Ahmedbek Karima, a Tajik refugee living in Djalal-Abad, Krygyzstan, one day collapsed from sharp pains in his lower back. Doctors at the local clinic told Karima that to receive treatment for a kidney ailment, he would have to pay for the surgery, the drugs, and the meals that the Soviet health care system once provided at no cost. Lacking sufficient funds for treatment, Karima appealed to local government officials and to humanitarian organizations, but he received no aid.

Eventually he obtained a small amount of medication to stem his pain. But after depleting this supply, Karima had to resort to selling his household goods to purchase more drugs.

When that prescription ran out, Karima's kidney failure worsened and he died. Dr. Jarnish Haribekov, a Tajik medical doctor who knew about him, said Karima, like many others, died believing that "no one cared."

The circumstances surrounding Karima's death are not unusual in Central Asia. For those in the most vulnerable sectors of society, including the poverty-stricken and the displaced, access to health care has been drastically curtailed. The World Bank reports that the soaring death rates are, in part, due to the reduction in health care expenditures by the Krygyz Republic. Located near the bottom of decreased health care expenditures amongst the former Soviet Republics, Krygyz spending on health care declined by more than 60 percent between 1990 and 1995.

Three years following Karima's death, leaders of the Tajik refugee community convened a series of meetings in Osh province to discuss the local health care crisis. During one session, some 40 people met to discuss the acute shortage of funds to support their need for health care. Gulmira Rahimova, a Tajik refugee from the Pamir Valley ceremoniously passed to a visitor a book of photographs to reflect upon the striking mountains she was forced to flee. Rahimova also described the access to health care her family enjoyed before "the collapse." As she spoke, several babies crawled along the cold cement floor.

"It's hard to keep our babies healthy," said Rahimova. "In the winter, families cannot buy coal to heat our homes; the children fall ill with pneumonia, and acute respiratory illnesses and colds are very common." For food, she said, "We can afford only tea and bread." Without money, food or health care, sick children remain untreated. "Our children die. This is not a secret," she said. "For six years we have been living in Kyrgyzstan and none of us have visited a physician, because we cannot afford it."

According to the World Bank, the percentage of adults and children who die without treatment has climbed since the Soviet collapse. Scattered data indicates that the death rates in refugee communities are far higher than those for the general population. In many cases, those who die – from alcoholism, drug abuse, heart attacks or maternal and childhood diseases, poverty – needed help long before they reached the emergency stage.

Rahimova cradled her two-year old son in her arms. He cannot walk. She had borrowed the equivalent of forty cents to bring her child to a nearby clinic where doctors discovered a serious ear infection. But the small sum paid only for a swab of his inner ear – it was not enough for the drugs necessary to treat his infection. As she pointed to the fluid that oozed from his left ear, she explained that the infection causes insufficient balance for him to walk.

Rahimova and several thousand others fled their homeland for Krygyzstan in 1992, when a civil war engulfed Tajikistan. Between 20,000 and 40,000 people were killed during the civil war, and more than half a million were displaced within the country. About 130,000 fled to the neighboring states of Afghanistan and Uzbekistan, and perhaps 3,000 to the Kyrgyz Republic. Many of those attending the Djalal-Abad meeting came from the mountainous northern and eastern regions of Garm and the Pamir Valley in Tajikistan.

Many Tajiks have returned home in recent years, but the United Nations High Commissioner for Refugees reports some 300 officially registered refugee families in Osh and Djalal-Abad provinces, and 600 more unregistered families who hope to build a new life in the Krygyz Republic. Unlike Krygyz nationals who fall under the state's constitutional provisions for access to health care, medical care is not provided to unregistered refugees. And registered refugees typically do not register with the state social fund.

Dr. Janilberk Cheraliev, Coordinator for the Family Group Practice Association in Osh province, who attended the Djalal-Abad meeting, explained that several clinics in the area have been licensed and accredited, but the state allocated no funds for health care in some of the country's poorest regions. Half of the 30 physicians in the area left, seeking better jobs in other locations. According to Cheraliev, many in the general population and refugee community rely solely on herbs from a local healer and a mullah's prayers, "Or else they wait to die," he said.

Dr. Machmoud Abulvalev, Director of Polyclinic Number One at nearby Osh province agrees with Cheraliev. Financial burdens have grown worse as the need to pay for health care has grown. "Hospitals like ours have no funds to pay for care," said Abulvalev, whose clinics are financially stretched and treat many at no cost. "Even if the sick can afford the costs of transport to reach the hospital, they must borrow funds from relatives, friends, Imams at the Mosques or doctors who occasionally pay from their own pockets."

Although Krygyzstan is a regional leader in implementing health care reforms, a far greater percentage of public funds are allocated to urban hospitals than to remote family clinics, where the majority of the population lives.

At the Djalal-Abad meeting, the participants, both refugees and Krygyz nationals, decided to grow wheat in their dry region. "If we have a crop next year, we will make a farm for cows. If we are to have health care, we must pay for it ourselves," said Gulmira Rahimova.

Following the meeting, on his way to the Kokanjova hospital, Tajik refugee and surgeon Dr. Haribekov reflected for a moment: "Tajiks have a saying," he said. "Tomorrow, we will have breakfast." Stubbing out his cigarette, Haribekov reflected, "