In effect, the region was wrenched out of Asia and
concepts of social order and propriety.
thrust into Europe. Traditional culture. was either destroyed or
Today, since the collapse of the Soviet Union and consequent
rendered invisible, confined to the most intimate and private spheres.
disintegration of the political and economic framework within which
In the public arena, new national identities were created, underpinned
the modernisation of Central Asia was accomplished, many aspects of
the Soviet legacy are being re-examined. In each of the newly
261
independent states a new phase of nation building has been initiated
and a redefinition of the national identity is under way. Traditional
cultural and social values are now being emphasised and Islam is
again beginning to play a prominent role in public life. At the same
264
Shirin Aldner
Contemporary Central Asian women
263
separate study. However, they do still share a sufficient number J:
common features - in large part the legacy of a shared Soviet
time, this region, which until very recently had almost no direct access
experience - for it to be possible to make some valid generalisation
to non-Soviet sources of information, is suddenly experiencing a flood
about their present situation. This may not continue to be the case/in
of exogenous influences: foreign films and publications, businessmen
the future, but as yet the divergences are quite slight. The issuest that
from all parts of the world, tourists, international civil servants, aid
affect the position of women in the settler communities are rather
workers and missionaries (representing every shade of Islam and
different and it is beyond the scope of this paper to consider these
Christianity, as well as other faiths or sects such as the Baha'i and
groups. Likewise, indigenous peoples such as the Bukharan Jews, who
Hare Krishna) are introducing new ideas and helping to shape new
have a different cultural background from the majority of the popula-
aspirations. Attempts at economic and political reform are also
tion, are not covered here.
creating an impetus for change.
The emancipation movement was one of the defining elements of the
ideological construction of Soviet Central Asian identities. It is not
Central Asian women in pre-Soviet society
surprising, therefore, that as part of the current, post-independence
Central Asia was incorporated into the tsarist empire over a period of
process of refashioning national identities, the validity of the Soviet
some 150 years, beginning with the creeping annexation of the
View of gender relations is being called into question. However, the
Kazakh steppes in the early eighteenth century and ending with the
situation is in flux. It is by no means clear whether the newly
subjugation of the Turkmen tribes in the deserts of the south in the
independent Central Asian states, individually or as an integrated
late nineteenth century. Russian policies towards their new subjects
group, will choose to remain within the European socio-cultural orbit
varied over time and from one area to another, but, in general, they
that they have inhabited for the past half century, or whether they will
were less interventionist than those of other European colonial
seek to associate themselves more closely with their earlier, Islamic/
powers. The tsarist government was mainly concerned with the
Asian heritage. Central Asian women themselves are caught between
creation of an effective administrative apparatus and the development
conflicting impulses: some feel the need to return to their 'authentic'
and exploitation of the economic potential of the region. The local
roots, with a renewed emphasis on traditional domestic obligations;
rulers were generally deposed (in most cases to be coopted into the
others, to continue along the road to greater personal independence
service of the new regime), but the emir of Bukhara and the khan of
and freedom of choice. The great majority, however, would like to
Khiva were allowed to retain semi-independent status. Even in the
retain the balance between tradition and modernity that was reached,
areas that came under direct Russian rule, there was very little
slowly and sometimes painfully, during the Soviet period. The dilemma
interference with traditional institutions. In the legal sphere, the most
that now confronts Central Asian women, poised between two value
serious crimes were transferred to the jurisdiction of the Russian
systems, subscribing in part to both, but not wholly to either, can only
courts, but in all other cases sharia (Islamic canon law) and adat
be understood in the context of the rapid, enforced, and not fully
(customary law) continued to regulate the lives of the indigenous
internalised, transition from a pre-modern to a modern society. It is
population. Although some Russian and Russo-native schools were
therefore necessary to take a broader chronological perspective when
opened, education, too, remained predominantly Islamic.
dealing with this region than with other parts of the former Soviet
Information on pre-Soviet Central Asian society (or more accurately,
Union, where the discontinuities have not been so profound. Hence,
societies, since there were many different groupings, all of which had
this paper begins by briefly reviewing the position of Central Asian
their own traditions and customs) is very sparse. Moreover, it is almost
women in the pre-Soviet period; it then looks at the relevant aspects of
entirely confined to the 'outsider's' view, as recorded in the accounts of
the Soviet emancipation movement; and, finally, at the challenges that
tsarist officials and ethnographers, West European and American
are confronting Central Asian women in the post-Soviet states.
travellers, and Soviet field researchers of the 1920s.¹ The evidence they
The term "Central Asian women' is here used to refer collectively to
present is valuable, but it is incomplete, and informed by very
the women of the titular peoples of these states, namely, the Kazakhs,
particular cultural biases. Inevitably, this has given rise to misunder-
Kyrgyz, Tadzhiks, Turkmen and Uzbeks. Ideally, were space to
permit, each of these national groups should form the subject of a
Contemporary Central Asian women
265
266
Shirin Akiner
standings and distortions. Indeed, such material generally reveals more
about the prejudices and ideals of the writers than about Central Asian
In urban communities, girls and women led a segregated existence,
perceptions of their own society. However, despite the inadequacies of
contact with males being restricted to close relatives. Within the family
these sources, it is nevertheless important to review the picture they
home they had their own quarters; when they went out, they wore a
provide of Central Asian life at this period, since this construct has
cloak-like over-garment (parandzha) and a waist-length horse-hair
formed the basis for two, mutually contradictory, mythologising
veil (chachuan) which concealed their faces. In nomad and semi-
projects: that of the Soviet activists, who used it to promote a negative
nomad communities, and possibly in remoter settled areas, women
image of traditional society; and that of anti- and post-Soviet national-
were not veiled, although they did wear some form of headgear which
ists, who created from it an idealised image of a 'golden age',
also covered part of their upper body. They did not have segregated
uncorrupted by Europeanising/Russifying influences, and hence an
dwellings, but there was a strict division of labour which served to
inspiration, if not a model, for the future development of the region.
mark out the boundaries of male and female space. Given the paucity
In this period (that is, the nineteenth century), large extended
of source material, it is impossible to gain a coherent picture of
families were the norm amongst nomads as well as sedentary peoples.²
regional, social and economic variations. It is generally supposed that
Several married groups, spanning at least two generations, would form
women in nomad communities enjoyed a greater degree of freedom.
a single entity, living, working and, in the case of the nomads,
This may not have been the case at the lower end of the social scale,
migrating, together. Marriages were arranged by close relatives in
but amongst the ruling elites, women appear to have been able to act
accordance with the rules of Islamic and customary law; neither the
with a substantial degree of autonomy.⁶ In settled communities,
bride nor, generally, the bridegroom had any say in the choice of their
women were probably subjected to greater formal controls, although
future partner. There was frequently a considerable difference in age
those who were skilled artisans could possibly acquire some indepen-
between husband and wife, since the financial obligations incurred by
dence through membership of craft guilds.⁷ By the early twentieth
the male were very heavy, especially the payment of the 'bride price'
century, there were some facilities for the education of girls. For the
(kalym); only young men from the wealthiest families could afford
most part, these took the form of elementary religious schools run by
this. The minimum age set by Islamic law at which a girl could be given
the wives of the local mullah (religious functionary). In middling and
in marriage was nine years. Islamic law permitted a man to be wedded
upper-class circles women received a fuller education; a few became
to up to four wives at any one time (on condition that all were treated
accomplished literary figures in their own right.⁸
equally), but local practice in some places allowed many more.³ Con-
Almost nothing is known about intra-family relationships and the
cubinage was also not uncommon. In theory, both husband and wife
way in which they affected the position of women. By analogy with
had the right to initiate a divorce, but in practice it was invariably the
societies that have similar traditions (for example, in Afghanistan and
husband who took such action.
Pakistan) and also with modern, post-Soviet family structures, it seems
reasonable to assume that although there was strong patriarchal
Female members of the family made an important contribution to
the family economy, producing foodstuffs, clothing and furnishings.
control, and overall gender asymmetry in terms of authority and
However, child-bearing was probably their most important function.
prestige, within their own domain women had parallel hierarchies that
Large numbers of sons were considered to be vital for the security and
were as rigidly ranked and almost as powerful as those of the male
world. Moreover, as wives, and the mothers of sons, women would
prosperity of the household, but proverbs suggest that daughters were
regarded as a burden.⁴ Female mortality was very high;⁵ this was
have been able to exert very considerable influence not only within the
probably owing to frequent pregnancies starting from a very young
family unit, but also in external affairs.
age, but it is possible that girls were given less care and nourishment
than boys. Medical help was minimal, for the most part restricted to
Soviet gender politics
the services of local holy men who were credited with supernatural
healing powers, occasionally enhanced by some knowledge of tradi-
In the aftermath of the Russian revolution, Central Asia, as other parts
tional remedies.
of the tsarist empire, was swept by civil war. The main contenders
were various Slav military and political factions, but in some areas
intemporary Central Asian women
267
268
Shirin Akiner
ntingents of foreign (mainly British) interventionists played an
tive role; there were also nationalist movements that sought to
republics. 12 This helped to dilute further the traditional culture and to
ablish autonomous states in Kazakhstan and Kokand, and amor-
accelerate the process of social and economic change.
ous bands of rebels, known as basmachi, under the leadership of
al warlords. By 1920, Soviet power had been firmly established in
Creating the legal and operational infrastructure
st areas, though the basmachi continued to offer a guerrilla-type
Ideologically, the campaign for the emancipation of Central Asian
sistance for almost a decade longer. They claimed to be fighting a
women grew out of Russian Marxist feminism, drawing inspiration
ply war' in defence of Islam and traditional values. Although they
and moral support from leading activists such as Nadezhda Krups-
rely represented a serious military threat, their influence amongst the
kaia, Klara Zetkin, Inessa Armand and Aleksandra Kollontai (who is
ligenous population was so strong, especially in the 1920s, that the
sometimes credited with being the instigator of the movement in
viet authorities were forced to temper their reformist zeal with a
Central Asia). 13 The project was organised and monitored by the
gree of caution, and to delay for some years the full implementation
central organs of the Communist Party in Moscow. From the earliest
programmes such as the emancipation of women and the campaign
days of Soviet rule it was regarded as a strategic priority. There were
ainst religion.
three main reasons for this. Firstly, there was genuine horror and
Nevertheless, a number of measures were introduced at this time
disgust at the social injustice: to Russian eyes, the treatment of Central
ich laid the foundations for later developments. The most impor-
Asian women in traditional society seemed tantamount to slavery.
it of these was the National Delimitation of 1924-5, whereby
ministrative-territorial units were created on the basis of the ethno-
Secondly, there was a political imperative to create a 'surrogate
guistic affiliations of the main indigenous peoples. Two of these
proletáriat to engage in the class war and also the related war against
religion. 14 Thirdly, there was an economic necessity to draw women
its, Uzbekistan and Turkmenistan, immediately acquired the status
into socialised production.
full Union republics, while Tadzhikistan, Kazakhstan and Kyrgyz-
During the first years of the emancipation campaign (c. 1918-26),
n were elevated to this status some years later. These formations
the main emphasis was on the creation of an organisational infrastruc-
re entirely new, with no basis either in the tsarist provincial
ture. One aspect of this was to establish a legal framework that
risions or in the pre-colonial khanates. The reasons for this exercise
codified women's rights, as well as the measures that could be used to
territorial division are debatable, but certainly it was more suc-
enforce them. Islamic courts, using the sharia and adat legal systems,
sful in consolidating the main ethnic groups within a single unit
functioned alongside Soviet courts until 1928, but their powers were
in were similar boundary-drawing projects enacted by other colo-
circumscribed and in some areas of family law they ceased to have any
I powers in Asia and Africa. Without any movement of peoples, an
jurisdiction in the early 1920s. Laws and decrees passed by the state
crage of some 90 per cent of the Uzbeks, Turkmen, Kazakhs and
took precedence over the provisions of all other codes. In 1918, the
rgyz were included within the borders of their respective titular
official registration of marriages, births and deaths was made compul-
its.9 The Tadzhiks fared less well: they were so closely intermingled
sory. Also, the option of having recourse to Soviet divorce law instead
:h the Uzbeks that it was impossible to make an equitable territorial
of the sharia code was introduced, in an effort to give women greater
ision of the land they both occupied; the new borders deprived
protection. Between 1921 and 1923, laws were passed banning such
m of the historic centres of Bukhara and Samarkand, and, as a
practices as polygamy, the payment of kalym and marriage without
ult, over a third of the ethnic Tadzhiks were brought under Uzbek
isdiction. 10 In addition to the indigenous Central Asian peoples,
the consent of the bride; the minimum age for marriage for girls was
set at sixteen years, for boys at eighteen years. Any violation of these
re was already a sizeable Slav (mainly Russian) presence in the
laws was treated as a criminal act and subject to severe penalties. The
ion;¹¹ the percentage share of the titular people in the total
land and water reforms of 1925-9 gave women an independent
bulation of each of these republics decreased. during the first
entitlement to a share of these resources, thereby emphasising their
ades of the Soviet period owing to the constant influx of migrants
autonomous status in law and in society. Great efforts were made to
m other parts of the Soviet Union, especially from the European
publicise these new legal provisions: the laws were translated into the
ontemporary Central Asian women
269
270
Shirin Akiner
ocal languages and the texts disseminated widely. Public meetings
Casting off the veil
nd rallies were held to explain women's civil and constitutional
ights. Moreover, Central Asian women were urged to take an active
The decision to intensify the emancipation campaign by initiating the
art in the legal process. Several were given basic training in Soviet
mass unveiling of Central Asian women was taken in Moscow in the
aw and attached to the courts as People's Assessors. Later, longer
autumn of 1926. 20 The organisation and preparatory propaganda
courses were provided and towards the end of the 1930s they began to
work was delegated to specially constituted regional party committees,
enter the judiciary. 15
but the overall strategy continued to be formulated and directed by the
Another aspect of the work of these years was the training of local
central authorities. By this time some 25,000 Central Asians had
cadres. The first activists were almost all young Russian
joined the party and almost 55,000 were members of the Young
communists; few of them had any knowledge of the local languages
Communist League; thus there was a body of 'shock troops' in place
or customs. Gradually, however, from about 1925 onwards, they
to carry out the operation. 21 In Uzbek it was known as the khudzhum
were joined by Central Asian supporters. These were mostly young
(the attack), and indeed it was conceived in terms of a military
girls from poor backgrounds who, for one reason or another, had
exercise. The key target areas were the densely populated cities of
become isolated from their families; they joined the Communist Party
Uzbekistan, where the practice of wearing the veil was most deeply
and became actively involved in the emancipation movement. 17 By
entrenched.
1920, a number of women's sections (zhenotdely) of the Communist
The first large-scale public displays of unveiling took place in 1927,
Party had been organised in Central Asia. At first they made little
on International Women's Day (8 March). Preliminary estimates
impact on the lives of the indigenous population, but they were later
claimed that on that one day 8,500 had cast off their parandzha and
to play an important role in strengthening and consolidating the
chachvan and ceremonially incinerated them on giant bonfires. 22 In
emancipation movement. Much of the practical support and training
reality, the figure of those who unveiled was far lower; moreover, of
for Central Asian women in this period of transition was channelled
those who did make this gesture, many, including several Young
through these bodies; they also acted as watchdog committees,
Communist League members, redonned the veil the following day.
monitoring working conditions and ensuring that local officials and
However, this did not deter the party-state authorities. The wearing of
employees fulfilled their statutory obligations towards women. They
the veil was not banned by law (although some activists were in
were likewise responsible for ideological education and were much
favour of this), but a variety of so-called 'administrative' measures
involved in consciousness-raising activities among the local women.
were used to further the campaign. Special privileges were given to
One of the most important areas of the work of the women's
women who discarded the veil; the husbands of those who did not
sections was the organisation of social clubs exclusively for women.
were liable to be penalised. 23 In some enterprises it was a condition of
Here they were able to provide a secluded, protected environment in
employment that women should be unveiled. On occasion, more
which Central Asian women could feel at ease outside their own
ruthless methods were used; women were intimidated into unveiling,
homes. The first such club was established in the old quarter of
or unveiled by force.24 Meanwhile, there was ceaseless ideological
Tashkent in 1924; others soon appeared throughout the region, even
indoctrination through newspaper articles, films, posters, lectures and
in remote, rural areas. 18 The clubs offered a range of medical, legal
even house-to-house visits. 25 The results of these efforts was that by
and educational services; other activities included sewing and reading
the mid-1930s it was increasingly rare to see a fully veiled woman.
circles; amateur dramatics, devoted mainly to the performance of
However, in country areas or in the old quarters of the cities, women
playlets on contemporary themes; consultations on nutrition, hygiene
continued to cover their heads and shoulders with large headscarves.
and child care; and also lectures, film shows and concerts. 19 Given the
The khudzhum was a definitive episode in the social transformation
very controlled and segregated conditions of female existence in
of the region. To the Russians, the parandzha symbolised everything
Central Asia at the time, the clubs were a remarkable innovation.
that they were fighting to eradicate: oppression, ignorance, injustice
They represented the first tentative step towards women's full partici-
and human degradation. However, from the little contemporary
pation in public life.
and circumstantial evidence that is available, it would seem that, for
Contemporary Central Asian women
271
272
Shirin Akiner
Central Asians, the veil had a very different range of associations. It
was a protection against unwanted contact with strangers and also
was to remedy this situation. Special ABC (likbez) courses were set up
against the physical grime of the environment. It could be, too, a
in railway coaches, tents, factories and every other conceivable venue.
status symbol, indicating social standing. 27 Most importantly of all, it
Great efforts were made to reach the female population. The women's
was a statement about the fundamental ordering of society: the nature
sections were especially active in this field, but the trade unions
of gender relations, the division between public and private space, the
(profsoiuzy), Young Communist League and other socio-political
conventions of civility. For the Russians, the success of the khudzhum
organisations also contributed to the campaign. At the same time, the
was an ideological victory. For the Central Asians, it was a defeat and
network of schools and teacher-training colleges was expanded, while
a brutal rape: the honour and dignity of the community was suddenly
the Islamic educational institutions were gradually phased out; by
and monstrously violated. No other measure of Soviet policy - not the
1927, the entire educational system had been Sovietised. 31 In the
closure of the mosques, the sedentarisation of the nomads, collectivisa-
larger towns and cities most of the schools were co-educational, but in
tion or the purges provoked such violent and outspoken resistance.
rural areas many families refused to allow their daughters to attend
Even senior party officials at first refused to allow their wives to
mixed establishments. Fully integrated education was not achieved
unveil. 28 Women who did throw off the parandzha were often
until the 1930s.
rejected by their families. More than a thousand unveiled women were
Primary schooling was made compulsory for boys and girls alike by
murdered, either by their relatives or by the basmachi, in these years.
about 1930. This was later expanded to an eight-year (incomplete
It was not, however, only men who were opposed to the khudzhum.
secondary) course;³² eventually an optional two to three years (higher
Published Soviet sources generally present the reaction of Central
secondary) were added. Central Asian girls began to embark upon
Asian women to the campaign to cast off the veil in very enthusiastic
tertiary education in significant numbers in the late 1930s and there-
terms. Occasionally, though, there are hints that there were some who
after to enter the professions, particularly law, medicine, teaching and
were prepared to speak out openly against it.³⁰ However, the terror
scientific research. Nevertheless, in the 1970s the proportion of
that was unleashed in the 1930s effectively put an end to any further
Central Asian women with higher education was still considerably
opposition. The trauma of the khudzhum was suppressed, buried in
lower than the average for the Soviet Union as a whole. 33 The chief
the sub-conscious, as were so many of the other tragedies of this
obstacle to raising the level of attainment was the tendency of Central
period. A new generation of women grew up in a world in which
Asian girls to leave school early in order to marry. Some later returned
Soviet values had already become the accepted norm: for them, the
to full- or part-time education, but the majority did not progress
discarding of the veil took on the significance of a rite of passage that
beyond the minimum school-leaving qualifications.
marked the entry into a new era of progress and enlightenment.
School was not only the place where a general educational pro-
Concomitantly, the former way of life was made to seem very remote,
gramme was provided; it was also the channel through which the
alien and primitive, an attitude which facilitated the inculcation of a
values and goals of communism could be inculcated in the younger
negative evaluation of traditional society as a whole.
generation. The educational process was also used to challenge
inherited conventions regarding the role of women in society. As one
former Soviet citizen put it, 'they constantly told us that women must
Political and economic mobilisation
be fully equal with men, that women can be flyers and naval engineers
The Soviet authorities regarded education as an essential component
and anything that men can be'.34 Central Asian girls were encouraged
of political and economic mobilisation. In Central Asia, in the early
not only to study, but also to take part in physical training and team
1920s, the level of literacy amongst the indigenous peoples (as
sports; in performing arts such as ballet, acting (on stage and in films)
estimated in Soviet sources) ranged from an average 7 per cent
and singing; and in occupations requiring technical skills such as
amongst the Kazakhs, to just over 2 per cent amongst the Turkmen
tractor driving. Perhaps nothing so vividly illustrates the changes that
and Tadzhiks; in rural areas it was lower, and amongst women,
were taking place at this time as the appearance, in the 1930s, of the
scarcely above 1 per cent. One of the first priorities of the new state
first female parachutists in a society in which only ten years previously
women had been heavily veiled.³⁵
ontemporary Central Asian women
273
274
Shirin Akiner
During the same period, energetic efforts were made to involve
reached 27,000. Anti-religious circles were set up in most enterprises
Central Asian women in the political-administrative process. Female
and about 80 per cent of the members were local women.³⁸
lelegates were elected to represent their communities in public meet-
The result of this onslaught was that knowledge of the religion was
ngs at local and republican level. Activists were sent for training to
reduced to a minimum. Almost all that survived were some of the
he Communist University, the Turkic School of Soviet and Party
rituals connected with the major life-cycle ceremonies (male circumci-
Work and other such institutions. In the early 1920s, Central Asian
sion and burial rites, for example), and some semi-folk, semi-Islamic
women began to join the party, some no doubt impelled by idealism
practices such as visits to the graves of revered individuals, where
and belief in the reform programme, but others by a realisation of the
prayers and sacrifices were offered up in the hope of securing benedic-
practical benefits that would accrue from such a move. In percentage
tion. Women remained active in keeping such informal aspects of
terms their participation remained low, but actual numbers were quite
Islam alive. So far as more orthodox beliefs and practices were
high, given their lack of previous political experience; in Uzbekistan,
concerned, some of the older generation of women continued to
for example, by the beginning of 1929 there were over 1,000 Uzbek
perform as best they could some of the prescribed ritual prayers and to
women party members.
observe at least a part of the fast of Ramadan. However, few of the
In response to Lenin's injunction that more women should be
generation that grew up after the Second World War maintained this
elected to the soviets, Central Asian women gradually came forward
tradition. Islamic prohibitions on the consumption of pork products
to stand as candidates. However, progress was slow; not only were
and alcohol were increasingly disregarded by Central Asian men,
the women reluctant to take part in elections, but there was much
many of whom spent most of their working lives in multi-ethnic
covert opposition from the male members of the community. Never-
environments, where they were under constant pressure to conform to
theless, the authorities continued to press for an improvement in the
the norms of Soviet society; women, however, protected by the
situation. There was a constant monitoring of the proportion of
privacy of their homes, were able to observe these dietary laws more
women in senior managerial posts, and shortcomings as well as
strictly.3
successes in this field were widely publicised. 37 Positive discrimina-
The first steps to draw women into socialised labour were made
tion was used to accelerate promotion and a quota system was
through women's cooperatives. These were organised in the early
introduced whereby women were allocated approximately a third of
1920s, and represented a half-way stage, enabling women to continue
the posts in government and in party-administrative organs. This,
practising their traditional tasks, such as weaving, sewing and
along with the effusive public acclaim that was accorded to women's
dairying, but outside the family home, in a group environment and for
achievements in other fields such as the arts, sports and science,
financial reward. Special shops and consumer cooperatives were set up
provided a high degree of female visibility in society. It created a
through which women could sell their products directly, without the
range of positive, 'progressive' role models with whom Central Asian
intervention of middlemen. Towards the end of the decade there was
girls could identify.
a proliferation of light industrial enterprises, and increasing numbers
Another important aspect of the political mobilisation of Central
of local women found work in factories concerned with food-proces-
Asian women in these years was their role in the anti-Islamic cam-
sing, silk-spinning and the production of garments and hosiery. Heavy
paign. Since women were regarded as the chief victims of religious
industry was developed somewhat later, but relatively few female
oppression, it was they who were selected to take a leading part in the
workers were employed in this sector since conditions were considered
campaign to eradicate Islam. The mullahs were equated with the
to be unsuitable for women for physical as well as psychological
wealthy peasants and represented as both class enemies and the
reasons.
enemies of progress. Branches of the Godless League (later renamed
By contrast, the agricultural sector was regarded as eminently
the 'Militant Godless League') were set up in all the Central Asian
suitable for female labour and a concerted effort was made to draw
republics. They grew rapidly in the frenzied, fear-dominated atmo-
Central Asian women into the work-force. In the north, this was
sphere of the day. In Uzbekistan, for example, in 1928, 3,500 Uzbek
mainly devoted to various forms of animal husbandry, while in the
women were members of the League; by 1931, the number had
south, the chief areas were cotton cultivation and silk-worm breeding.
Contemporary Central Asian women
275
276
Shirin Akiner
Women's involvement in the development of the cotton-growing
This is less surprising than it might at first appear: Central Asian
industry was the most problematic area, and subsequently attracted
women (and men), confronted with the headlong pace of change in
much adverse criticism. By 1934, women were involved in almost all
the public sphere, reacted by holding on yet more firmly to the order
aspects of the production of the cotton crop; however, the majority
they knew in the domestic sphere, where they had a greater degree of
were employed on a seasonal basis for the back-breaking job of
control. Thus, Central Asian women did not in fact assume the role of
harvesting the cotton by hand.⁴¹ Their achievements in helping to
a revolutionary force to destroy traditional society. Rather, they
secure 'cotton independence' for the Soviet Union were praised in the
colluded in its preservation: by accommodating external pressures
mass media and those who exceeded their set norms were rewarded
through the adoption of additional identities, appropriate to the
with medals and special privileges. The other side of the coin was that
public sphere, they deflected intrusions into the private domain,
work conditions in the plantations were very arduous and that the
thereby protecting the integrity of the older disposition of family roles.
women were, in effect, used as human tools.
This is not to imply that the public identities were a sham; on the
Central Asian girls were taught that it was their right, and also their
contrary, all the indications are that they were the product of
duty, to seek useful and gainful employment in the public sector. As
genuinely held perceptions and aspirations. However, they were
adults, most of them were to have some experience of work outside
confined to one area and were not permitted to penetrate beyond that
the home, but the period of employment was often quite limited,
space, and thus could not bring about the radical change of society
owing to the almost continuous cycle of child-bearing and child-
that had been anticipated.
rearing. Moreover, the goal of gender equality at work was never fully
attained. Here, as in other parts of the Soviet Union (and in many
Family and community
other countries, too), employers were reluctant to take on female
workers on the grounds that they were less productive than their male
Family and community relations were (and remain) the most con-
counterparts; there were also complaints about the length of the
servative areas of Central Asian society. Even in cities, amongst the
statutory maternity leave. Women were frequently (and illegally) paid
most educated and travelled groups, there was relatively little struc-
less for the same work as men; they were also not given as many
tural ange during the Soviet period; in rural areas, social conven-
opportunities for in-service training to raise their qualifications. As a
tions were even more strongly preserved. Hence, there were
result, many remained trapped in low-paid, unskilled or semi-skilled
perceptible continuities with the pre-Soviet period. The extended
jobs. This made them vulnerable to redundancy when more efficient
family networks remained powerful. The actual size of cohabiting
technology was introduced.⁴³
units fell sharply, owing to such pressures as the nature and avail-
The main motivation for the economic mobilisation of Central Asian
ability of accommodation, changes in employment patterns (including,
women was undoubtedly the need to boost the labour force at a time of
of coûrse, collectivisation) and the general regimentation and homo-
major industrial and agricultural expansion. However, it was seen,
genisation of life under Soviet rule. Nevertheless, close contact was
too, as a means of reinforcing the emancipation movement, since it
retained amongst the members of the larger family even when they
gave women the possibility of achieving financial independence
were physically dispersed through frequent (wherever possible, daily)
through waged work. It also provided them with an opportunity to
visits and telephone calls.44 Adult sons would often continue to live at
experience new conditions, and to come into direct contact with people
home even after they had married. In such cases, it remained
from different social and ethnic backgrounds. In most parts of the
customary for them to hand over their wages, as well as any earnings
world, the move to paid employment outside the home has had an
of their wives, to the head of the family to use as he pleased. The
important impact on the way women regard themselves, as well as on
absolute authority of the father was mirrored by the less formal,
their position in the family and in the broader community. In Central
though perhaps psychologically yet more compelling, authority of the
Asia, however, this did not happen to any significant degree. There was
mother. In accordance with the Islamic precept, 'Happiness lies at the
scarcely any redefinition of gender roles, scarcely any extension of the
feet of the mother', sons treated their mothers with huge respect,
traditional kin-based networks of friendship, solidarity and support.
regarding her every word as a sacrosanct command. This honoured
278
Shirin Akiner
Contemporary Central Asian women
277
support from other female members (including, sometimes, the
status gave her as great a degree of control over their lives, and over
mother-in-law herself) and normally the bride was assimilated into the
the lives of their dependents, as she herself wished to exercise.
new environment quite quickly.
Within the family unit there was a high degree of order. This
Community relations usually involved extended kin-networks as
expressed itself through a strong, almost ritualised, code of civility
well as neighbours. There was a high level of group solidarity,
which regulated every aspect of behaviour. Children were socialised in
reinforced through numerous joint activities. The practical prepara-
this environment to accept their place in the hierarchical structure,
tions for such events as a wedding or a wake were undertaken by the
with the attendant obligations, responsibilities and privileges. Con-
community as a whole, thus relieving the strain on the individual
structions of masculinity and femininity were internalised at this stage
family. These were often huge affairs, requiring vast quantities of food
and gender roles assigned. A strong sense of sibling solidarity was
(80 kg each of meat and rice were not uncommon provisions), chairs,
fostered, as well as respect and affection for the older members of the
tables, crockery, and pots and pans. The utensils and furniture were all
family. Habits of obedience, conformity and submission were fostered
provided from the communal stock. Women, whatever their status and
in girls and boys alike; the latter may have had greater freedom of
professional qualifications, would take their place at the stove and the
action outside the home, but within the family both genders were
chopping board. These occasions provided an important opportunity
equally bound by strict conventions. Discipline was maintained
for gossip to be exchanged, a family's reputation and standing in the
through positive encouragement in the form of praise and little gifts.
community to be monitored, problems to be aired, and advice to be
Corporal punishment was very rare: patriarchal authority was clearly
given and received. Thus, the community helped to offset the possible
enough understood, even by very young children, for a warning tone
isolation of family life. In cases of major family disputes, the senior
of voice and a stern demeanour to serve as a sufficient reprimand.
female of the community would act as counsellor and arbitrator,
There was still a residual preference for sons, though in terms of care,
guiding the different sides towards a compromise. The community also
affection and opportunities, daughters no longer appeared to be less
provided additional opportunities for socialising children in traditional
privileged than sons.
values, supervising them when they were out of the home and reinfor-
On marriage, brides moved to the patrilocal residence. From the
cing habits of civility, consideration and courtesy. The positive aspect
outset, they were expected to conform to the conventions of their
of community life was that it provided a highly effective, informal and
husband's home. Attitudes towards the newcomer were often harsher
very sensitive social security network. The negative aspect was that it
and more demanding than towards the children of the family. For the
was very difficult to escape from its all-embracing control.
young bride, the mother-in-law's word was final. If there was a
dispute, the husband would almost always side with his mother, even
if he sympathised with his wife's position, and this could cause the
Marriage and fertility
young bride to feel very isolated. Her defencelessness was underlined
It has become an accepted axiom, confirmed by evidence from all over
by the fact that her husband would normally take control of any
the world, that rises in female literacy rates are accompanied by a
money she might earn, giving back to her only what he considered to
decrease in birth rates. Central Asian women, however, have to date
be an adequate allowance (thereby defeating the Soviet aim to give
proved to be an exception to this rule. Under Soviet rule the crude
women economic independence through waged work). A girl would
birth rate remained very high. Consequently, the age structure of the
often not be able to visit her family without her husband's permission.
titular peoples of the Central Asian republics continued to conform to
In case of a complete marital breakdown, however, she would
the model of the broad-based demographic pyramids of countries such
normally return to her parental home. There was no social stigma
as India, Kenya and Nigeria, with well over half the population under
attached to divorce or to remarriage. A wife's status in the family
twenty years of age. There are a number of reasons why this pattern
improved with time, with the birth of children, also with the arrival of
was maintained, but principally it was the result of a convergence
other daughters-in-law, the wives of younger sons. Initially, the
between pro-natalist attitudes in traditional and Soviet society.
experience of learning to live in the new household could be difficult.
Custom, mediated through family and peer pressure, ensured that
However, there was usually a great deal of encouragement and
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marriage, preferably at an early age, remained the natural goal for
which also helped to perpetuate the tradition of large families. Close-
Central Asian girls. As in the past, children were regarded as a
knit kinship networks ensured that there were generally other females
blessing, the foundation of the family's happiness and prosperity.
available to help with child care and other domestic chores. 48 Women
Moreover, within the family unit, the young wife's status was to a
who wished to pursue professional careers, therefore, did not have to
large extent still determined by the number of children, especially
make a choice between having a family or continuing to work. At the
boys, that she produced. At the same time, with improved medical
same time, the close proximity of senior relatives meant that they were
care, female life expectancy rose and hence the period of fertility was
able to exert continued psychological pressure on the younger wives to
extended. Since infant mortality was likewise reduced, the result was a
produce children. This, coupled with a high level of ignorance about
high level of natural increase. The financial strain of a large family was
sexual matters, very little medical counselling on family planning and
relieved by the state provision of child and maternity allowances. The
a very inadequate supply of contraceptives, meant that even those who
lump sum allocation at birth, as well as the monthly welfare benefit,
wished to limit their pregnancies were unable to do so.
increased in accordance with the number of children. Thus, a mother
who had only one child received a considerably smaller sum for that
Ill-health, domestic violence and self-immolation
one child than she did for her fourth or fifth child; for the eleventh
child and above, the benefits were quite large. In the European
For most of the Soviet period the campaign for the emancipation of
repúblics, where wages were generally higher and families smaller,
Central Asian women was described in very positive terms, with great
these allowances were not of great importance. In Central Asia,
emphasis on the achievements, and a glossing-over of mistakes and
however, they could constitute a substantial contribution to the family
unfulfilled goals. In the mid-1980s, however, during the period of
budget.
perestroika and glasnost, a more critical attitude began to emerge.50
There were also other forms of state support for motherhood. There
One of the issues that attracted wide coverage, both in Moscow and in
was a statutory obligation for employers to provide sixteen weeks'
the Central Asian republics, was the use of harmful substances to
paid maternity leave, as well as entitlements to further unpaid
sustain the cotton monoculture, and the effect that this was having on
maternity leave without loss of job or seniority. The status of mother-
the health of the workforce, the great majority of whom were women
hood was reified by the ceremonial award of honours, medals and
and schoolchildren (who every autumn spent several weeks assisting
privileges. The highest rank, that of 'Heroine Mother', was bestowed
with the cotton harvest). It was revealed that a highly toxic chemical,
on those who had borne and reared ten or more children. In Uzbeki-
similar to Agent Orange, was being used to defoliate the cotton.
stan alone, by 1987 over 100,000 women had been given this title;
Immediately after the spraying had been completed, women and
over a million had been awarded the order 'Mother's Glory' (seven to
children were sent into the fields to pick the cotton with their bare
nine children) and over 2 million that of 'Medal of Maternity' (five or
hands, without any protective clothing. Another malpractice was the
six children). The holders of these honours were treated with great
use of huge quantities of chemical fertilisers, pesticides and herbicides
respect, their maternal achievements noted in the press and praised in
to boost the yield; these then leached into the soil and water and in
party reports, alongside accounts of industrial and agricultural suc-
turn contaminated the food chain. 51 Concerns were voiced at this time
cesses. Thus, motherhood, or rather, the child-bearing aspect of
as to the possible long-term effects of measures such as these on the
motherhood, was set on a par with other important contributions to
health of the population. Some feared that irreparable damage had
society. By contrast, the domestic routine of child-rearing was re-
already been inflicted on their immune systems; the term 'ecological
garded as an obstacle to full emancipation, hence to be eradicated as
AIDS' was coined to describe this condition.
soon as possible through the provision of a full range of socialised
Some of these reports undoubtedly owed more than a little to
welfare services. In fact, this goal was not realised and Central Asian
journalistic licence. There was also an element of political manipula-
women continued to be childrearers as well as child-bearers for a large
tion, with this and other examples of environmental mismanagement
portion of their lives.
being used by the liberal-reformist lobby as a stick with which to beat
In addition to these pro-natalist measures, there were other factors
the Soviet system as a whole. Until further, unbiased, medical research
Contemporary Central Asian women
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Shirin Akine
has been carried out it will be impossible to assess the full gravity of
there is no evidence that they sanctioned human immolation. Inte
the situation. It is, nevertheless, beyond dispute that there was gross
views with the local population revealed a wide variety of reasons
exploitation of women and children and that this was causing major
at least triggers, ranging from persistent bed-wetting among young
health problems.
teenagers to quarrels with best friends; from aspersions cast on the
More attention also began to be paid to shortcomings in the
virginity of a young bride to arguments over the payment of the bride
domestic sphere. As elsewhere in the Soviet Union, there was criticism
of the heavy 'double shift' of work that women had to endure. In
price. The method of death, by the girl dousing herself with oil, thei
setting it alight, was excruciatingly painful; the very few who survived
Central Asia, the burden was the more onerous owing to the preva-
were dreadfully disfigured. Yet this did not seem to act as a deterrent
lence of large families, relatively low provision of communal amenities
but rather as a goad to others to take more care with the preparations
such as crèches, canteens and laundries, and, outside the main cities,
Visitors to areas where there had been recent instances of self
the chronic scarcity of labour-saving devices such as washing machines
immolation described an atmosphere of contagious, almost physically
and electric vacuum cleaners.⁵² Concerns were voiced, too, about the
dangers of frequent, closely spaced pregnancies and the debilitating
palpable hysteria. 55 Whether this phenomenon was in any way
effect this was having on the physical and mental well-being of Central
provoked or stimulated by conditions that were specific to the Soviet
regime lust be a matter of speculation. What it does indicate,
Asian women, as well as on the health of the nation as a whole. The
however is that even after more than sixty years of Soviet rule, there
question of family planning began to be raised in public in the second
were areas of Central Asian life that were still unknown and
half of the 1980s, though was soon dropped on account of strong
unfathomable to outsiders.
local opposition.⁵³
At this time, there was also some discussion of the psychological
pressures that were inflicted on women within the confines of the
Post-Soviet readjustments
family. There was little specific mention of physical violence, but
The Central Asians acquired political independence not as a result of a
anecdotal evidence suggested that it was quite widespread, indicating
struggle for national independence, but as a consequence of the
that it was an accepted, or at least acknowledged, feature of marital
disintegration of the imperial power. In January 1992, the govern-
behaviour. The one aspect of domestic violence that did come to light
ments of the new states inherited, almost literally overnight, direct
was the horrifying and baffling incidence of suicide by self-immola-
responsibility for a formidable array of problems. Other former Soviet
tion. According to official sources, in Uzbekistan, in one year alone
(1986-7), 270 girls and young women killed themselves in this way.54
republics encountered similar difficulties, but in Central Asia the
situation was rendered more acute by a number of factors that were
It was generally agreed that the actual figure was probably far higher
specific to the region. One of these was the high level of specialisation
and that many such deaths were being passed off as accidents. The
in the production of primary commodities and the relatively low level
phenomenon appeared to be limited to Uzbekistan and Tadzhikistan.
of industrialisation; these republics were thus more dependent on
Some commentators believed that it was the relentless drudgery of
inter-republican exchanges than were other regions. They were also
women's lives, compounded by oppressive patriarchal attitudes in the
poorer and therefore more reliant on budgetary transfers from the
family, that were to blame; others sought an explanation in a possible
central government to help support their welfare services. The geo-
nutritional deficiency (a lack of protein, for example), which might
graphic location of these states, surrounded by steppes, deserts and
cause depression and disorientation. It was also suggested that the
mountains, and over a thousand kilometres in any direction from an
practice might have its origins in some form of religious belief.
open sea, was an added disadvantage. Moreover, the transport and
However, Islam is categorically opposed to suicide. The more ancient
communication links that had been developed during the Soviet
faith of Zoroastrianism, which in pre-Islamic times had many adher-
ents in Central Asia, did involve the practice of fire-worship, but the
period tied the region to Russia; there were virtually no direct
connections of any sort with the world beyond the borders of the
flame was regarded as holy and pure, not to be defiled by any form of
live sacrifice. Animistic cults regarded fire as a cleansing force, but
Union. The difficulties of transition from Soviet republics to independent
Contemporary Central Asian women
283
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states are today being compounded by social problems. The rapid rate
conformity and solidarity. A form of self-censorship has re-emerged;
of demographic increase is placing ever greater pressure on the
stifling the discussion of potentially controversial questions. Thus, for
resources of the new states. There is a high ratio of dependents to
example, it is acceptable to discuss mother and child welfare, since
wage-earners, thus the rise in unemployment has affected the living
these are matters that relate to the health of the nation as a whole;
standards of a wider section of the population than in the European
moreover, problems in these areas can be blamed (with some justifica-
regions of the CIS, where families are far smaller. The economic
tion) on the shortcomings of the Soviet system. Domestic violence or
deterioration has likewise contributed to a heightening of inter-ethnic
the phenomenon of female self-immolation, however, are issues which
tensions. The settler communities feel threatened and many thousands
do not fit easily into the idealised image of traditional family life; also,
have chosen to emigrate. In some ways this has helped to defuse the
they cannot easily be resolved without the public examination of
situation, but the sudden loss of large numbers of senior managers and
questions that are still regarded as essentially private, falling within
technical personnel has inflicted substantial damage on the nascent
the domain of the patriarchal family. They are therefore treated, as in
post-Soviet national economies of the region.
the pre-perestroika period, as taboo subjects.
The most potentially dangerous effect of the collapse of the Soviet
Union was that it created an ideological vacuum. It was not only that
the economic and administrative framework within which the modern
New parameters for gender relations
Central Asian states had been developed abruptly ceased to exist, but
Nation-building projects in the newly independent Central Asian
that the theoretical justification for their formation was discredited.
states are drawing on three main elements: the reinstatement of
Consequently, the physical boundaries of the new states, and even the
Islamic values as the guiding ethic for society; the rearticulation of the
validity of the national identities that had been crafted during the
national culture by such means as the rewriting of the historical
Soviet period, were suddenly open to question. The result could have
narrative to establish linkages between the pre-colonial past and the
been the instant Balkanisation of the region. However, with the
post-Soviet present, and the reviving of 'authentic' traditional institu-
exception of Tadzhikistan (arguably the most flawed of the Soviet
tions, symbols and concepts of propriety; and the reassertion of
nation-building projects), this has not happened. The instinctive
patriarchal authority through the symbolic identification of the head
response to the threat of chaos has been a reassertion of the most
of state as the 'Father of the Nation'. All three elements are con-
conservative features of society. There has been no transfer of power
tributing to a redefinition of the parameters of gender relations.
to new leaders: on the contrary, it is because of their links with the
The Islamic resurgence in Central Asia began in the 1970s with the
previous regime that incumbent ruling elites are regarded as guaran-
emergence of a small-scale revivalist movement in the Ferghana Valley
tors of stability. Equally, the majority of the population are prepared
(eastern Uzbekistan, southern Kyrgyzstan, northern Tadzhikistan). A
to accept a high degree of authoritarian control in order to guard
second and stronger impetus was provided by a sudden shift in
against the perceived danger of social and regional fragmentation.
government policy towards Islam. Previously, Islam had been con-
In all the Central Asian states, some appearance of political
demned as a pernicious force, inimical to progress. At the end of the
pluralism is currently permitted, but in reality, only those parties that
1980s; however, there was evidence of a more conciliatory attitude.
support government policies are granted official registration. Genuine
This was partly the result of a greater tolerance to religion throughout
opposition movements have been suppressed, either, as in Uzbekistan,
the Soviet Union, but was also an attempt to combat the perceived
Tadzhikistan and Turkmenistan, by formal bans, or, as in Kazakhstan
threat of Iranian influence by fostering a sense of pride in an
and Kyrgyzstan, by indirect, but scarcely less effective, controls (for
indigenous Islamic tradition. More mosques were opened in 1989
instance, by restricting access to the media or creating obstacles to
than in the whole of the previous decade, the public celebration of
registration). Yet even without these curbs, it is unlikely that dissident
Islamic feast days was given official support, and copies of the Qur'an
groups would attract much support. In the late 1980s, their efforts to
and records and cassettes of Qur'anic recitations suddenly began to
draw attention to political and social abuses were welcomed, but
appear in state-run kiosks. The number of Soviet Muslims allowed to
today they are regarded as perilously divisive. The emphasis now is on
perform the haji (prescribed annual pilgrimage to Mecca) rose from
Contemporary Central Asian women
286
285
Shirin Akiner
thirty in 1989 to 1,500 in 1990, and, in general, links with Muslims in
Muslim women's organisations in Central Asia have not so far been
other countries increased. These measures did not result in a mass
very successful. Fledgling 'Leagues of Muslim Women' were founded
return to religion, but they did reintroduce Islam into the public arena.
in Uzbekistan, Kyrgyzstan and Kazakhstan soon after independence.
Islamic symbols and references became an accepted part of life:
However, the Kazakh organisation collapsed within months, owing to
Muslim clerics were accorded a new respect and invited to contribute
financial improprieties in the handling of its accounts; the other two
to the process of perestroika. 56
groups are now also moribund. Schoolgirls and young university
After independence, the re-Islamicisation of the social environment
students have begun to wear the hejab (Muslim headscarf) and ankle-
was used as a substitute for the liberation struggle that had not taken
and wrist-length clothes, but this practice is still rare, especially in the
place. There was a triumphalist fervour in the rash of mosque building
cities; in the Ferghana Valley, a few of the older women have resumed
that took place in the immediate aftermath of the collapse of the
the full parandzha. As yet, however, the veil is still regarded as a
Soviet Union. In Turkmenistan, for example, there were only four
symbol of a personal commitment to Islam. It has not become
mosques open for worship in the 1980s; by 1994, there were 181,
politicised as has been the case elsewhere.
with 100 or more at the planning stage; in Uzbekistan there were 300
While some women are certainly adopting an Islamic way of life of
in 1989, but over 5,000 by 1993.57 There was a similar proliferation
their own volition, in some areas there is a growing tendency for men
of mosques in the other republics. Schools and voluntary bodies began
to impose Islamic norms on women. This is most noticeable in the
to teach the Arabic script (abolished in Central Asia in 1930) and to
Ferghana Valley and in Tadzhikistan. Here it is men who set the
give instruction in reading the Qur' an. Madrassah and Islamic cultural
standards for female modesty in behaviour and dress. It is also the
centres were opened throughout the region. The finance for these
men who decide whether or not women should be allowed to attend
undertakings was provided jointly by local Muslim communities,
the mosque or to play an active role in religious undertakings outside
district authorities and charitable donations from Muslims abroad.
the home. 60 The women here are more vulnerable because not only is
Today, although most Central Asians welcome the reintroduction
the protection offered by the state now much weaker, but usually
of Islam into the public space, the majority do not want it to assume
these women do not know their rights in Islamic law and are therefore
a regulative function: they still feel strongly that religion and the state
unable to argue their case on those grounds.
should be separate. Nevertheless, a core of active and committed
The second element in the post-Soviet nation-building process - that
believers has begun to emerge. Quite a large proportion are from
of a rearticulation of the national culture - has not brought about a
villages and provincial towns, or the poorer quarters of the capital
qualitative change in gender relations, but it has given renewed
cities, but there is also a substantial number of university students
respectability to attitudes and practices that, during the Soviet period,
and young professionals. The proportion of women who actively
were regarded as socially and politically unacceptable. This is most
espouse an Islamic way of life is as yet very small in relation to the
marked in matters concerning the family. The traditional power
total population of each of the five states. However, the fact that they
balance - patriarchal control allied to maternal authority - is now
have so categorically rejected the Soviet model of female emancipa-
acknowledged with a sense of pride rather than decried as a vestige of
tion (and likewise the more recently proffered Western versions) has
primitive practices of the past. This new mood was vividly illustrated
a significance that goes far beyond mere numbers. Some interpret it
by the comment of a young Uzbek, who, when asked recently what
as a portent of an imminent mass return to Islam. It is too early to
were the qualities that had most attracted him to his bride-to-be,
predict whether or not this will happen, but certainly there has been
answered without hesitation, 'That she should be as a floor-cloth to
an upsurge in the demand for a Muslim education for girls. In
my mother, then to my elder brothers' wives, then to me. ,61 The
response to this, several women's madrassah have been opened and
phrasing is,: of course, crude, and more urbane Central Asian males
courses at some of the men's madrassah now accept women. 58
would certainly not formulate their view of their relationship with
Women are also beginning to go abroad for further training to
their wife such terms. However, the very fact that anyone should
Islamic universities in Turkey, Egypt and other Middle Eastern
voice such sentiments in public is in itself a sign of the changing times:
countries.
a decade ago, this would have been inconceivable.
Shirin Akiner
Contemporary Central Asian women
287
288
Other indications of the shift in attitude include a greater readiness
Economic pressures
to admit to the continued existence of a practice such as polygamy:
The dislocation of supplies, services and trade which followed the
this is still illegal, but the fragmentary evidence that is now emerging
collapse of the Soviet Union has had a devastating effect on the newly
suggests that it is quite widespread and, moreover, not regarded with
emergent national economies of the Central Asian states. Prices for
the disapproval that characterised Soviet writings on the subject. 62
industrial and domestic commodities continue to soar; transport net-
The positive aspects of traditions such as the payment of the bride
works have been decimated owing to fuel shortages. Many industrial
price - now usually presented in the form of gifts of clothes, jewellery
and household items - are also stressed. Likewise, participation in
plants have been forced to close down, or to introduce sweeping
redundancies, because of lack of supplies, loss of markets and huge
large-scale family and community functions, formerly frowned upon
debts. Unemployment has spiralled. Welfare benefits, including child
by the authorities, is now regarded as a positive feature of social life.
and maternity allowances, have been increased at regular intervals,
In Uzbekistan, the role of the local neighbourhood (mahalle) in
but have been unable to stave off severe material hardship for large
poverty alleviation and other social welfare projects has been institu-
of the population. Education and medical care have also been
tionalised through the allocation of government funds and the formal
sectors severely affected; standards have fallen dramatically, while the intro- has
recognition of the authority of community elders. Finally, the cen-
duction of 'hidden charges' to services that were formerly free
trality of motherhood is being reaffirmed, but with a telling shift of
further reduced the scope of welfare provision. Poverty and malnutri-
emphasis: during the Soviet period, the maternal role was divorced
tion now becoming serious problems.
from domesticity. Now, the domestic context has been reinstated and
Women are have been the chief victims of the shrinking labour market.
child-rearing is being accorded the same importance as child-bearing.
It is not only the unskilled or semi-skilled workers who have been The
Concomitantly, the role of women as the moral educators of the new
savagely hit by redundancies, but also the trained professionals. of
generation is being highlighted.
The third element, that of the cult of the father-leader, is yet another
quota female employment during the Soviet period have been
system and positive discrimination that operated in abandoned. support
reversal of a fundamental tenet of Soviet ideology. The image of the
whenever there is a choice between employing a male or a
head of state as the loving but stern, wise but generous, head of the
Now, female, the former is automatically given precedence, on the grounds time,
family-nation firmly reinstates the patriarchal discourse. This was
that he is the main breadwinner in the family. At the same
implied in the personality cults that evolved around Soviet leaders, but
in the mass media and the pronouncements of public figures the
in Central Asia-today, especially in Uzbekistan and Turkmenistan, the
features helping to alter social opinion, creating a climate in which 'right
notion has been elaborated far more comprehensively. The concept of
are rather than the shop floor or the office, is regarded as the attitudes
male guardianship has now been re-established as a parameter of
home, for a woman. Even in Kyrgyzstan, where official esti-
private as well as of public life. Society has finally freed itself from the
place' towards working women are still generally favourable, it was were
emasculation imposed by the khudzhum. From a traditionalist per-
spective, it might be said that order and propriety are being restored.
mated the economic crisis has deepened considerably since then worse.
that by mid-1993 almost 70 per cent of the unemployed and
The result has been that gender asymmetry in power and status has re-
women; likely that the present position is a great deal in
emerged in unashamedly vigorous form, giving rise to a rapid mascu-
it is very it is difficult to gain an accurate picture of the situation abstruse,
linisation of the positions of authority. Today, women in Central Asia
However, of these states since, firstly, definitions of joblessness are (a
are not excluded from public affairs, but their participation is depen-
any to conceal rather than reveal the true state of affairs secondly,
dent on male sufferance. 63 Nevertheless, as in other male-dominated
designed that is by no means unique to Central Asia); institution,
societies, individual women, especially those who are closely related to
phenomenon women are often retained on the staff of an enterprise or
the ruling elites, may be accepted as honorary males in the highest
but rately given any work and paid, if at all, a nugatory salary.
echelons of the power structures with relatively little difficulty. It is
those lower down the social scale who are beginning to experience the
female education. pressures Schooling used to be free, compulsory and a
Economic are also beginning to have an adverse effect of on
brunt of gender discrimination.
Contemporary Central Asian women
289
290
Shirin
reasonably high standard. Today, the quality of tuition in the state
year). Since in all five countries the great majority of the titular peop
schools is so poor that those who can afford it send their children to
live in the countryside, it is not surprising that in most areas ther
private schools. These are very expensive. The state schools, too,
been a relatively small fall in the average rate of natural increase
though still nominally free, require so many extra contributions from
the last three decades. The governments in the newly independe
parents that even this form of education is becoming a financial
Central Asian states are beginning to realise the economic implication
burden for poor families with large numbers of children. In these
of this high level of expansion. To date, however, it is only (i)
cases, it is the daughters' education that is sacrificed. The girls become
Uzbekistan that an official family planning policy has been launched
semi-permanent truants, and are often set to work selling assorted
This has involved intensive preliminary research into social attitudes
oddments on street pavements in order to supplement the family
followed by education and information campaigns. The scheme is still
income.
too new for it to be possible to evaluate the likely impact. It is also
There are rumours that in return for a substantial down payment to
difficult to know how the related scheme of (semi-) compulsory pre
the parents, some young girls are being sent to the Gulf states to work
marital medical counselling for young couples will develop. It is
as household servants; this may be utterly untrue, but the level of
intended to raise awareness of health, sex and family welfare issues,
material deprivation is reaching such a point that even if this is not so,
but as it is formulated at present, with the emphasis on producing a
it is already taking shape as a fantasy solution. Female (and, to a lesser
population that is sound in mind and body, there is a hint of an
extent, male) prostitution is on the rise in Kazakhstan and Kyrgyzstan;
underlying eugenic agenda.
for students, it is sometimes the only way of financing their studies. 65
In Kyrgyzstan, questions have been raised in parliament as to the
External influences
desirability of licensing brothels, in order to limit the risk of spreading
sexually transmitted diseases. The majority of those who are involved
In the immediate aftermath of independence, there was an influx of
in prostitution are Slavs and members of other immigrant groups, but
missionaries and various cultural delegations from Islamic countries.
there are also quite a few Kazakhs and Kyrgyz. In the other Central
Such events were a novelty and aroused great interest. Now, however,
Asian states it is uncommon for women of the titular groups to work
the visits of delegations have become more of a routine activity and
as prostitutes. However, in the capital cities of the region (and perhaps
are greeted with less pomp, while the missionaries are, in most areas,
in other large urban settlements), sexual conventions are no longer as
subject to close state supervision. In all, the impact of Islamic countries
strict as they once were and it is not unknown for local girls to enter
on the Central Asian states has been considerably weaker than had
into extra-marital relationships in return for financial benefit.
originally been anticipated. The chief sources of external influence,
Another consequence of the economic crisis has been to bring about
particularly so far as women are concerned, are Western. There are
changes in attitudes to family planning. In urban areas, at least among
two very different areas in which the effects of this pressure are felt:
the professional classes, young couples are beginning to worry about
concepts of glamour and concepts of human development.
the cost of rearing a large family. Before, this was not a consideration,
Little is known of traditional Central Asian concepts of female
since all the major expenses were covered by the state. Now, it is not
beauty other than the stereotyped descriptions of classical literature
only that the price of essentials such as health care and education are
and the elegant, stylised figures in miniature paintings. These,
rising, but that many more choices are available in terms of optional
however, are almost entirely images conceived by men; female percep-
extra-curricular activities, fashionable clothes, toys and electronic
tions of style and fashion, and attitudes to luxury, beauty care and
gadgetry. Parents in these circles are coming to feel that they will only
physical perfection, are largely uncharted territory. 68 During the
be able to provide the type of upbringing that they would wish for
Soviet period, new stereotypes were introduced, projecting robust
their offspring if they limit the size of their families to two or, at the
workers and indefatigable mothers as the ideal models, but how, why
most, three children.
and for whom these women beautified themselves or even if they did
In rural areas, especially in Uzbekistan and Tadzhikistan, birth rates
- was regarded as a matter too inconsequential to merit attention.
are still amongst the highest in the world (over forty per thousand per
Over the past two to three years, this has changed: the region has been
292
Contemporary Central Asian women
291
inundated with Western soap operas, video cassettes of the latest
the Soviets gave us schools and hospitals along with their
feature films, fashion magazines, advertisements for hair and skin
these give us only the ideology.' 71 Similar sentiments are to
with increasing frequency throughout the region.
treatments (sometimes even the actual products), and, most recently,
beauty parlours and aerobics classes. Initially, Central Asian women
A third cause of complaint is the 'packaging' of Central Asian
were very cautious in their response to these blandishments, but, as
for the international community. Inevitably (and again as with Soyk
with the women's clubs of the early Soviet era, they are gradually
activists in the 1920s), foreign aid and development programme
being overcome by curiosity and in the larger cities are starting to try
to enlist the support of local women. However, since project organ
these new recipes for health, beauty and a shining future. If the
sers are often more interested in pursuing their own agendas than
appearance of female parachutists and tractor drivers symbolised one
gaining an understanding of local conditions, still less of local cultur
turning-point in the modern history of Central Asia, then perhaps the
what they seek is confirmation of their views. Those who would world
appearance of the first be-swimsuited beauty contests may be said to
with them, sometimes out of conviction but sometimes, inevitably
have marked another.
a means of securing the per diem allowances and other fringe benefits
A very different form of potential Western influence is diffused
reflect back what their sponsors want to hear. These are the women
through aid and technical assistance programmes. These are adminis-
who then become the 'independent representatives' of the community
tered through international organisations, the agencies of national
and are invited to international conferences and seminars in order to
governments, and also through non-governmental organisations
articulate the required position. 72 Translators and interpreters com-
(NGOs). Most have a brief to integrate women into development
pound the problem, encasing their words in a straitjacket of jargon.
programmes. In principle, this may be a helpful approach; in practice,
that effectively extinguishes any spontaneity or genuine insight into
however, it often misfires. Central Asians, both men and women,
the situation. It is little wonder that such women tend to be regarded
deeply resent what they regard as the patronising attitude of some of
as opportunists by their compatriots. The fact that they receive such
the administrators of these programmes. The schemes the latter
attentic is viewed as additional proof of the insincerity (or at the very
least, naïvety) of Western agencies. This severely undermines the
propose often have little relevance to local conditions; in particular,
they frequently fail to take account of the existing high levels of
credibility, and hence the efficacy, of programmes that might other-
wise have much to offer.
literacy, indigenous professional experience and relatively wide range
of modern amenities (albeit that these are now under threat owing to
the economic crisis).
Passivity: a coping strategy?
Another cause of irritation is the implicit, or even explicit, bias that
some Western (or Western-trained) staff display against Islam and
There has been strikingly little attempt on the part of Central Asian
traditional society. 70 The message, in effect, is that the Central Asians
women to articulate their views on what their rights should be. In the
must adopt Western institutions and norms since their own culture is
Soviet period, this passivity could be explained by the fact that they
characterised as 'underdeveloped'. However, many Central Asians
had no option but to support official policies. Now, however, they
now travel abroad and have access to the Western media, and thus are
have a greater awareness of possible choices, and it might have been
able to form their own opinion of Western societies. They find much
expected that they would take the initiative in gaining more control
over their lives and in extending their political, economic and social
to admire but, equally, are appalled by the social problems, especially
those caused by the breakdown of the family. Thus, it is galling for
demands. Yet to date there has been little sign of this. In 1991-2, a
them to have to endure the disparagement of their own values by
few women's movements made a fleeting appearance, most notably,
those who, in their opinion, have been even less successful in creating
the Uzbek-based Tumaris (the female wing of the opposition party
an acceptable social environment. By contrast, respect for the achieve-
Birlik). The Muslim Women's Leagues referred to above fared little
better, also proving to be unsustainable.
ments of the Soviet period are growing. As one Uzbek writer, formerly
known for his outspoken criticism of the Soviet regime, commented
Since independence, throughout the region semi-official Women's
recently, 'These Western activists are just like the Soviets, but at least
Committees have been formed, closely modelled on the women's
Contemporary Central Asian women
293
294
ShirinA
councils (zhensovety) of the Soviet period. These are chiefly concerned
Central Asians are today under greater strain than at almos
with the dissemination and implementation of official social welfare
other period in recent history. Under Soviet rule, despite
policies relating to women. There are also bodies that are specifically
external changes, these societies remained, in Durkheimian
devoted to mother and child health care. These organisations are
largely 'mechanical', with a high degree of homogeneity, conformit
mostly staffed by women and, indeed, provide one of the main outlets
and group solidarity. Now, faced with massive economic, social
for female participation in public affairs. However, although they may
environmental pressures, they are in danger of sliding towards anomi
have some input into policy formulation, their sphere of action is
- the loss of shared values and the consequent breakdown of social
circumscribed by the fact that, as members of these committees, they
controls. The civil war in Tadzhikistan has provided a draman
have an official function. Consequently, they do not have the same
example of how easily and quickly this could happen. There is,an
degree of independence as representatives of NGOs in Western
acute awareness that the same process could be repeated elsewher
countries.
This has provoked an almost maniacal insistence on the need to
an individual level, some women are exercising choice in the life-
preserve stability; all other freedoms are seen as of secondary impor-
styles or careers that they follow. Some have entered the private sector
tance. This is not mere political rhetoric. it is a constantly realtring
and are becoming successful entrepreneurs. Regional Businesswomen's
theme in private as well as public discussion.
Associations are beginning to appear; these, however, are professional
Against this background, the 'passivity' of Central Asian women
bodies that, for the most part, focus on issues relating to the general
may be seen as a positive rather than a negative stance, a choice rather
business environment and not specifically to conditions for women. A
than a failure to choose. Today, as during the Soviet period, women
number of women are engaged in careers that take them to foreign
are instrumental in moderating the pace of change, helping to mediate
countries for study or training; a few have taken the opportunity to
the effect of external influences. The perceived passivity could be
remain abroad for relatively long periods. In the larger cities, more
interpreted as a sophisticated coping strategy for protecting the central
typically in Kazakhstan and Kyrgyzstan, some younger women (gen-
values of society in a time of flux and stress, thus a crucial contribution
erally those who have spent a considerable time in study or work away
to community life, and of fundamental importance in maintaining
from home) have distanced themselves somewhat from their families
continuity and identity. It may of course be argued that even if this is
and kin-group networks in order to lead a more independent existence;
so, the women are nevertheless involuntary victims of the system,
such a choice often entails the corollary of rejecting, or postponing,
trapped in a vicious circle of dependency and self-sacrifice. This does
marriage. In a very different way, those who have opted to follow an
not seem to be borne out in practice. There are undoubtedly cases of
orthodox Islamic way of life have also taken control of their lives.
abuse and oppression here, as in any other part of the world but, in
The above examples of Central Asian women's attempts to establish
general, Central Asian women, whether in urban or in rural areas,
their own space may seem insignificant when compared with develop-
appear to be able to negotiate a position that is, to them, acceptable. If
ments elsewhere in the former Soviet Union, but even these are
they do not take a public stand to articulate their demands this does
exceptional in the context of the region. The great majority of women
thot necessarily mean that they are too weak or too ignorant to do this:
have not shown any inclination to exceed the limits sanctioned by
it could equally well indicate that they believe they are able to operate
society. This apparent apathy is often regarded by outsiders as a sign
more effectively by working in an indirect way, using the social levers
of 'backwardness', from which Central Asian women need to be
that are available to them within their families and their communities.
liberated. Yet they themselves view their situation in a very different
This could change in the future: if there were to be a breakdown of
way. They are conscious of being part of an organic whole, no one
society, then they might be forced to take a more independent
particle of which can be altered without the whole being affected. It is
position, to fight for their rights. Under such conditions, politicised
not that Central Asian women see their situation as perfect - indeed,
feminist movements, either of a Western or an Islamic orientation,
they have as many complaints as women elsewhere - but that they
might emerge. It is, however, noteworthy that this does not, as yet,
perceive that it has compensations as well as shortcomings, that it
appear to have happened to any significant degree even in Tadzhiki-
offers good-neighbourly support as well as social constraints.
stan. The upheavals of the war and the experience of the refugee
contemporary Central Asian women
295
296
Shirin AE
ettlements have not acted as a mobilising impetus. Rather, there has
it is this discovery of sympathetic cultural echoes in the east and
been a consolidation of existing networks and of established patterns
which Has perhaps had the greatest effect on the morale of the
of behaviour.
Asian states, giving them new confidence in the validity of
traditional values. This might well foster the emergence of
Conclusions: Eurasia revisited
conservative trends in the future.
There are still too many uncertainties for it to be possible at?th:
Central Asia lies at the heart of the Eurasian landmass. Once, it was
stage, scarcely five years after the traumatic transition to indepe
the nodal point on the 'Silk Roads' of antiquity, the global trade
dence, to predict how these new states will develop. However, in view
network of the day. Today, after years of partial isolation on the
of their past history, it seems likely that there will be a very caution
periphery of Europe, the region is regaining its centrality: the old,
and gradual recalibrating of the balance between public and privati
long-suspended ties with neighbours to the east and to the south are
spheres, leading to a greater emphasis on traditional structures
being restored through modern transport and communications links.
eventually, possibly, of a revivalist hue. It is unlikely that there will be
This does not mean that the Central Asian states will sever relations
a qualitative change in the position of women in the near future
with Russia or reject the Soviet heritage. The complex network of
Further ahead, however, it is possible that in some of the states there
personal and professional, political, economic, cultural and educa-
may be a move towards a more Islamic way of life, with a reintroduc
tional linkages that has been established over the past seventy years
tion of the constraints, but also of the freedoms and rights, that Islam
will certainly not be erased in the near future, though in time it may
gives women. In the north-eastern parts of Kazakhstan and northern
become a less dominant feature of contemporary Central Asian life.
Kyrgyzstan, where there has long been influence from the settler
Similarly, many of the aspirations that were nurtured during the
communities, it is possible that there will be a more pronounced
Soviet period, such as, for example, that of gender equality, will
Westernisation of society, at least in the public sphere. However,
continue to shape people's hopes and expectations, even if they are
much will depend on the resolution of present economic problems. If
not actively promoted. It is also very unlikely that contacts with the
the recession continues to deepen, there could be a very rapid unravel-
West will diminish. On the contrary, the Central Asian states have
ling of society, with consequences that are impossible to predict,
signalled their desire to remain a part of this world through numerous
exce for the very obvious point that in such conditions it is
trade and diplomatic missions, as well as through membership of
invariably the women and children who are the most vulnerable and
organisations such as the Organization for Security and Co-operation
are therefore likely to suffer a major deterioration in their situation. In
in Europe (OSCE) and NATO's Partnership for Peace programme.
these circumstances, perhaps the present preoccupation with stability
Western-sponsored aid and development projects, whatever their
is no bad thing.
shortcomings, will no doubt continue to be implemented. Informal
channels of Western influence, such as the media, will likewise
continue to be a major source of influence.
Notes
However, these new states are also looking in other directions and
Conventional systems of transliteration have been used for foreign words. It
finding points of reference and mutual understanding in, for example,
should be noted, however, that in a term such as khudzhum, which is here
China, Korea, Japan, Indonesia, Malaysia, India and Pakistan. These
transcribed from the Cyrillic script (as used, for example, for Uzbek), since it
countries present models that differ very greatly one from the other, as
refers to a specifically Central Asian phènomenon, the sound i (as in 'John') is
well as from those of Western countries. Yet they also have some
rendered by dzh; however, in Arabic words which refer to general Islamic
common characteristics, loosely described as 'Asian values', which
practices and are already, therefore, in use in English (e.g. haji), the same
sound is rendered by i, since this is a more familiar spelling.
include an emphasis on the importance of the family, on the interests
1 Good surveys of tsarist/Soviet source material relating to this period are
of the community rather than those of the individual, and on
given by Ol'ga A. Sukhareva, Bukhara: XIX nachalo XX v (Moscow:
consensus rather than confrontation. Central Asians recognise here a
Nauka, 1966), pp. 3-22; Tahira Kh. Tashbaeva and Mane D. Savurov,
sense of social priorities similar to their own. Over the past few years
Novoe i traditsionnoe v bytu set skoi sem'i uzbekov (Tashkent: Fan, 1989),
Contemporary Central Asian women
297
298
Shirin Ad
Western source for this period is probably
8 In the early nineteenth century, there were a number of talented
digarden.of Asia,and its people
poets at the court of the khan of Kokand, including Nadira (b. 1790)
NIIE)
wife of the ruler, Umar Khan; they were presumably not merely
Ve been an exception in this regard in that the
but highly educated. On girls' schools in the early twentieth century
idence suggests that average family sizes were small, consisting
for example, Meakin, Russian Turkestan, p. 87. However, literacy
6 individuals (Sukhareva, Bukhara, pp. 106-11). However, the
varied greatly from one place to another. According to Sukhan
definition of terms is not always clear, hence it is difficult to draw firm
(Bukhara, p. 104), in 1926, 13.4 per cent of the female population
conclusions.
Bukhara were literate, compared with 46 per cent of the male populatic
3 Bibi Pal'vanova, Emansipatsiia musuľmanki (Moscow: Nauka, 1982),
The overall average literacy rate for the Uzbek SSR as a whole, thous
PP. 7-8.
was only 3.8 per cent (Akiner, Islamic peoples, P. 280).
4 E.g. 'Qiz bola tuqqandan kora tosh tuqqan iakhshiroq, negaki, tosh hech
9 According to the 1926 Soviet census, 84.5 per cent of Uzbeks were
bolmasa devor qurishga iaraidi-ku' ('It is better to give birth to a stone
included within the territory of the Uzbek SSR, 94.2 per cent of Turkmen
than a girl-child, because at least you can build a wall with a stone').
in the Turkmen SSR, 93.6 per cent of Kazakhs in the Kazakh ASSR, and
Quoted by Z. R. Rahimboboieva, in her speech to the 'First Uzbekistan
86.7 per cent of the Kyrgyz in the Kyrgyz ASSR. For a summary of the
Women's Conference', March 1958, published in Ozbekiston khotin-
regional distribution of these peoples, see Akiner, Islamic peoples, under
gizlarining birinchi s'iezdi: stenografik hisobot (Tashkent: Uzbek SSR
the relevant ethnic entries. (Reference is made here to Kazakh ASSR and
Davlat Nashriioti, 1960), P. 16. Meakin (Russian Turkestan, p. 97)
Kyrgyz ASSR because at the time of the census they were Autonomous
confirms that disappointment was the usual reaction to the birth of a
Soviet Socialist Republics, not yet full Soviet Socialist Republics.)
daughter.
10 In 1926, 63.1 per cent of the Tadzhiks were included within the territory
5 Sukhareva (Bukhara, p. 105) gives some statistical information on female
of the Tadzhik ASSR, which at that time formed a subordinate adminis-
life expectancy in Bukhara. In 1920, the percentage ratio of females to
trative unit within the Uzbek SSR; there were a further 35.8 per cent
males in the Turkestan region was 47.7 to 52.3 (Pal'vanova, Emansipat-
located elsewhere in the Uzbek SSR (see further Akiner, Islamic peoples,
siia, p. 49). Cf. Russia in 1926, where the percentage ratio was 52.8 to
p. 306). These figures are based on the official ethnic designations as
47.2, thus with a preponderance of females, unlike the situation in Central
recorded in the 1926 census; some would claim that they do not accurately
Asia, where there was a preponderance of males. (Source: Soviet Census of
reflect the population's self-perception of their historical ethnic origins.
1926, cited in Shirin Akiner, Islamic peoples of the Soviet Union (2nd edn,
The negotiation of territorial rights was by no means a smooth and
London: Kegan Paul International, 1987), under the relevant ethnic
amicable affair: there were many bitter arguments over border regions,
entries. Note: the information in this book is drawn from Soviet statistical
especially those with mixed populations. A detailed account of this process
material; for ease of reference, the ultimate sources of data are not cited in
is given by Rakhim Masov, Istoriia topornogo razdeleniia (Dushanbe:
this article unless they are of particular interest.)
Irfon, 1991).
6 For example, Khansha Pupai, the wife of Abulkhair, mid-eighteenth
11 In 1926, Russians numbered 1,279,979 (19.7 per cent of the total
century khan of the Kazakh Little Horde, seems to have played an active
population) in the Kazakh ASSR; 116,436 (11.8 per cent) in the Kyrgyz
role in steppe politics; see Begezhan Suleimenov (ed.), Kazakhstan v XV-
ASSR; 5,638 (0.7 per cent) in the Tadzhik ASSR; 75,357 (7.7 per cent) in
XVIII vekakh (Alma-Ata: Nauka, 1969), p. 141.
the Turkmen SSR; 246,521 (4.7 per cent) in the Uzbek SSR. By 1959,
7 Very little information is available on this subject. Meakin (Russian
these figures had increased to 3,972,042 (42.7 per cent of the total
Turkestan, pp. 100-2) indicates that several of the educated women in
population) in the Kazakh SSR; 623,562 (30.2 per cent) in the Kyrgyz
urban areas were engaged in trade, generally of objects that they had
SSR; 262,611 (13.3 per cent) in the Tadzhik SSR; 262,702 (17.3 per cent)
produced themselves. Zbigniew Jasiewicz, 'Professional beliefs and rituals
in the Turkmen SSR; 1,092,468 (13.5 per cent) in the Uzbek SSR. (See
among craftsmen in Central Asia: genetic and functional interpretation' in
further Akiner, Islamic peoples, under the relevant ethnic entries.)
Shirin Akiner (ed.), Cultural change and continuity in Central Asia
12 By 1959, the percentage share of the titular group in the total population
(London: Kegan Paul International, 1991), p. 173, speaking of a somewhat
of their eponymous republic was as follows: Uzbeks 62.1; Turkmen 60.9;
later period, mentions the existence of 'a certain form of organisation'
Tadzhiks 53.1; Kyrgyz 40.5; Kazakhs 30.0 (Akiner, Islamic peoples, under
amongst craftswomen of the region, notably women potters in the
the relevant ethnic entries).
mountains of Tadzhikistan.
13 Richard Stites, The women's liberation movement in Russia: feminism,
299
Contemporary Central Asian women
300
Shirin Aldr
nibilism, and Bolshevism 1860-1930 (Princeton: Princeton University
Press, 1978), p. 332. For an account of the broader Soviet context of
24 Pal'vanova, Emansipatsiia, p. 168, also personal communications made
female emancipation see Mary Buckley, 'Soviet interpretations of the
the present author by Professor Pal'vanova in London, in 1992.
women question' in Barbara Holland (ed.), Soviet sisterhood (London:
25 Lobachev, Protiv t'my, p. 40.
Fourth Estate, 1985), pp. 24-53.
26 This was not only a Russian view; see, for example, the comments
14 The term was coined by Gregory Massell, The surrogate proletariat
Joshua Kunitz, Dawn over Samarkand (London and New York: Lawren
(Princeton: Princeton University Press, 1975); this is the first, and to date
and Wishart, 1936), p. 274, where he describes the garment as 'monstrod
only major study by a Western scholar on the politics of female emancipa-
and degrading', resembling 'a gray or dark-blue coffin standing stiffly on
tion in Central Asia.
end, covered with a black, bulging, heavy lid'.
IS For accounts of the creation of the legal infrastructure, see Dilorom A.
27 Meakin (Russian Turkestan, pp. 128-9) noted that ""the man in the
Alimova, Reshenie zhenskogo voprosa v Uzbekistane 1917-41 gg.
street" can generally tell at a glance the social standing of a woman by the
(Tashkent: Fan, 1987), PP. 11-12; Shodmon M. Masharipova, Raskre-
quality and condition of her parandzha; those worn by the rich were often
poshchenie zhenshchin Khorezma i vovlechenie ikh v sotsialsisticheskoe
made of silk, but the majority were of cotton. The usual colour was a dull
stroitel'stvo (Tashkent: Fan, 1990), pp. 12-13; Aleksandr M. Lobachev,
grey, but Tatar women would sometimes wear bright colours, such as
Protiv t'my (Tashkent: Uzbekistan, 1990), pp. 32-6; Pal'vanova, Emansi-
emary yellow or bright red. Only women from the lowest strata of society
patsiia, PP. 26-36; Rakhima Aminova, The October Revolution and
(e.g. beggars) would venture out of the house without a veil.'
women's liberation in Uzbekistan (Moscow: Nauka, 1977), pp. 37-8, 59-
28 Alimova, Zhenskii vopros, pp. 25-8; Aminova, October Revolution,
60.
pp. 92-103.
16 Leading Russian activists included: Ida Finkel'shtein, widow of the
29 Alimova, Zhenskii vopros, p. 76; Masharipova, Raskreposhchenie,
Tashkent commissar; Lidia Dvorkina; Berta Bendetskaia (b. 1898); Lukiia
pp. 23, 32, 51-6; Aminova, October Revolution, PP. 49-57.
Shumilova (1873-1939); Lidiia Otmar-Shtein (b. 1899); Eustaliia Ross (b.
30 Aminova, October Revolution, p. 92.
1896). Serafima Liubimova (b. 1898), who was sent from Moscow to
31 Alimova, Reshenie, p. 55; Aminova, October Revolution, pp. 179-92.
Tashkent in June 1923 to head the women's section of the Central
32 The move to an eight-year course was completed by 1962/63; see K. F.
Committee of the Turkestan Communist Party, was responsible for
Fazylkhodzhaev (ed.), Deiatel'nosť kompartii Uzbekistana i usileniiu
creating an infrastructure of social organisations to support the emancipa-
sotsial'noi aktivnosti zhenshchin: Sbornik dokumentov i materialov
tion movement. See further Pal'vanova, Emansipatsiia, pp. 49-57;
(1959-1975 88.) (Tashkent: Uzbekistan, 1986), P. 26.
Alimova, Reshenie, pp. 14-15; Aminova, October Revolution, pp. 12-15;
33 The numbers of women of the titular groups of the Central Asian republics
R. Ia. Radzhapova, et al. Khhdzhum - znachit nastuplenie (Tashkent:
who possessed higher (tertiary) educational qualifications in 1970 were as
Uzbekistan, 1987), PP. 117-87.
follows (per 1,000): Uzbeks 13; Kazakhs 20; Tadzhiks 7; Turkmen 10;
17 These included Risoliat-khon Alieva (b. 1898); Shamsikamar Gaibdzha-
Kyrgyz 15; cf. Soviet average of 37 (Akiner, Islamic peoples, under the
nova (b. 1897); Tadzhikhon Shadieva (b. 1905). See further Pal'vanova,
relevant ethnic headings).
Emansipatsiia, pp. 62-7; Lobachev, Protiv t'my, p. 136; Masharipova,
34 H. Kent Geiger, The family in Soviet Russia (Cambridge, Mass.: Harvard
Raskreposhchenie, pp. 14-17.
University Press, 1970), p. 130.
18 Pal'vanova, Emansipatsiia, p. 106.
35 Aminova, October Revolution, pp. 211-12.
19 Masharipova, Raskreposhchenie, p. 37; Pal'vanova, Emansipatsiia,
36 Ibid., pp. 17-18.
pp. 108-10.
37 Pal'vanova, Emansipatsiia, p. 270.
20 Pal'vanova, Emansipatsiia, p. 165.
38 Alimova, Reshenie, p. 55.
21 Ibid., pp. 97, 147-8; Masharipova, Raskreposhchenie, pp. 61-2;
39 Probably the best study to date on Soviet Islam is Tolib Saidbaev, Islam i
Aminova, October Revolution, pp. 63-4; Alimova, Reshenie, p. 61.
obshchestvo (Moscow: Nauka, 1984); see also A. Ahadov, Islom zamonga
Dilorom A. Alimova, Zhenskii vopros u Srednei Azii (Tashkent: Fan,
moslashganda (Tashkent: Uzbekistan, 1989). For more recent develop-
1991), p. 25.
ments, see Shirin Akiner, 'Islam, the state and ethnicity in Central Asia in
22 Aminova, October Revolution, p. 95.
historical perspective' in Religion, state and society: the Keston Journal 24
23 Alimova, Zhenskii vopros, P. 23; Alimova, Reshenic, pp. 30-2; Aminova,
(2-3), December 1996 (forthcoming).
October Revolution, p. 121.
40 Alimova, Zhenskii vopros, pp. 35-8.
Contemporary Central Asian women
301
302
41 Alimova, Zhenskii vopros, pp. 47-9; Lobachev, Protiv t'my, p. 55;
intond to have. According to an Uzbek informant, mothers-in-la
Pal'vanova, Emansipatsiia, p. 244.
areas would often accompany their sons' wives on visits to theid
42 Pal'vanova, Emansipatsiia, p. 205; Darikha Saburova, Zhenshchiny Kar-
ensure that they did not seek contraceptive advice (communicati
akalpakstana (Nukus: Karakalpakstan, 1989), pp. 37-46; Alimova,
author, Tashkent, 1996). For a comparative international perspe
Zhenskii vopros, p. 46. The problems over equal pay, conditions and
Helen Ware, 'The effects of fertility, family organization, sex
opportunities for women were not of course restricted to Central Asia; for
the labour market, and technology on the position of women'
the broader Soviet context see Alastair McAuley, Women's work and
Federici et al. (eds.), Women's position and demographic change (O
wages in the Soviet Union (London: George Allen and Unwin, 1981),
Clarendon, 1993), pp. 257-84.
especially PP. 11-31.
50 See, for example, Saburova, Zhenshchiny Karakalpakstana, P. 49
43 Alimova, Zhenskii vopros, P. 112.
51 A great deal has been written on this subject in recent years.
44 This section is based mainly on material contained in Tashbaeva and
comprehensive account is given by Boris Rumer, Soviet Central Asia
Savurov, Novoe i traditsionnoe; also on personal interviews conducted by
tragic experiment' (Boston: Unwin Hyman, 1989), pp. 62-75. Sectify
the present author 1985-95. Although the section is written in the past
Aleksandr Minkin, 'Zaraza ubiistvennaia, Ogonek 13, 1988, PP.
tense, since in the context of this article it refers to the Soviet period, the
Aleksandr Minkin, 'Posledstviia zarazy', Ogonek 33, 1988, P. 25; Shirt
conditions described here are very much the same today, in post-Soviet
Akiner, 'Environmental degradation in Central Asia' in Reiner Weichhard
Central Asia.
(ed.), Economic developments in cooperation partner countries from
45 This is also part of the Islamic heritage; see, for example, Lois Beck et al.
sectoral perspective (Brussels: NATO, 1994), pp. 255-63.
(eds.), Women in the Muslim world (Cambridge, Mass.: Harvard Univer-
52 See, for example, Saburova, Zhenshchiny Karakalpakstana, pp. 71-80;
sity Press, 1978), pp. 87-8; Parveen Shaukat Ali, Status of women in the
Tashbaeva and Savurov, Novoe i traditsionnoe, P. 67.
Muslim world (Lahore: Aziz, 1975), p. 21. In 1959, the percentage of
53 Alimova, Zhenskii vopros, p. 118.
married girls of the titular group in the age group 16-19 years was as
54 Ibid., pp. 118-19; E. Gafurov, The flames of feudalism', International
follows: Uzbeks 31.8; Kazakhs 28.7; Tadzhiks 36.6; Turkmen 32.0;
Pravda 2(7), 1986, p. 24; Pal'vanova (Emansipatsiia, p. 8) indicates that
Kyrgyz 44.2; cf. Russians 9.3. By 1970, the percentage of married girls in
the practice was not unknown in pre-Soviet times.
this age group had fallen to the following levels: Uzbeks 21.7; Kazakhs
55 Personal communications to the author in Tashkent in 1990 by an Uzbek
12.3; Tadzhiks 24.9; Turkmen 19.1; Kyrgyz 20.1; cf. Russians 9.1
film-maker, Shukhrat Makhmudov, and his Kazakh wife.
(Akiner, Islamic peoples, under relevant ethnic groups).
56 Shirin Akiner, 'Islam in post-Soviet Central Asia', Harvard International
46 For the 1981 provisions see Bernice Madison, Social welfare in the
Review 15(3), 1993, pp. 18-21. The article was written on the basis of
Soviet Union (Stanford, Ca.: Stanford University Press, 1968), pp. 61-70;
information gathered by the author from informants in the Central Asian
for post-1981, see Jo Peers, 'Workers by hand and womb: Soviet women
republics 1989-92.
and the demographic crisis' in Holland (ed.), Soviet sisterhood, pp. 116-
57 Aziia, 11 June 1994, p. 24; Nezavisimaia gazeta, 6 January 1994, p. 3.
44, especially p. 136. In 1981 the lump sum payment for the first child was
58 Anara Tabyshalieva, Vera v Turkestane (Bishkek: AZ-MAK, 1993),
set at 50 roubles, for the eleventh and subsequent children at 250 roubles
p. 123; Slovo Kyrgyzstana, 30 November 1993, P. 3.
each.
59 These are subjective assessments, based on the author's personal observa-
47 Tashbaeva and Savurov, Novoe i traditsionnoe, p. 38.
tion made in the course of several visits in 1994-6 to Tashkent, the
48 Geographic mobility was low, hence kin-groups generally continued to
Ferghana Valley, Bishkek and Almaty. Some other observers feel that this
live within the same village, neighbourhood or collective farm. The level of
is an underestimation and that both the hejab and the parandzha are
urbanisation among the titular groups within their eponymous republics
becoming far more common. This perception may be influenced by the
also remained low; in 1970, it was less than 30 per cent for four of the
fact that such observers (local and foreign) regard the resurgence of Islam
groups (only 14.5 per cent for the Kyrgyz), and only just over 30 per cent
as a threat. It should be noted that the wearing of the hejab is a new
for the Turkmen (Akiner, Islamic peoples, under relevant ethnic groups).
phenomenon, imported from other Muslim countries; the traditional
Mixed marriages between different ethnic groups were also comparatively
Central Asian covering is the parandzha. To some extent, these different
uncommon, especially in rural areas.
interpretations of the Muslim dress code reflect divergent trends in Islam in
49 Such is the preoccupation with fertility that even visiting strangers will be
Central Asia today. Wearers of the hejab tend to favour a more reformist,
interrogated in great detail about the number of children they have, or
modernist approach to the religion, while wearers of the parandzha are
Contemporary Central Asian women
303
304
Shirm
generally more conservative. However, regional and social factors also
statistika, 1988, pp. 132-42.) The largest change was in Kazak
play a role here, hence no firm conclusions can be drawn about a woman's
where the birthrate fell quite steadily in rural and in urban are
religious orientation solely on the basis of her outer garments.
1980; thereafter it began to rise again. A similar pattern was
60 Gillian Tett, in an unpublished paper on 'Women and Islam in Tadzhiki-
observed in Kyrgyzstan. These two republics have long had large
stan', presented at the conference on 'Social change, demographic trends,
populations; the birthrate in these non-indigenous communities
family structure and gender relations in Muslim societies - with special
significantly lower than amongst the titular peoples, hence the
reference to Central Asia', held at the School of Oriental and African
slower rate of increase. In Uzbekistan and Tadzhikistan the rate of in
Studies (SOAS), University of London, July 1992, made the point that
is such that, according to some estimates, in the near future for every
while it was women who 'de facto carried the greatest religious burden
people who leave the ranks of the working age group, some thirty-five
during the Soviet years, it is now men who dominate Islam in the public
enter it (Viktor Perevedentsev, Moskouskie novosti 41, 11 October 1992
sphere' and that it is men who are setting the agenda for what Islami
p. 9).
should 'mean' for women.
68 Meakin, Russian Turkestan, pp. 120-8, is one of the few writers
61 Comment made to the author by a young Uzbek of about twenty-four
comment on this aspect of the lives of Central Asian women.
years of age, with secondary schooling and further educational training, in
69 See, for example, the report on the 'Kazakhstan Queen of Clubs - 95
the Ferghana Valley in 1994.
beauty contest, Delovaia nedelia, 11 August 1995. Dzhuma: Piatnited
62 Tatiana Savelieva, in an unpublished paper presented at the conference on
published in Kazakhstan, is a typical new-style women's paper, full of
'Social change, demographic trends, family structure and gender relations
advertisements for stylish lingerie, cosmetics and beauty treatments.
in Muslim societies - with special reference to Central Asia', at SOAS, July
70 This phenomenon has been noted elsewhere. See, for example, Angela
1992, gave an account of recent fieldwork carried out in Uzbekistan; in
Gilliam, 'Women's equality and national liberation' in Chandra Mohanty
one village, she reported, almost 20 per cent of the unmarried women were
et al. (eds.), Third World women and the politics of feminism (Bloo-
integrated into polygamous families.
mington, Ind.: Indiana University Press, 1991), pp. 215-50, especially
63 In June 1995, the senior government posts held by women included the
p. 218; also Chandra Mohanty, ibid., pp. 51-80, 'Under Western eyes:
following: in Uzbekistan, deputy prime minister, chairman of parliament
feminist scholarship and colonial discourses'.
(Olii Madzhlis), deputy chairman of parliamentary committee on labour
71 Personal communication to the author by a member of the banned
and social security, deputy minister of labour, first deputy minister of
opposition party Erk, in Germany, 1995.
social welfare; in Kazakhstan, deputy minister of trade and industry; in
72 Cf. Gilliam, 'Women's equality', p. 227, where the question is posed:
Tadzhikistan, deputy prime minister, deputy minister of health; in Kyrgyz-
'Which Third World Women speak for which Third World women?'
stan, minister of foreign affairs. No information was available on the
situation in Turkmenistan.
64 Personal communications to the author in Bishkek, 1996.
65 In one evening, a student can earn at least 30 US dollars, the equivalent of
some six times the value of a monthly stipend. (Personal communications
to the author in Bishkek, 1996.) In Kazakh and Kyrgyz newspapers of
1994-6 there have been several reports on rising levels of prostitution and
other criminal activities carried out by women. See, for example, Gul'mira
Arbabaeva, 'Na kollegii MVD otmechen rost zhenskoi prestupnosti',
Panorama 29, 23 July 1994, P. 9; Kanapiia Gabdullina, 'Bezrabotitsa,
zhenskim litsom', Dzhuma: Piatnitsa 17, 20 October 1995, P. 2.
66 Personal communications to the author in Bishkek, Almary and Tashkent
1996.
67 Levels of natural increase (per 1,000 of the population) in the five republics
in 1960/1987 respectively were as follows: Uzbekistan 33.8/30.1; Kazakh-
stan 30.6/18.0; Kyrgyzstan 30.8/25.3; Tadzhikistan 28.4/34.9; Turkmeni-
stan 35.9/29.3. (Source: Naselenie SSSR 1987, Moscow: Finansy