Under an icon of St. Nicholas hanging on her wall, 97-year-old Anna Belova drew her final breath. She passed away in her Bishkek apartment in the presence of a few neighbors and her two nieces, her last remaining family. Belova’s final days were not dignified. After a fall, she faded quickly, dehydrated and exhausted by a severe bout of diarrhea. Neighbors called an ambulance, but the paramedics refused to help, saying her age rendered her “not transportable.” Until her death in May 2013, Belova, though nearly deaf and blind, lived alone and relied mostly on herself. The fall may have broken her independent spirit, but a public health system to provide support or palliative care could have made her final days more comfortable. As it is, with Kyrgyzstan’s health system generally struggling and older people traditionally cared for by relatives, healthcare targeted specifically at the elderly is almost nonexistent.Though donor-led reforms have brought some improvements in overall care, the Health Ministry’s strategy does not address geriatric medicine at all. So needs are poorly understood. “There are problems [in healthcare for older people], but there is no discussion of the issue and it needs attention,” said Dinara Aldasheva, a policy consultant at the Health Ministry, adding that Kyrgyzstan does not have a single registered geriatric specialist. Theoretically, healthcare in Kyrgyzstan is free. But a lack of state funding means caregivers rely on informal payments and often turn away indigent patients, including the elderly, whose monthly pensions average a meager 4,500 som ($83). The World Health Organization estimates the Kyrgyz government spent $84 per person for healthcare in 2010. Though about 10 percent of the state budget, that is among the lowest in the region. (By comparison, per capita government spending on healthcare in Russia was $749 and in the United States $3,967.) This has led to underpaid doctors, who are either overworked or looking for ways to supplement their incomes, and poorly equipped medical facilities—especially for emergencies. The capital’s ambulance service – of particular importance to older patients – is overstretched. According to a Bishkek health official speaking on condition of anonymity, the city of approximately 1 million has only 33 public ambulances in service. Doctors make decisions on whether a person needs treatment over the phone. (There are private ambulance services, but relatively high fees make them accessible only to the wealthy.) The city has no general emergency room, another service crucial to older people. State hospitals are specialized and can turn away a patient whose symptoms are not that hospital’s focus, even in an emergency. Anecdotal evidence suggests this happens frequently and gives hospitals an easy way to refuse patients unable to pay the under-the-table fees. “Even after 12 years of working in the healthcare system here, I don’t always know where to send [sick] people,” said Dr. Barton Smith, an American practicing general medicine at the Family Medical Center, part of the Kyrgyz State Medical Institute for Retraining and Continuing Education in Bishkek. In non-emergencies, Bishkek residents can visit a local family clinic. But long lines (and sometimes rude staff) put people off. Specialists – such as cardiologists and gynecologists – often request unofficial payments to perform treatments. “There is not much accountability for quality and the level of corruption does not seem to be decreasing,” Smith said. Moreover, a young generation of doctors is considered less qualified than their Soviet-trained predecessors. As the overall standard of education declines, and poorly paid university professors are said to solicit bribes for passing grades, the quality of care is falling. Despite these challenges, for most elderly in Kyrgyzstan the traditional multi-generational family home ensures basic care well into old age. “[Here] in the East, it is a little shameful if you don’t look after your parents,” Aldasheva at the Health Ministry said.But the plight of older people has worsened in recent years due to widespread labor migration to Russia and the subsequent breakup of the traditional family, which has left increasing numbers of elderly people alone, said Aidai Kadyrova, director of Babushka Adoption, a non-profit that helps isolated older people with small monthly donations and food assistance. Many of the older people struggling to afford utilities, food and other regular expenses also have little recourse to fight against unofficial health charges. “And they don’t know their rights,” Kadyrova said, such as entitlement to free medical care and discounts on certain prescription medicine. Still, a small charity like Babushka Adoption can only help about 1,000 elderly people throughout the country of approximately 5.7 million. For families that need additional assistance, particularly where migration has torn apart the traditional family, “there aren’t many choices,” said Smith, the American doctor.Ultimately, any reforms in Kyrgyzstan must combine health and social services to meet the needs of older people, said Eppu Mikkonen-Jeanneret, head of policy at HelpAge International, an NGO. Under the current approach, older people “are not seen as curable,” said Mikkonen-Jeanneret, so “the system ignores them.”
David Gullette is an anthropologist and development specialist based in Kyrgyzstan.