CHAPTER 1 INTRODUCTION Naken K. Kasiev 1.1 Geography, Population, and Culture The Kyrgyz Republic is located in the center of Central Asia and shares borders with Kazakhstan, Uzbekistan, Tajikistan, and China. The Kyrgyz Republic is primarily mountainous with dry fertile valleys and deep gorges. The two main areas which are the base of Kyrgyz agriculture are the Ferghana Valley, in the Southwest, and the Chu Valley, in the North. Lake Issyk-Kul, located in Northeast Kyrgyzstan, is the second deepest mountain lake in the world. It is the main tourist and recreational spot in the country. The population of the Kyrgyz Republic is more than 4.5 million. The country has an ethnically diverse population. According to the National Statistical Committee, in 1997 the ethnic breakdown was as follows: 61 percent Kyrgyz, 15 percent Russian, 14 percent Uzbek, and 10 percent a mix of Ukrainian, German, Kazakh, Tatar, Dungan, Tajik, Uigur, Korean, and others. Thirty-four percent of the population lives in urban areas, 66 percent in rural areas (National Statistical Committee, 1997). The national language is Kyrgyz, which belongs to the Turkic language group. Russian is widely spoken and is an important language of communication. The primary religion of the people of the Kyrgyz Republic is Sunni Islam. There are many ancient and modern cultural values in the Kyrgyz Republic. The great epic “Manas” characterizes the Kyrgyz people’s independence and courage, and glorifies the legendary nobleman Manas. It is one of the longest epics in world literature (longer than the Iliad and the Odyssey combined), and is passed on orally from generation to generation. It is estimated to be nearly one million lines long, and makes early observations of the Kyrgyz people on geography, medicine, and astronomy. 1.2 History of the Kyrgyz Republic The Kyrgyz belong anthropologically to the south Siberian group of the Mongolian race. There are different theories of ethnogenetic origin of the Kyrgyz. According to one of them the Kyrgyz are believed to have emerged from various groups that settled in Central Asia over 2,000 years ago. In the 9th and 12th centuries, some of these tribes moved to the central and western Tien Shan and Pamir regions and eventually formed what is today the Kyrgyz ethnic community. The area that Kyrgyzstan now occupies has been a crossroads for centuries. Lying on one branch of the fabled Silk Road, armies and traders have left their marks on the land and history of Kyrgyzstan. Many kaganats (kingdoms) have ruled the area in different centuries. During the 10th to 12th centuries, the Kara Khanid dynasty ruled from their capital Balasagun, not far from present day Bishkek. The beginning of the 13th century brought Mongol rule and eventually Timurlane’s hordes. In the middle of the 19th century, Central Asia and its people were incorporated into the Russian Empire. In 1924, seven years after the 1917 Bolshevik Revolution, the Soviet Union established the Kara-Kyrgyz autonomous region, later renamed The Kyrgyz Autonomous Republic. In 1936, its status was elevated to a Kyrgyz Soviet Socialist Republic of the USSR. 1 On August 31, 1991, after the collapse of the former Soviet Union, the Kyrgyz Republic officially declared itself an independent state. Through the leadership of President Askar Akaev, the Kyrgyz Republic has started on the road to economic and political reforms, reclaiming the democratic and independent roots of the Kyrgyz people. 1.3 Economy The dominating sectors of the Kyrgyz economy are industry and agriculture. According to the World Bank, the GDP in 1995 was US$ 3.2 billion (US$700 per capita) (World Bank, 1997). Within the industrial sector, the most developed areas are electrical production and mining. In 1993, industry accounted for 37.8 percent of the GDP, agriculture for 28.6 percent, service for 22.6 percent, construction for 6.9 percent, and transportation/telecommunications for 4.8 percent. The industrial sector of the Kyrgyz Republic is represented primarily by light industry (30 percent), food industry (22 percent), and manufacturing-building industry (20 percent). The mining and metallurgy industries provide 10 percent of industrial production and employ 11 percent of the industrial labor force. At present, the main areas of mining and production are gold, antimony, antimony oxide, metallic mercury, uranium oxide molybdenum, coal, oil, and gas. Agriculture is the second most important sector of the Kyrgyz economy after industry. It includes wool, livestock, and fruit and vegetable production. Labor resources and output of the stockbreeding sector amount to two-thirds of the agricultural GDP. Following three years of sharply declining production—output is currently 45 percent below the 1991 level—the Kyrgyz economy showed the first signs of recovery in 1995, led by modest growth in crop production and a growing private service sector. Preliminary data suggest that GDP grew by 1 percent in 1995 and at an annual rate of 2 percent in the first quarter of 1996. Indications are good for growth of 2 to 3 percent for 1996 as a whole. This positive result reflects the wide range of stabilization and adjustment measures the government has pursued, including introducing a new currency (the som), bringing inflation down to low monthly rates, nearly completing liberalization of the trade regime, removing controls on current and capital account transactions, privatizing most industrial and trade enterprises, dismantling state and collective farms, and distributing land-use rights. The Kyrgyz Republic has entered into a three-year Enhanced Structural Adjustment Facility arrangement with the IMF (World Bank Review, 1997). The Kyrgyz Republic is shifting to a market economy based on equal development of different forms of ownership, encouragement of entrepreneurship, and privatization. The new economic policy is based on recent legislation on land, entrepreneurship, and banking adopted by the parliament of the Republic. 1.4 Health Care System The health care system in the Kyrgyz Republic, which developed as part of the Soviet-planned system, was designed to provide adequate access to health services for all citizens and to emphasize preventive care. Primary health care in the Kyrgyz Republic is provided in such institutions as polyclinics, outpatient clinics (ambulatories), doctor’s assistant/midwife posts (FAPs), primary health facilities at large enterprises, women’s consulting centers (which are a primary source of family planning services in urban areas), and delivery hospitals. The main focus of the health services in these institutions is disease prevention (for example, immunization against infectious diseases), and providing antenatal care services, delivery assistance, and family planning services. 2 On the secondary level, health services are provided by specialized dispensaries and city and rayon hospitals where screening programs are carried out to identify individuals with early manifestations of disease, and treatment programs are implemented to halt the progress of the disease. Tertiary health services in the Kyrgyz Republic are provided within oblast and republican hospitals, specialized hospitals and dispensaries, and research institutes. The clinical treatment offered at these facilities is aimed at minimizing the effects of disease and disability. Maternal and child health services in the Kyrgyz Republic are largely provided through wide network of primary health care institutions. Almost all deliveries occur at delivery hospitals and, in rare cases, at regular hospitals. Antenatal care is provided mainly by doctors at the women’s consulting centers (part of urban polyclinics), rayon and rural ambulatories, FAPs. Antenatal care starts early in pregnancy (usually during the first trimester of pregnancy) and continues on a monthly basis throughout the pregnancy. Child health services in the Kyrgyz Republic include neonatal care, which is usually provided in the first week after delivery when a woman and her newborn are still in the delivery hospital, and other pediatric services at older ages. After discharge from the delivery hospital, a child is visited by a patronage nurse who provides the mother with general counseling on child care and carries out a physical examination of the child. A mother is required to bring her child in for a regular checkup and vaccination at the polyclinic or outpatient clinic several times during the first two years of life. A doctor in the polyclinic can refer the child to a pediatrician in case the child develops disease or other conditions that require special care or hospitalization. The child vaccination schedule in the Kyrgyz Republic requires that BCG and oral polio vaccines be given in the delivery hospital during the first 3-4 days of life. Revaccination with oral polio vaccine is usually done at age 2, 3.5, 5, 16, and 18 months, and 6-7 years. The vaccination schedule for diphtheria, pertussis, and tetanus toxoid (DPT) is similar to the schedule for the polio, except that the first DPT vaccination is given at age 2 months. Measles vaccinations are given at 12 months and 6-7 years of age (Steinglass, 1995). The vaccination schedule is controlled throughout childhood by several mechanisms. During the first two years of life, the patronage nurse is responsible for maintaining vaccination records and ensuring that the child receives vaccinations at the appropriate time. After that period, the vaccination schedule may still be under the control of the pediatrician of polyclinics or the records can be transferred to a day care center if the child attends one. In the latter case, vaccination is coordinated by the day care nurse. Finally, when the child starts to attend primary school at the age of seven, the school nurse becomes responsible for the child’s vaccinations. Unfortunately, maintaining such a system requires substantial and continuous budgetary support and enormous human resources and appropriate management. The socioeconomic changes in the Kyrgyz Republic during the last five years have influenced the health sector.