Care and Community

Mental Health Services in the Kyrgyz Republic

A Country Report

Picture by kind permission of Gennadiy Klementiev, Bishkek

June 2005Olga & Andriy Vasylchenko

© InterMindsPO Box 23121, Edinburgh EH6 4YL Scotland

Tel. 00 44 131 467 0117Email: InterMindsPK@aol.com

Scottish Charity Number SC 025132

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CONTENTS

Acknowledgements 3

Introduction 4

PART 1

MENTAL HEALTH SERVICES IN KYRGYZSTAN

Overview 7

Non Governmental Organisations in Mental Health

International Organisations 10

National and Local Organisations 11

Human Rights in Psychiatric Facilities

Monitoring by YHRG and MHS 13

Monitoring by MDAC 14

Visiting the Institutions

Republican Mental Health Centre 16

Ward 12 of the RMHC 17

Chym-Korgon Mental Hospital 18

Iskra Social Care Institution 19

PART 2

KYRGYZSTAN TODAY

Geography 22

History 23

The People 25

Culture 26

Politics and Society 27

The Economy 28

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CONCLUSIONS

A Potential Role for InterMinds 32

ANNEXES

Schedule of Visits and Meetings 34

Persons and Organisations 36

Excerpt from “Law of Kyrgyz Republic: On psychiatric care andguaranteeing the rights of persons receiving such care” (1999) 38

Information for the Collegium Meeting“On State of the Mental Health Service” (Excerpt) 40

Materials of the 13th Local Policy Forum 42

Joint Press Release by the Mental Disability Advocacy Centre

and Kyrgyz NGO “Mental Health and Society” of 16 February 2005 43

Principal References 45

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ACKNOWLEDGEMENTS

Many people and organisations have contributed to this report in a variety of ways. Weowe our deepest thanks to Burul Makenbaeva and all colleagues from Mental Healthand Society: Without their comprehensive introduction to mental health problems inKyrgyzstan our visit would hardly have achieved its aims. We wish to express ourgratitude to the Ministry of Health of Kyrgyzstan, who gave us better understanding ofthe national picture. Thanks also go to the Republican Mental Health Centre, Chym-Korgon mental health hospital, Iskra social care institution, and all the otherorganisations we visited in Kyrgyzstan.

We owe our profound thanks to all people directly involved in mental health serviceswhom we had a chance to meet and whose knowledge and experiences we had theprivilege to share.

In writing this report we also gathered information from a wide range of written sourcesand are grateful to all the authors of books, reports and articles on Kyrgyzstan to whichwe had access. The principal sources of information are listed at the end of the report.

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INTRODUCTION

InterMinds is a Scottish mental health charity working internationally in partnership withlocal organisations to help people with mental health problems live ordinary lives withincommunities where human and social rights are respected. Peter Kampman, theDirector of InterMinds, was the head of our mission in Kyrgyzstan. It was of great benefitthat we had a chance to learn from Peter’s abundant international experience in mentalhealth and to discuss with him our impressions straight away as they were beingshaped. The main purpose of InterMinds’ visit was to find out the opportunities andlimitations within the Kyrgyz mental health situation in order to develop, in closecollaboration with our Kyrgyz partner NGO1 Mental Health and Society, a preliminaryvision of priorities for a potential IBPP2 project.

Kyrgyzstan is a lively and constantly developing society in which the role of NGOsshould not be underestimated. Erkinbek Kasybekov, the head of the Kyrgyz branch ofthe NGO Counterpart International. states:"[In Kyrgyzstan] it’s already maybe 10 yearsof intensive NGO development and we see now very well advanced NGOs dealing withvery sophisticated works”.

NGOs provide a space for civil initiatives to be pursued and a forum for discussions, aswell as enabling projects that would otherwise not be supported by state organisations.NGOs may challenge state organisations by monitoring their policies, disseminatinginformation and encouraging political participation. Many NGOs in the country areunited in the coalition ‘For Democracy and Civil Society’ – an organisation thatconsistently stands up for civic rights and freedom of speech during election campaigns.

Our visit to Kyrgyzstan took place at the beginning of 2005, only a few days after the‘orange’ revolution in Ukraine. Since then Kyrgyzstan has itself been undergoingupheaval, following strong demand from the people and resulting in the departure of thepresident. It is a time of turmoil but we have been encouraged that social actions arebeing taken for the sake of the oppressed and vulnerable. We are keen to offer ourprofessional skills to help the new undertakings of our Kyrgyz colleagues who work forthe good of people with mental health problems.

Everything is interrelated in human society and the way vulnerable people are treated ina particular community reflects the general political and social situation. If we want tocontribute as professionals to improving a particular aspect of human life, such as lifefor people with mental health problems, we will succeed better if we take into accountand build on our knowledge of the opportunities as well as the limitations of the politicaland cultural context in which people live. A large part of this report therefore describesthe background to present day Kyrgyzstan, including geography, history, economy andculture as well as the current political developments.

The report will focus optimistically on the opportunities now available, while notminimising the significant and major problems that exist for people with mental healthproblems. A Chinese traveller-monk who visited Kyrgyzstan in the seventh century wasamazed not only by “tall peaks which reach to the very sky” but also by “dragons whichmolest uninvited guests” (we were leased to have been invited in!). There remain many

1 Non-Governmental Organisation2 European Commission Institutions Building Partnership Programme

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paradoxes in this society. A post-Soviet authoritarian rule has co-existed with a sense ofnomadic freedom in people’s bearings and gestures. Almost total corruption andenormous administrative control in governmental establishments has lived in relativeharmony with a developed civil society and mature political opposition. The notuncommon practice of torture in mental health institutions occurs nevertheless within asystem that could allow some patients in institutions to complain to an independentNGO.

In summary, we can to a great extent share the amazement of the Chinese monk whohad the privilege of contemplating the stunning beauty of mountains through a fierydragon breath. Perhaps the most important result of our visit is that, unexpectedly andirrevocably, we have fallen in love with Kyrgyzstan. We cannot help being amazed by itsnature and culture, and we cannot be indifferent to the life of the Kyrgyz people.

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PART I

MENTAL HEALTH SERVICES IN KYRGYZSTAN

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OVERVIEW

Mental health services are provided in 3 mental healthcare facilities, including 2 mentalhealth centers (republican center with two affiliates and Osh oblast center), as well asrepublican mental hospital in v. Kyzyl-Jar, by 9 psychiatric departments in public healthhospitals and 55 psychiatric units at the primary care level (in Family medicinecenters).1

The health care system in the Kyrgyz Republic, including mental health services, iscurrently under transition towards decentralisation with the need to meet an ever-increasing demand. As part of the attempt to reform the mental health system in 1999the government passed the Psychiatric Care Law and in 2000 a national strategy waslaunched, Mental Health of the Population of the Kyrgyz Republic in 2001-2010. Boththe law and the programme anticipate a shift from institution-based mental health careto more local community-based care, with an emphasis on bringing mental health careto individuals in their local communities. Due to lack of funding, implementation of theprogramme has been suspended.

The position of the Kyrgyz Ministry of Health is that, ideally, the Kyrgyz mental healthsystem should function on three levels:

• Primary care at the rayon (district) level by general practitioners;

• lntermediate care facilities staffed with psychiatrists at the oblast(province/region) level; and

• Tertiary long-term care at the national level in the Republican Mental HealthCentre (RMHC) in Bishkek.

In practice, psychiatric facilities operating at district and regional levels areadministratively part of general medical hospitals and funded through them, thus havingfewer resources than facilities funded directly by the national government. Many mentalhealth patients do not receive proper psychiatric help at either the rayon or oblast level,thus causing the RMHC to become in effect a ‘primary’ rather than ‘tertiary’ level facility.

Only just over half of all patients in the psychiatric hospitals are suffering from severemental disorders (including learning disability), which implies that a significant numberhave less severe conditions, such as neurotic difficulties or have no mental illness at all.In most other countries such people would receive treatment outside hospital. Delays indischarge have transformed mental hospitals into long-term asylums, where two thirdsof patients don’t need hospital treatment. This applies especially to people with learningdisability, most of whom can live in the community with support.

There are serious deficiencies in the organisation and delivery of non-hospital care. Insome family medicine centres, there are physicians in mental care units who are notspecialised in psychiatry. They often lack basic knowledge about mental illness, so thatmental health patients are often referred directly on to the RMHC or another largemental hospital.

The Mental Disability Advocacy Centre concluded in its review ‘Mental Health Law ofthe Kyrgyz Republic and its Implementation’: 1 This information is dated by January 2004.

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“In general the current mental health care system in the Kyrgyz Republic remainsantiquated, based on large institutions and overly centralised. The attempts to bringabout change have been met with strong resistance. Additional barriers are posed byinadequate funding, lack of trained mental health professionals to provide the necessarycommunity-based mental health care, particularly in rural areas, and the lack of privatepay psychiatrists.”

Table 1. Prevalence of Mental Disorder in 2002/2003

2002 2003

No. of people with mental disorder 57,882 55,630

No. per 100,000 population 1,161.2 1,110.1

Table 2. Firstly Admitted People with Mental Disorder (per 100,000 population)

2000 132.2

2001 136.3

2002 141.6

2003 147.4

Table 3. Patient Diagnoses

2002 2003

Percentage of patients withschizophrenia 19.5% 19.6%

Percentage of patients withlearning disability 45.0% 46.0%

Percentage of patients with non-mental disorders 8.4% 10.2%

Table 4. Proportion of Children and Teenagers among Patients Suffering fromMental Disorders

2002 2003

Percentage of adult patients 81.6 82.2

Percentage of children 11.8 10.9

Percentage of teenagers 6.6 6.9

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Table 5. Work of Inpatient Psychiatric Institutions

2001 2002 2003

Total number of beds 2,572 2,406 2,398

Average length of stay (days) 86.1 92.0 82

Average bed rotation(patients per year) 3.6 3.3 3.5

Amount of patients treated 9,263 8,043 8,514

Table 6. Staff of Inpatient Psychiatric Institutions

2001 2002 2003

Psychiatrists 148 143 144

Psychotherapists 10 8 7

Medical psychologists 2 3 4

In the development of the Kyrgyz mental health services, there are two opposedtendencies. On the one hand, mental health morbidity is growing. The Table 2 showsthis clearly, while a certain decrease in morbidity from 2002 to 2003 shown in the Table1 may be explained only by incidental factors (most likely, increase of mortality or/andchange of registration methods). On the other hand, the total number of beds inpsychiatric institutions is being reduced. However, such a decrease happens not as apart of certain plan of de-institutionalisation (as it is the case in many Europeancountries), but as a result of a lack of resources. Unfortunately but understandably, nooutpatient alternative to institutional care is being proposed.

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NON-GOVERNMENTAL ORGANISATIONS IN MENTAL HEALTH

International Organisations

Since 1992, Kyrgyzstan has been a member of the World Health Organization (WHO).The objective of WHO is the attainment by all peoples of the highest possible level ofhealth. Health, as defined in the WHO Constitution, is a state of complete physical,mental and social wellbeing and not merely the absence of disease or infirmity. Aspecialised agency of the United Nations with 191 Member States, WHO promotestechnical co-operation for health among nations, carries out programmes to control anderadicate diseases and strives to improve the quality of human life. WHO wasestablished in 1948, with its headquarters in Geneva, Switzerland.

WHO has four main functions:

• To give world-wide guidance in the field of health

• To set global standards for health

• To co-operate with governments in strengthening national health programmes

• To develop and transfer appropriate health technology, information and standards

Based on an agreement between the Government of the Kyrgyz Republic and the WHORegional Office for Europe, approved by the Governments of other Central AsianRepublics, the WHO Information Centre for health for Central Asian Republics was setup in Bishkek in 1993 and the WHO Liaison Office was established the following year.

In 1996, the government adopted the MANAS1 National Health Care Reform Program,which was developed with considerable support from WHO. This was constituted as a10-year program of comprehensive reform of the organisation, financing and content ofthe health system. The broad aim was to adjust the system to the economic realities ofa transitional and post-transitional country and to replace certain outmoded practicesinherited from the Soviet Union with modern, evidence-based practices. It also aims toshift from the highly specialised Soviet model to a system based and led by primarycare.

The reform in mental health stated in the national programme Mental Health of thePopulation of the Kyrgyz Republic in 2001-2010 is a natural continuation of this policy.

The Mental Disability Advocacy Centre (MDAC) is an international non-governmentalorganisation based in Budapest, which promotes and protects the human rights of peoplewith mental health problems and intellectual disabilities across Central and Eastern Europeand Central Asia. MDAC works to improve the quality of life for people with mentaldisabilities through litigation, research and international advocacy. It promotes publicpolicies that respect human rights and foster community integration. MDAC hasparticipatory status at the Council of Europe and is a co-operating organisation of theInternational Helsinki Federation for Human Rights.

In Kyrgyzstan, MDAC monitors the state of mental health law and its implementation,and works with the Kyrgyz government, advocating for the rights of people with mental 1 Named after the important historical Kyrgyz epic

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disabilities. A key recommendation in MDAC’s 2004 report on human rights andpsychiatry in Kyrgyzstan was to establish an independent advocacy service for patientsat the Republican Centre. MDAC works with the Kyrgyz NGO Mental Health andSociety for the support and development of such an advocacy service, which hasexisted since November 2004.

Other international organisations that have been involved in mental health work locally are:Geneva Initiative in Psychiatry, Hamlet Trust, OSCE1 in Bishkek, Freedom House,and the Soros-Kyrgyzstan Foundation. All these bodies are partners of Mental Healthand Society.

National and Local Organisations

The public association Mental Health and Society (MHS), founded in 2000, is anational not-for-profit, non-governmental organisation. Its objective is to help protecthuman rights and freedoms, especially the rights of people with mental disorders,learning disabilities and psychosocial problems. In its activities, MHS adheres to theprinciples of pluralism and equal opportunities and promotes the involvement of mentalhealth service users in taking decisions about their life and medical treatment andinfluencing the conditions of institutional care and mental health policy and reform.

The main goals are:

• To integrate mental health services, to ensure optimal care for users, to provideeducation to the public about mental illness to reduce stigma

• To provide information to users, families, health professionals and communitymembers about mental illness so that treatment and prevention may be improved

• To provide programmes that will enable users to become involved in developing theability to become active participants in supporting one another and in decisionmaking about their own care and about mental health policies

• To promote the humanisation of psychiatric care

• To counteract the violence that affects the mental health of the citizens

• To promote the integration of people with mental disorders into society

• To support stable family life, social cohesion and human development

• To promote the improvement of Kyrgyz Mental Health Law

The main activities are:

• Legal support for people suffering from mental health problems

• Monitoring human rights in psychiatric institutions

• Promotion of self-help groups, including training in group work skills

1 Organization for Security and Co-operation in Europe

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• Working with the media to raise public awareness about mental health problems

• Exerting influence over government’s policy in mental health

Mental Health and Society collaborates, in attaining its objectives, with the Ministry ofHealth of the Kyrgyz Republic, the Office of the Ombudsman of the Kyrgyz Republic,and with a wide range of NGOs and individuals – professionals in mental health.

Youth Human Rights Group (YHRG) is a not-for-profit NGO founded in 1995. Theobjective of the organisation is the protection and affirmation of human rights. The mainpriorities are:

• Promotion of the rights of children

• Legal reform as regards juvenal law

• Observance of human rights in custodial institutions of different types

• Effective use of international mechanisms of human rights protection

• Raising public awareness about human rights

Special importance is given to collaboration with other organisations. A crucial activity isthe monitoring of compliance with human rights in state boarding schools andpsychiatric institutions, as well as for particular vulnerable groups like child refugees.

Another important organisation on the mental health scene is the Kyrgyz PsychiatricAssociation (KPA). The President of the Association is Professor Valery Solozhenkin,Head of the Chair of Clinical Psychology and Psychiatry at the Kyrgyz State MedicalAcademy and the Chief Psychiatrist at the Ministry of Health of the Kyrgyz Republic.KPA promotes self-help initiatives by users of mental health services, their relatives andprofessionals and it is currently establishing a users’ organisation. ProfessorSolozhenkin, while supporting in principle the monitoring/advocacy activities of MSH,YHRG and MDAC, criticises these organisations for what he calls “moral maximalism”and stresses the need to create a “respectful, constructive dialogue” between humanrights activists on the one hand and psychiatrists and other professionals working inpsychiatric institutions on the other hand. KPA intends to promote a wider co-operationbetween different NGOs in mental health, and works for the creation of an effectivedialogue between all sides of the mental health scene in order to balance human rightsissues with other facets of productive work for the benefit of people with mental healthproblems.

There are a number of other organisations working for mental health development in thecountry: Family and Society, Act in Support of the Family, Solomon’s Rays (Osh),and others. There is also a national system of centres for children with autism andlearning disabilities where qualified professionals work.

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HUMAN RIGHTS IN PSYCHIATRIC FACILITIES

Monitoring by YHRG and MHS

In 2000 the Youth Human Rights Group conducted monitoring of human rights andmaintenance conditions in a number of psychiatric institutions in the Kyrgyz Republic.

As a result of this monitoring, a number of serious problems were discovered. In generalthe situation of patients in psychiatric institutions was characterised as unfavourable.The majority of legal requirements were not complied with and many employees andpatients were ignorant of the law. In order to improve the situation, recommendationswere suggested based on the following principles:

• De-institutionalisation of services

• Development of the autonomy of patients

• Protection from exploitation

• Prevention from abuse in psychiatry

• Judicial control over forced admission

• Active involvement of patients in their treatment

• Ensuring the patients’ access to information

• More effective financing of institutions

The second and third stages of human rights monitoring in psychiatric facilities in 2003and 2004 were carried out again by Mental Health and Society and Youth HumanRights Group. The monitoring was focused on the observance of human rights in theRMHC (second stage) and in the Chym-Korgon branch, now Chym-Korgon RepublicanMental Hospital (third stage). As a result, the monitoring organisations elaboratedfurther their claims and recommendations about the observance of human rights inpsychiatric institutions. In particular, it was concluded that, in spite of some initialimprovements, the right to access of information was not being followed. Numerousviolations of patients’ rights were reported, such as rights about giving consent totreatment, the provision of information related to existing disorders, goals and methodsof treatment, anticipated duration of treatment, possible side effects of administeredmedication and involvement in the care plan development, etc.

To achieve a greater observance of human rights, the following measures wereproposed:

• Improving professional qualification of doctors

• Introducing education on mental health and related law for the staff of psychiatricfacilities

• Introducing such education also for people with mental health problems, their friendsand relatives

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• Creating an independent service for the protection of the patients’ rights

• Creating alternative forms of care in the community

• Distributing resources according to real needs of institutions

• Facilitating access to appropriate medication for people with mental health problems

• Facilitating access to treatment of non-mental diseases for people with mental healthproblems

• Promoting self-help groups for relatives of people with mental health problems

• Strengthening control of the work of psychiatric institutions

Monitoring by MDAC

In 2003, the Mental Disability Advocacy Centre (MDAC), at the request of the Office ofthe President of the Kyrgyz Republic, conducted an examination of the extent towhich the mental health law and practice in Kyrgyz Republic complies withinternational standards and then gave recommendations to the Kyrgyzgovernment. In a report of 2004, MDAC analysed the system of mental healthcare in the Kyrgyz Republic against the international standard set out in 1991 inthe United Nations General Assembly Resolution 46/119 ‘Principles for theProtection of Persons with Mental Illness and the Improvement of Mental HealthCare. In particular, serious violations of basic human rights were reported:failures in providing patients with adequate food, medicine, and general medicalcare plus sexual exploitation of female patients. MDAC In order to resolve this,proposed the following measures:

• Developing an independent service to protect the human rights of psychiatric in-patients

• Providing training to mental health clinicians, hospital staff, lawyers, and judgesregarding the Kyrgyz mental health law, with a particular focus on the specificprovisions of the involuntary treatment procedures

• Providing training for judges, lawyers, and clinicians regarding the legalrequirements for forensic mental health assessments

• Implementing formal monitoring by an independent, qualified NGO with expertise inthe area of mental health law – or by a group of similarly qualified NGOs, workingcollaboratively – regarding the implementation of the involuntary mental healthtreatment procedures

• Ensuring sufficient funding to implement mental health law and the 2001-2010National Programme, and to implement involuntary commitment legal procedures ofthe 1999 Psychiatric Care Law

• Providing training to individuals with mental disabilities and their family about legalrights, how to obtain assistance with patients’ rights violations, and self-advocacyskills

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Since the publication of MDAC report, certain steps have been taken towards theimplementation of its recommendations. Since November 2004, Mental Health andSociety has been operating an advocacy service with the support of MDAC, on the baseof funding by the Open Society Institute. As part of the service, there are now complaintboxes in each ward of the Republican Center where patients can anonymously depositgrievances. Lawyers in the advocacy center and former users of mental health servicesare working together to resolve the complaints, which thus far include complaints aboutlack of food, involuntary detention and lack of information about diagnosis andtreatment.

On February 16, 2005, the Ombudsman of the Kyrgyz Republic, Mr. T. Bakir Uulu,signed a Memorandum with Mental Health and Society and MDAC, in which he pledgedto work with Mental Health and Society and MDAC to support the further developmentof the advocacy service. The Memorandum also encourages the government toimprove implementation of the 1999 Kyrgyz Law on Psychiatric Care, and goes on toemphasize the importance of human rights protection for people in Kyrgyz psychiatricinstitutions.

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VISITING THE INSTITUTIONS

Republican Mental Health Centre

The Republican Mental Health Centre (RMHC) is the main mental healthcare facility inthe Kyrgyz Republic. It is located in Bishkek, the capital, in vast green territory close totransport communications. The wards are located in brick buildings built in 1956,designed specially as a mental health clinic.

RMHC consists of 12 wards:

• 1, 7 & 9 – male wards for acute patients;

• 2, 8 & 10 – female wards for acute patients;

• 3 – mixed ward of open type for individuals with non-psychotic (‘psychosomatic’)disorders

• 4 –day care ward of open type;

• 5 – adult outpatient department;

• 6 – children outpatient department;

• 11 – ward for military examination;

• 12 – male ward located separately, in Novo-Pavlovka village

RMHC is a clinical facility for the Kyrgyz State Medical Academy and MedicalDepartment of the Kyrgyz–Russian Slavic University. The staff and patients of RMHCbenefit from a close association with the Kyrgyz Institute of Psychiatry and Neurology,headed by Dr. Valery Solozhenkin, Chief Psychiatrist for the Ministry of Health of theKyrgyz Republic. This university-affiliated institute provides professional training andcertification to students of psychiatry.

The average number of patients served today is 800.

The representatives of InterMinds were given an opportunity to talk to the doctors of thehospital during their regular meeting. There was clear interest in collaboration, both fromthe administration and from the doctors themselves. The staff of the rehabilitation wardand the children’s ward showed a particular interest. We met with these two groups ofpsychiatrists separately and heard a demand for a training programme about new formsof work with clients in the community. Both these groups of professionals work withclients’ families and are interested in getting to know more about similar experiencesfrom professionals in other countries.

Due to the efforts of NGOs, first of all Mental Health and Society, a user-oriented advicecentre, Infocentre, was opened in RMHC, in ward 5. Patients of the hospital and otherpeople with mental disabilities can get professional advice regarding the observance oftheir rights as well as information and other support to help resolve their problems. Aswell as this support, a self-help group is based in the Infocentre. The group meetsregularly in a warm and light room that is a good communication space for people who,in many cases, have lost contact with families and friends. Through the common efforts

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of staff and users of the Infocentre a few celebrations have been organised and the firstuser newspaper has been published.

The most discussed problem in the self-help group is the lack of employmentopportunities and the related impossibility of leaving the hospital and settling in theoutside world. As far as we know, this self-help group for users is unique to Bishkek.Groups for relatives meet in the rehabilitation ward with the support of the staff. Out ofthe hospital, in the community, there are no groups at all for users or their relatives.

Ward 12 of the RMHC

Ward № 12 is a male ward located on the outskirts of Bishkek, in Novo-Pavlovka villageand it is currently in the process of transition. The YHRG 2000 Monitoring reportdescribed the situation in the ward as “more disastrous” than in the other departmentsof the RMHC. Absence of telephone communications and transport is a problem. Alsothere is a great lack of staff and stealing by the local population takes place (theprovision of a guard is not envisaged). The buildings are in overall disrepair.Temperatures are low because of lack of coal for the stoves and due to a bad heatingsystem carbon monoxide seeps into rooms. The walls are painted dark, there are slotsof up to two centimetres in walls, and the floor in the dining facility is made of cement.

The MDAC 2004 report (that describes the situation in mid-2003) described theshortage of food and clothing in Ward 12. “Many of the patients stated that they werealways hungry and that in the winter they were very cold. Staff members stated that, forthe most part, patients survive on a few crusts of bread and water.” The electricalsystem worked only intermittently. A coal stove provided the only heat for the ward.Many of the windows were broken. “Water for bathing and drinking has to be carriedfrom a rusted pump in the yard”. The single toilet, at the time of MDAC’s visit, wasoverflowing with human waste and could not be used. Several of the patients had nomattresses and so had to lie directly on their iron bedsteads. Bed linens and blanketswere in short supply. The patients’ clothing was threadbare. Patient rooms werecrowded with beds, allowing for little room for movement and no privacy.”

Resulting from the efforts of human rights activists, the administration of RMHC becameaware of the problems at ward 12 and decided to transfer the patients kept in the wardinto the main part of the Centre in Bishkek. In practice, however, some patients whopreferred to stay in ward 12 were allowed to do so. A mini-ward with only 8 patients anda home-like atmosphere was what we saw when we visited Novo-Pavlovka in 2004, aconsiderable improvement.

Indeed the attitude of the clients of this ward toward their problems differedadvantageously from the spirit that prevailed in all other institutions we saw in thecountry. An oven is being stoked at the building, but it is warm only in one room whereall eight patients live. “To live” (zhit’) is the only verb that the patients use referring totheir stay in the ward. Zhekshen Aralbaev, the doctor of the ward who works mainly inthe main RMHC premises and comes to Novo-Pavlovka once a week, told us that allthose patients who had moved to Bishkek now wished to come back to ward 12. Theinhabitants of the ward cook and keep things in order themselves. They can go out fromthe ward and come back if they wish. They maintain good relations with neighbours. Anurse comes every day and helps the patients to organise their daily life. When wespoke to the clients, the talk was about plans to renovate the building, to plant flowers inspring, to bring in order their lives after stay in the hospital. The patients proudly keep a

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little library that mostly consists of religious literature. The territory of the ward embracesnot only the main building and a few household constructions, but a large yard: that isvacant ground that could be transformed into a garden.

Despite this very little, if anything has been improved in the physical environment in theward since the period of MDAC monitoring. The situation with heat and electricity ispractically the same. Water still has to be carried from a pump. However, the quality oflife of those who live in the ward after the majority have moved away has been visiblyincreased. Why?

The quality of life can be understood in different ways. Food, heat, clothing andmedicines are very important indeed. But for many people with mental health problemsself-dependency, freedom, and life in the community are more significant than safepredictability and artificial comfort. Both good material conditions and a good socialenvironment that allows autonomy and self-respect are essential.

Chym-Korgon Hospital

The psychiatric hospital in Chym-Korgon village is located 85 km away from the capital.The hospital serves the whole of the Kyrgyz Republic and also the southern oblasts ofKazakhstan. The YHRG 2000 Monitoring Report stresses the long length of patients’stay as a specific feature of the institution. The reason for this is the remoteness of thehospital and also that some patients have lost their identification documents, have nofamily or cannot afford staying at the RMHC in Bishkek (as this requires fees formaintenance and treatment). The hospital is comprised of 12 wards including a ward forTB patients, a ward for forensic examination of patients being in forced treatment, agerontology ward and rehabilitation wards. The hospital is meant for 850 beds but only400 were used when we visited.

Staff wages in Chym-Korgon hospital vary from 400 soms ($10) to 1,200 soms ($30)monthly, with the biggest salaries being those for psychiatrists. Director GhanybekAzhibekov told us that there is a high level of staff fluidity due to the low wages. Dailymaintenance of a patient is 30 soms ($0.75) although the maintenance of TB patients issomewhat larger, 40 soms ($1). This includes food (25 and 35 soms respectively), andmedicines (5 soms). The annual budget of the hospital amounts to 15 million soms($375,000).

Chym-Korgon Hospital is remote, located at the foot of the mountains (at least such isan impression, for mountains dominate over the landscape) and it naturally evokesidyllic associations. What can be as healing for a human soul as pastoral life close tonature? However, the institution has not escaped ill fame. A few clients who talked to usmentioned that whoever happened to come to Chym-Korgon will never get out of thecustodial system of psychiatric services (psikhushka).

Director Ghanybek Azhibekov invited us (we had come together with colleagues fromMental Health and Society) to his office, answered patiently to all our sharp questions,gave us an opportunity to see all the wards and to talk to the staff and clients. Duringour visit to the wards, a senior member of staff accompanied us all the time and literallysaw us to the gates. We interpreted this as a sign of hospitality and respect. Thismember of staff was in her forties or fifties and lives in a nearby village. Her salary in thehospital is about $12. The lady says that most young people in the village have goneabroad in search for their fortune, while she is not daring to move off. Life is hard at

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home, but at least she has a job here. This job is something she knows quite well, andall changes are frightening, after all. Better stability than uncertainty.

We saw two wards renovated by the staff and clients themselves (materials wereprovided by sponsors) and it was very warm because sponsors had provided newradiators in every room. Clients now have the opportunity to see their relatives in specialmeeting rooms, so step by step, the conditions are becoming better in all the wards. Yetthere is very little connection of the clients with the outside world and there is noopportunity for out-of-hospital care. The more clients remain in the hospital, the morethe medical staff are paid, so there is a perverse incentive to keep people in hospitaland admit new patients.

We saw a desolate ward that a year or two ago had been reported to sponsors as fullyrenovated, funded by the Central Asian Bank. There were modern double-glazedwindows (so called evropaket, “europackage”) bought from the most expensive window-producer in the country (maybe someone’s relative?) and a luxuriously tiled floor in theentrance hall. But there were no inside doors, not even door-frames, no plastering, nofloor. No electricity. No finish, in every sense of the word. A photographer who workswith Mental Health and Society took photos showing cobwebs and construction rubbishin the foreground. MHS is monitoring this situation carefully and highlighting it throughthe mass media as well as letting the authorities know about power abuses in mentalhealth institutions etc.

A power abuse story monitored by MHS is related to the ‘subsidiary farm’ (podkhoz) ofChym-Korgon hospital. There were all sorts of bad rumours about the farm. It was thebase of a separate hospital ward providing “vocational therapy” for patients but knownas a “labour colony”; numerous violations of human rights have been committed thereand the exploitation of patients was tolerated. These problems are very well reflected inthe MHS and YHRG 2003 report, and in the MDAC 2004 report. To quote the latter: “Atthe ‘Labour Colony’ patients are required to do work such as growing vegetables andother crops, as well as other types of labour, when residing at the hospital. Althoughthese patients spend all day, almost every day doing work to benefit the hospital, theyreceive no payment.”

Due to the efforts of human rights activists, the labour colony was closed. Howeversome patients were interested in having the opportunity of part-time work in the farm.MHS supports the efforts of the newly appointed Director of the farm, ZhenishbekEsezhaliev, in organising a social enterprise that will be able (such is the intention) tocombine the part time employment of patients while respecting their human rights inproviding the hospital with agricultural production.

In the meantime, some livestock is kept on the farm, but MHS discovered that muchmore livestock was present than the hospital officially holds. We witnessed how this factwas testified by the representatives of MSH, and a relevant formal statement was drawnup.

Iskra Social Care Institution

In Russian, the name of this kind of institution is Internat dlia psikhokhronikov, that is, “ahostel for chronically ill mental patients.” Such hostels, typical in all post-Sovietcountries, are designed for people with mental health problems who have lost theirfamilies or cannot live in the family for other reasons. The Internat is meant for 150

21

beds; at the time of our visit a few of them are free. There is an annual budget of 3million soms ($75,000) and the average daily maintenance fee is 30,7 soms ($0.75) perperson. Relatives rarely visit the inhabitants of the Internat, as most people who livehere have come from remote parts of the country. It is a state policy to move clients faraway from their communities and quite often the relatives’ desires go along with thispolicy.

The institution is situated on the outskirts of Iskra village, which provides an opportunityfor eight to ten men living in the Internat to find modest jobs in the village. The salary isfood rather than money, but this gives a chance for otherwise isolated and marginalisedpeople to go outside the institution and have a feeling of normal human life. The clientsof the Internat are men aged from 16 to 70.

Only twelve clients receive pensions, so very few inhabitants have cash in their privatepossession. All others are fully dependent on the Internat maintenance, whichabsolutely ties people to the institution and leaves no chance of moving away. All thepeople who receive pensions have been admitted recently and this minimal financialstability has been achieved due to the current Chief Psychiatrist of the Internat, herpredecessors never paid attention to the social problems of patients. She has abackground in paediatrics and is free from some negative professional attitudes found incertificated psychiatrists. She tries to resolve their social problems and wins theirrespect. It goes without saying that no social worker is provided for this, or for any othermental health institution in Kyrgyzstan.

Building renovation is underway and some clients live four persons in a room that isrelatively warm. However the first floor has not been renovated yet and is in a worsecondition. People live eight in a room there. The inhabitants of the institution have onlyone entertainment: to watch TV. Most books from hospital library are puffed away forrolled cigarettes.

There is a room in the basement where clients can have their hair cut and one of theresidents’ works as a hairdresser. He is happy to have this job. The hairdresser isyoung, and was transferred to the institution from an orphan boarding school. He stillhas friends in the outside ‘large’ world and is one of a few inhabitants of the Internatwho wishes to move away, believing that one day he will find a job beyond theboundaries of the institution.

The Internat has its own bakery, and equipment for cooking macaroni was beinginstalled when we visited. The refectory is quite large, but people eat in two shifts. Themidday meal (obed) is the central daily event. People start gathering in the refectorybeforehand, and do not hurry to break up afterwards. The refectory has two entrances:one connects it to the residential building, another one is external. The area outdoorsaround the external entrance is open to a little Internat garden. This is a place whereclients talk to each other and smoke after the meal. Occasionally, ladies from the juniorstaff talk to them, as if it was a habitual gathering of people in a village. The talk is vividbut short: it is quite cold in January, in spite of sunny weather. Ladies go aside soon andstart talking about their families. Men finish their cigarettes, and huddle up. They haveonly one opportunity left, to come back to the building and the area outside the refectorybecomes empty.

Only giant mountain peaks, covered by snow, still stay in the garden. As usual, theyseem much closer than they really are. A permanent feature of Kyrgyz life, these samemountains are seen from the windows of every mental health institution in the country.Unlike living beings who come and go, mountains are always a part of the landscape.

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PART 2

KYRGYZSTAN TODAY1

1 Information contained in Part 2 is borrowed from a number of sources quoted at the end of the report, inthe section “Principal References”, subsections “Part I” and “Internet Resources”. We express our specialgratitude to R. Stewart and S. Weldon, the authors of the excellent book “Kyrgyzstan” (2002), and to theauthors of International Crisis Group Asia papers N°25 (2003) and N°81 (2004).

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GEOGRAPHY

Kyrgyzstan has a population of just over 5 million1 people, the same as Scotland, in aland covering approximately 198,500 square kilometres, about the size of Great Britain.It is a mountainous country in the Tien Shan and Pamir systems, with an averagealtitude of 2,750 metres. About a third of the country is perennially covered with snowand glaciers and many lakes and fast-flowing rivers drain from mountains. Deep valleyscut dramatically through majestic Alps, with flat areas only in northern and easternvalleys. The domination of the Tien Shan, ‘Mountains of Heaven’, gives to Kyrgyzstanits unique character as the ‘jewel’ of Central Asia. The climate varies from polar in highTien Shan to subtropical in Ferranti Valley on the southwest, but in most places thesummers are hot and dry while the winters are cold, with temperatures ranging from 2°Cin January to 18° C in July.

The country is bordered by Kazakhstan in the north and north-west, Uzbekistan in thesouth-west, Tajikistan in the south and China in the south-east. This geographicalposition has historically made Kyrgyzstan a gateway to the west for warriors as well astraders. The major cities are Bishkek (the capital), Osh, Dzhalal-Abad, Tokmak andPrzhevalsk.

Kyrgyzstan has a large variety of flora and fauna and is particularly rich in medicinalherbs. However, many industries use highly poisonous substances without properstorage sites. Radioactive pollution related to uranium dumps, contamination by DDT,water and soil pollution with increasing soil salinity, overgrazing of grasslands,degradation of forests and the extinction of animal and plant species are part of a longlist of major environmental problems. The government has recently developed aNational Biodiversity Strategy to start addressing this.

Ecological and social issues are correlated today more than ever. Preserving the fragileenvironmental balance is appreciated as a task of similar value and complexity asensuring a balanced system of social justice in human society.

1 July 2004

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HISTORY

The presence of human society in what is modern Kyrgyzstan began about 200,000 to300,000 years ago. The first written records of a Kyrgyz civilisation appear in Chinesechronicles beginning about 2000 B.C. If there has been anything permanent in a longline of emerging and dying great khanates and empires since that time, it is probably theSilk Route, a trade road throughout the Kyrgyz valleys, connecting a range ofcivilisations from Beijing to Rome. A titanic exchange between cultures, religions andtraditions has thus contributed to the genesis of Kyrgyz people from the very beginning.

The modern nation of Kyrgyzstan is based on a civilisation of nomadic tribes whomoved across the eastern and northern sections of Central Asia. They mixed with othertribes and peoples who have influenced the current character of the Kyrgyz people. Thefirst Kyrgyz state, the Kyrgyz Khanate, existed from the sixth until the thirteenth centuryAD and established intensive commercial contacts with China, Tibet, Central Asia andPersia.

The invasion of Mongols into Central Asia in the fourteenth century devastated theterritory of Kyrgyzstan, costing its people their independence and their written language.For the next 200 years, the Kyrgyz remained under the Golden Horde (Mongols) andthe Oriot and Jumgar khanates that succeeded that regime. Freedom was regained in1510, but the Kyrgyz tribes were then overrun by the Kalmyks in the seventeenthcentury, the Manchus in the mid-eighteenth century and in the early nineteenth centuryby the Uzbeks. The Kyrgyz began efforts to gain protection from more powerfulneighbouring states in 1758, when some tribes sent emissaries to China. A similarmission went to the Russian Empire in 1785.

In 1876 Russian troops defeated the Kokand Khanate and occupied northernKyrgyzstan. Within five years, all Kyrgyzstan had become part of the Russian Empire,and the Kyrgyz people slowly began to integrate themselves into the economic andpolitical life of Russia. In the last decades of the nineteenth century increasing numbersof Russian, Ukrainian and German settlers moved into the northern part of present-dayKyrgyzstan. The negative effects of the Russian Empire's repressive policies becameclear. Land confiscation, large taxes, forced labour, and price policies all targeted theindigenous population and raised discontent and regional tension. The great rebellion of1916, which rushed through Central Asia, gave expression to widespread resentmentagainst the injustices of the Russian Empire.

The nomadic Kyrgyz resisted conscription into the tsarist army in 1916 and fought theestablishment of Bolshevik control from 1917 to 1921. As a result of war anddevastation there was a famine in 1921–22 in which over 500,000 Kyrgyz died. Thearea was formed into the Kara-Kirghiz Autonomous Region within the Russian SovietFederated Socialist Republic in 1924, becoming an autonomous republic in 1926 and aconstituent republic in 1936.

In 1990, Askar Akaev, president of the republic’s Academy of Sciences and a non-Communist, was elected president by the legislature. After fighting off an attemptedcoup in 1991, the government declared Kyrgyzstan independent of the Soviet Union.

Kyrgyzstan proclaimed its independence from the Soviet Union on 31 August 1991 andon 21 December 1991; Kyrgyzstan joined the Commonwealth of Independent States.The country joined the UN and the IMF in 1992 and adopted a radical economicprogram after voters endorsed market reforms in a referendum held in 1994. In 1996

25

referendum voters overwhelmingly endorsed proposed constitutional changes thatenhanced the power of the president. Representatives of the country along with those ofRussia, China, Kazakhstan, and Tajikistan signed a non-aggression agreement in April1996.

In 1997, Russian border control was extended as authorities in Kyrgyzstan grewincreasingly concerned about the growth of the illegal narcotics trade in the country.Another concern has been that since 1999, several groups of radical Islamic gunmen,believed to be from Uzbekistan or Tajikistan, have led raids and kidnappings fromcamps in Kyrgyzstan's mountains.

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THE PEOPLE

Kyrgyzstan is a multi-national society comprising at least 23 national groups. The ethnicmajority are the Kyrgyz who form 64.9% of the population. Minorities include Uzbeks(13.8%), Russians (12.5%), Dungans (1.1%), Ukrainians (1%), Uygurs (1%) and other(5.7%). The main religions are Muslim (75%) and Russian Orthodox (20%).

A major problem following independence has been large-scale migration. In particular,considerable numbers of minority populations have returned to the countries of theirancestors’ origin. According to UNDP statistics, between 1991 and 1998 the Russianpopulation reduced by 273,000 and the German population by 61,000. In general,during the same period one seventh of the population of Kyrgyzstan moved into, out ofor around the country. Migration can be explained mainly due to economic motives,although some inter-ethnic tensions have been reported by independent observers.

Following independence in 1991, Kyrgyz was established as the state language. Inpractice Russian remained dominant and most commonly used in government andofficial business, although Russians and other minorities were faced with the need tolearn Kyrgyz. A Kyrgyz language exam was established in 2000 for presidentialcandidates and in 2001 the Parliament made Russian a second state language, on anequal footing with Kyrgyz.

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CULTURE

The tightest geographical and historic description of Kyrgyzstan is the one given by TheWorld Factbook: “A Central Asian country of incredible natural beauty and proudnomadic traditions.” The emphasis on nomadic traditions might seem to be anexaggeration, but it is not. One of the most striking features of modern Kyrgyz culture isthat its core values have survived the enforced century-long transition from nomadic tosettled life.

One of these values consists in the central role of tribal and regional lineage for Kyrgyzidentity and society. Today there are some 30 Kyrgyz tribes (sanjira). They are groupedinto two main regional blocks, the northerners (Tagai), who include the tribes of thecentral plateau and the Kyrgyz living in Kazakhstan; and the southerners (Ich Kylyk),who include the Kyrgyz of Tajikistan and China. Tribes of the central plateau are alsooften considered to be a ‘third force’. This tribal division has a clear influence on Kyrgyzpolitics and cannot be underestimated as an important societal factor relevant to mentalhealth issues

Tribal connections are a natural extension of traditional family ties and an extraordinaryrespect is given to the family in the Kyrgyz society. Many traditional practices related tofamily life have survived through Soviet times: dowries are still given, and even brideprices are occasionally paid in spite of the fact that bride price was considered to be acrime against the Soviet state. A traditional hierarchy of family roles, fastened togetherwith respect for elders is imbued in children and constitutes the real ground of Kyrgyzsocietal life, as opposed to officially declared policies such as communist ideology in theSoviet times. Traditional society consisted of villages (ails); each ail was a kind ofextended family and comprised one man (the chief), and his unmarried daughters andthe families of his married sons. At the head of a group of ails was an elder called bi, ormanap. The competence of a bi concerned the general welfare of the group; he madedecisions for the good of his community with a help of a council of advisers (aksakals),elder men from the ails of his community. Neither the bis, nor the aksakals, wereelected, instead their authority came from their age and wisdom.

In accordance with the Kyrgyz tradition, one of the advantages of being nomadic lies inthe privilege of the ail to move away and join another group of tribes if the bi’s rule isunwise. A 19th-century scholar stated that the Kyrgyz “had neither princes nor nobles;the elders… were not chosen by any kind of election, but owed their position entirely totheir personal influence.” Thus love of freedom is a peculiarity of Kyrgyz nomadicculture. Among nomads, the power of clan leaders is much stronger than that of anyappointed governor. Similarly, the impact of the natural world on personal identity ismuch stronger than that of any sort of fixed state system. Kyrgyz folklore, music andhandicraft perfectly reflect this nomadic attitude to nature.

Any system of care for people with mental disabilities must take account of such culturalissues.

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POLITICS AND SOCIETY

Kyrgyzstan has managed to retain at least some of the liberalism that marked it in theearly 1990s. The Kyrgyz government has succeeded in showing itself more progressivein terms of economic reform and liberalisation than other neighbouring countries. It hasbeen particularly good in presenting itself to international community as a democratic,reforming partner in an otherwise difficult region. But high-level corruption and poorgovernance have inhibited economic growth. As a result, many ambitious plansannounced at international gatherings have not turned into reality

Increasingly the political system came to be dominated by a small group aroundPresident Akaev and the opposition was sidelined and independent media came underpressure. In 2000, President Askar Akaev easily won re-election with nearly 75% of thevote, but the election was marred by allegations of fraud, diminishing Kyrgyzstan’s claimto be the centrepiece of Central Asian democracy.

In 2001, Kyrgyzstan permitted troops from the US and seven other nations to bestationed in the country in support of efforts to fight against the Taliban and al-Qaeda inneighbouring Afghanistan. In 2002, construction of a large US airbase began outside ofBishkek. In February 2003, a controversial referendum expanded Akaev's powers, andin June Parliament granted him lifelong immunity from prosecution.

Akaev did achieve much, particularly in laying the foundation for economic reform andensuring political stability. The constitution commits the Kyrgyz government to ademocratic, secular society with freedom of worship and expression and uncensoredpress, but the sincerity of the government’s commitment to this over the last few yearswas seriously put in doubt.

Kyrgyzstan faced the difficult question of how to achieve political transition peacefullyand without losing the gains of the past decade. In March 2005 protests against theresults of the February election forced the resignation of the government and Akaev leftthe country. A new government was formed. At the moment, there are signs of growingstability. Many people pin their hopes on the presidential elections which are expectedon the 10th of July, 2005. People believe that Kyrgyzstan is destined for a democraticand prosperous future.

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THE ECONOMY

The Kyrgyz people have traditionally excelled in wood carving, carpet weaving, andjewellery-making. In agriculture Kyrgyzstan has rich pasturage for goats, sheep, cattle,and horses. Over 80% of the cultivated area is irrigated and cotton, potatoes, sugarbeets, tobacco, vegetables, fruit and grapes are grown. Grain crops are cultivated in thenon-irrigated areas. Kyrgyzstan has deposits of antimony, gold, molybdenum, tin, coal,tungsten, mercury, uranium, petroleum, and natural gas. Industries include foodprocessing, sugar refining, non-ferrous metallurgy, and the manufacture of agriculturalmachinery, textiles, building materials, appliances, furniture, and electric motors. Thenegative impact on the environment of these industries has already been mentioned.The leading exports are cotton, wool, meat, tobacco, metals (particularly gold, mercury,uranium, and steel), hydropower, and machinery; chief imports are grain, lumber,industrial products, ferrous metals, and fuel. The main trading partners currently areother former Soviet republics and China. In 1998, Kyrgyzstan became the first formerSoviet republic to join the World Trade Organisation.

Despite all its problems, Kyrgyzstan makes some slow moves forward. Privatisation ofagriculture was initially a disaster in many areas, as farmers sold their cattle for moneyrather than invest for the future. But now in some areas private agriculture is beginningto pick up. In 2002 agricultural exports were up 30 per cent, and new schemes forfarmers in southern Kyrgyzstan led to possible exports of fruits, vegetables and flowersto Russia, Europe and elsewhere. Most of these schemes are still a long way fromfruition, but at least tobacco and cotton are now exported privately.

Some evidence of modest economic progress can be seen from the official data of theKyrgyz National Statistical Committee presented below.

Table 7. Main indicators of social and economic development of theKyrgyz Republic in 1998-2002 (in % to the previous year)

1998 1999 2000 2001 2002Gross domestic product 102.1 103.7 105.4 105.3 100.0Gross capital formation 15.4 18.0 20.0 18.0 17.6Gross savings -8.2 1.2 14.4 16.8 17.4Industrial products 105.3 95.7 106.0 105.4 89.1Gross output of products andservices of agriculture, hunting andforestry. 102.9 108.2 102.6 107.3 103.1Capital investments 64.6 121.5 137.3 85.5 90.4Passengers carried by all types oftransport 114.5 95.7 111.4 100.8 92.7

Annual average of employed ineconomy, thsd. people 1704.9 1764.3 1768.4 1787.0 1807.1Average wage, soms 840.6 1049.9 1227.0 1455.1 1684.4Number of unemployed, thsd. people 106.4 136.8 144.3 152.1 169.5

Including officially registeredunemployed people 55.9 54.7 58.3 60.5 60.2

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Exports of goods and services 597.9 527.5 572.7 560.6 636.5Imports of goods and services 931.4 705.4 655.7 565.1 697.6Som’s rate to dollar (for the end ofthe period) 29.38 45.43 48.30 47.72 46.09External debt 1480.3 1647.4 1703.8 1677.7 1784.6Minimum consumer budget percapita ,soms 799.3 1097.1 1205.31 1316.45 1404.78

Poverty level, in % 54.9 55.3 52.0 47.6 44.4Among them extreme poverty 23.0 23.3 17.8 13.5 13.8

Table 8. Main indicators of social and economic development of theKyrgyz Republic in 2004 (million Soms)

Actual Jan-Dec 2004as a

percentage ofJan-Dec 2003

Referencedata: Jan-Dec2003 as a % ofJan-Dec 2002

Gross Domestic Product(preliminary estimation) 5413.5 105.5 105.5Industrial Production Volume(works, services) – Total 4580.1 101.6 102.7

Mining 73.8 102.0 94.1Manufacturing 3221.5 99.0 105.0Energy, gas and waterproduction and distribution 1284.8 106.9 97.5Agriculture, hunting and forestrygross output 1826.5 101.1 100.0Agricultural Production Output byall holding categories, thsd. tons:Cattle and poultry for slaughter(live weight) 24.8 100.2 100.1Raw milk 60.3 102.3 98.0Eggs, mln. pieces 16.1 113.2 120.0

Fixed assets investments(investments) accounting allfinancial sources 152.7 95.7 84.1Gross construction output 153.8 108.2 101.9Consumer Price Index 103.6 105.7- as of December 2004 101.3Officially registered unemployed,thsd. Persons 58.4 101.3 95.6Nominal average monthly wageper employee, Soms 2202.9 114.7 117.6Export, mln. USD 718.8 123.6 119.8Import, mln. USD 941.0 131.3 122.2

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Our overview of recent economic development in Kyrgyzstan can be summed up by aquotation from ICG paper “Central Asia: A Last Chance for Change” (2003): “PresidentAskar Akaev has managed to achieve the most liberal political and economicatmosphere in the region, but fine words do not always translate into good practice. …Some economic reforms have been made, but much more could be achieved if aserious effort was undertaken to tackle corruption at all levels and if the presidentialfamily and friends restricted their appetites to control the most lucrative sectors.”

“Kyrgyzstan's society has become more mature since independence but its governmentmore authoritarian,” suggests an International Crisis Group Report on political transitionin Kyrgyzstan. The Kyrgyz regime of this day can be best described as a kind of softauthoritarianism: a semblance of democratic politics with some independent media andopposition representation in parliament remains, partly due to particular aspects of Kyrgyzpolitical culture – nomadic tradition and lack of authoritarian political customs – and partlyto decisions taken in the early 1990s to forge a political system based largely on pluralismand tolerance.

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CONCLUSIONS

33

A POTENTIAL ROLE FOR INTERMINDS

There is considerable need to develop community mental health services in Kyrgyzstan.The representatives of InterMinds discussed with Mental Health and Society theopportunities for common projects. Four directions of work for the improvement of themental health situation in Kyrgyzstan were proposed.

1. Creation of new and support for existing groups that work on mental health problemsout of hospital, involving users in the work of these organisations, and supportinguser initiatives in creating independent self-help groups. As a result of this work, anetwork of mental health organisations working in the community can be created.

2. Elaboration and implementation of a training programme for relatives of people withmental health problems. In the organisation of this programme, a range of NGOssuch as Act in Support of the Family, Family and Society etc. should be involved.Knowledge about the needs of users of mental health services, their relatives andprofessionals, systematically carried out by Mental Health and Society, should beaccumulated.

3. Training professionals in methods of out-of-hospital work through workshops oncommunity care for psychiatrists, psychologists and social workers.

4. Transformation of ward 12 at RCMH into a community based service for people withmental health problems. Users can be involved in the renovation work of the buildingand surrounding land. Such a community based service can serve differentpurposes: provide out-of-hospital accommodation for users, be a placement for adaily community centre with a range of leisure and training programmes, etc. Thiswould require co-ordination between InterMinds, Mental Health and Society, theadministration of RCMH and the Ministry of Health.

The final selection of the directions of InterMinds’ and MHS joint project is subject tofurther consultations between the two organisations.

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ANNEXES

35

SCHEDULE OF VISITS AND MEETINGS

(Participants from the part of InterMinds are shown in brackets)

2005, January 11, Monday

11.00: Acquaintance with Public Association “Mental Health and Society”

Conversation with the members of the Association (Olga, Andriy)

January 12, Tuesday

8.30: Official introduction to the staff of the Republican Mental Health Centre

(Olga, Andriy)

9.00: Visit to the Information Centre at RMHC (Olga, Andriy)

11.00: Meeting at Freedom House with Stuart Kahn, Programme Director

(Olga, Andriy)

16.00: Meeting at the OSCE Centre in Bishkek with Christian Knust, Human

Dimension Officer, and the staff of the (Peter, Olga, Andriy)

January 13, Wednesday

11.30: Visit to Iskra Social Care Institution (Peter, Olga, Andriy)

Interviewing Kylychbek Akhmatov, Director

Interviewing staff and patients

14.00: Visit to the Chym-Korgon Psychiatric Hospital (Peter, Olga, Andriy)

Interviewing Ghanybek Azhibekov, Director

Interviewing staff and patients

January 14, Thursday

11.00: Meeting with users’ self-help group at the RMHC Information Centre

(Olga, Andriy)

Interviewing users

14.30: Meeting with the staff of RMHC (Peter, Olga)

Interviewing staff and patients

16.30: Visit to the Ministry of Health of the Kyrgyz Republic (Peter, Olga)

Interviewing Dinara Sagynbaeva and Gulmira Ibraeva

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January 15, Friday

10.00: Meeting with Zhenishbek Esezhaliev, Director of Chym-Korgon Farm

(Peter, Olga, Andriy)

11.00: Meeting with Keneshbek Usenov, Head of Bishkek City Centre of

Psychiatric Help (Peter, Olga, Andriy)

11.30: Meeting with Kanchaiym Tokusheva, NGO “Act in Support of Family”

(Peter, Olga)

12.20: Visit to the Ward 12 of RMHC (Peter, Olga, Andriy)

Interviewing Zhekshen Aralbaev, Head of the Ward 12

Interviewing staff and patients

15.00: Meeting with Public Association “Mental Health and Society”

(Peter, Olga, Andriy)

Elaborating a plan of common actions

16.00: Meeting with the activists of the Kyrgyz Psychiatric Association

(Peter, Olga, Andriy)

Interviewing Victoria Malobekova, Lilia Panteleeva and Mikhail Popkov

17.30: Meeting with Larisa Lee, journalist, newspaper “MSN” (Peter, Olga, Andriy)

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PERSONS AND ORGANISATIONS

(In chronological order of meetings)

Burul Makenbaeva, Director of NGO “Mental Health and Society”

Members of the Public Association “Mental Health and Society”: Kanchaiym Tokusheva,Keneshbek Usenov, Aigul Kyzalakova, Svetlana Akhmatova, Azeema Ibraeva, ChinaraIsmailova, Salkynaj Akaeva, Bermet Tolubaeva, Almaz Kalbaev, Almaz Bekbaev,Andrey Danilchenko, Nurbek Toktakunov

Keneshbek Usenov, Head of Bishkek City Centre of Psychiatric Help

Psychiatrists at RMHC

Aigul Kyzalakova, Andrey Danilchenko, Information Centre at RMHC

Stuart Kahn, Programme Director, Freedom House

Christian Knust, Human Dimension Officer, the OSCE Centre in Bishkek

Staff at the OSCE Centre in Bishkek

Larisa Lee, Journalist, newspaper “MSN”

Kylychbek Akhmatov, Director of Iskra Social Care Institution

Staff and patients at Iskra Social Care Institution

Ghanybek Azhibekov, Director of Chym-Korgon Psychiatric Hospital

Staff and patients at Chym-Korgon Psychiatric Hospital

Zhenishbek Esezhaliev, Director of Chym-Korgon Farm

Toktayim Umetalieva, President of the NGO Association

Users’ self-help group at RMHC

Dinara Sagynbaeva, Gulmira Ibraeva, Ministry of Health of the Kyrgyz Republic

Kanchaiym Tokusheva, NGO “Act in Support of Family”

Zhekshen Aralbaev, Head of the Ward 12 of RMHC

Staff and patients at the Ward 12 of RMHC

Victoria Malobekova, Kyrgyz Psychiatrist Association

Lilia Panteleeva, Mikhail Popkov, Kyrgyz Psychiatrist Association and NGO “Family andSociety”

Nazgul Turdubekova, Youth Human Rights Group

Uulkan Itikulova, Children Psychiatrist at RMHC

Juliana Chigaeva, Children Psychiatrist at RMHC

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Yelena Dolgikh, Psychoteurapist, Centre for Children with Autism and LearningDisabilities, Bishkek

Zhanyl Alyshkulova, Speech Therapist, Centre for Children with Autism and LearningDisabilities, Bishkek

Marina Zemlianykh, Co-ordinator, Centre for Children with Autism and LearningDisabilities, Bishkek

Nazgul Mirzamatova, Children Psychiatrist at RMHC

39

EXCERPT FROM THE LAW OF KYRGYZ REPUBLIC

On Psychiatric Care and Guaranteeing Rights of Persons Receiving SuchCare (1999)

“Article 5. Rights of persons having mental disorders.

1. Persons having mental disorders have all the rights and freedom provided by theConstitution of the Kyrgyz Republic. Limitations of rights and freedom related topsychiatric care are permitted only in cases provided by the legislation of the KyrgyzRepublic.

2. All persons having mental disorders and receiving psychiatric care have rights for:

• respectful and humane treatment excluding humiliation of human dignity;

• receiving information about their rights, the nature of mental disorders and treatmentmethods applied in a comprehensible manner and taking into account their medicalcondition;

• psychiatric care in conditions limiting their freedom to the least possible extent and ifpossible at home;

• to be kept in in-patient psychiatric institutions only for a period necessary forexamination and treatment;

• all kinds of care (including resorts) based on medical indications in the absence ofcontraindications;

• psychiatric care in conditions satisfying basic sanitary-hygiene requirements;

• prior permission or rejection at any stage regarding usage as objects of experimentsof medical means and methods, scientific research of training process,photo/video/film recording;

• invitation of any specialist participating in the provision of psychiatric care to engagein activities of medical committee regarding matters specified in the present Law;

• assistance of a lawyer, legal representative or other persons in accordance withprocedures set by the legislation of the Kyrgyz Republic.”

“Article 16. Types of psychiatric care and social protection guaranteed by the state.

1. The State guarantees:

• emergency psychiatric care;

• consultative-diagnostic, treatment, preventive and rehabilitation care in out-patientand in-patient institutions;

• all types of psychiatric assessment, identification of temporary inability to work;

• social and legal assistance and support in finding employment for person havingmental disorders;

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• guardianship issues;

• consultations on legal matters and other kinds of legal assistance in psychiatric andpsycho-neurological institutions;

• provision of social assistance for the disabled and elderly having mental disorders aswell as provision of care;

• training of disabled and minors having mental disorders;

• psychiatric care during disasters and emergencies.

2. For the provision of psychiatric care and social protection for persons having mentaldisorders, the State:

• establishes all kinds of institutions providing out-patient and in-patient care, ifpossible near the residence of the patients;

• organises mainstream and vocational education for minors having mental disorders;

• creates special production enterprises for work therapy, vocational training andemployment for persons having mental disorders, including the disabled as well asspecial production shops or sections with simple working conditions for suchpersons;

• receives complete and efficient information regarding the availability of vacanciesfrom employment agencies;

• establishes obligatory quotas for various enterprises, institutions and organizationsto employ persons having mental disorders;

• applies methods of economic stimulation for enterprises, institutions andorganisations accepting persons having mental disorders;

• creates dormitories for persons having mental disorders who have lost their socialconnections;

• takes other measures necessary for the social support of persons having mentaldisorders.

3. Provisions of all types of psychiatric care and social protection for persons havingmental disorders, is implemented by central and local government agencies inaccordance with their competencies determined by the legislation of the KyrgyzRepublic.”

“Article 17. Funding of psychiatric care.

Funding of institutions and persons providing psychiatric care is implemented from thestate budget, the fund of compulsory medical insurance and other sources not forbiddenby the legislation of the Kyrgyz Republic in amounts necessary for the guaranteed leveland high quality of psychiatric care.”

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INFORMATION FOR THE COLLEGIUM MEETING (Excerpt)On State of the Mental Health Service in Osh, Jalal-Abad, and Batken

Oblasts and on Activity of Republican Mental Health Center asOrganizational and Methodological Center of the Service

(Translation was provided by Mental Health and Society)

Lethality in psychiatric hospitals remains at the level 1-1,4 (in 2002 it became 1,4),however, it was founded that death rate was persistently underestimated in the affiliateof the №1 RMHC starting from 1997, what impacted the general country indicator. So,for example, in 2002, instead of 146 died patients only 61 (41,8%) was reported, in2001- instead of 142 cases - 55 (38,7%) was recorded, in 2000, instead of 75- 45 (60%)patients, etc. And besides, there was a wide practice of burials without autopsy (in2002- 66,7%.) or there were cases of discharging patients as alive, and receivingsignatures of their families for receiving corpse (5 cases). There are no patients’ dyingdescriptions, courses of death are not mentioned in epicrisis, appropriate health care isnot provided in case of a patient’s state deterioration, diagnosis very often are correctedon cover pages of patients’ files. In 8 patient records, of patients died in 2001, there isno mentioning of burial or handing in the body to its relatives. Since1997 up to 2002 -24 corpses were sent to the department of operative surgery of the Kyrgyz MedicalAcademy in 2002, but results of autopsy are mentioned only in 2 case histories.Therefore, the share of autopsies in 2001 was 2,1% (3 ), in 2002 – it was 28,2% (40 ).Analysis of 43 autopsies, made in 2001-2002 showed that in 35 cases (81,4%) thecourse for death was intoxication of the body as a result of tuberculosis, in 5 cases(11,6%) – ischemic heart disease and in 4 other cases – there were some othercourses. For the period from 1997 up to 2002, the affiliate №1 of the RMHC handedover 157 unclaimed corpses and 33 died people in hospital-house for chronic mentallyill patients in a village Iskra to the department of operating surgery and topographicalanatomy. During supervision, it was founded that in 16 cases died people wereregistered as discharged, but in fact, their corpses were handed into the plastinationcenter of the Kyrgyz State Medical Academy. There are no death certificates for those146 died people in the affiliate №1 of the RMHC and 33 died people in hospital-housefor chronically mentally ill patients in a village Iskra, and in accordance to statisticsthese patients are alive, as their deaths were not registered in special registrationagency.

Since 28.08.02 director of the hospital-house for chronic mentally ill patients Akmatovand chief doctor of the affiliate №1 of the RMHC Mamyrbayeva B.К. made anagreement (№ 02/255 dated 4.09.02.), where the administration of the hospital-housefor chronic mentally ill patients is committed to pay the affiliate 350 soms per eachburied corpse and promise to deliver it to mortuary for burying in hospital cemetery.However, breaking their own agreement, the affiliate №1 of the RMHC sent 33 corpsesto the operative surgery departments, and none of documents registered receipt of themoney agreed in amount 11 thousands 550 soms. In Osh oblast center, there were 4cases of death in 2003 and 12 cases of death in the Republican mental health hospitalin a village Kyzyl-Jar, and in no cases the autopsy was made, and the course of deathwas not founded.

Unjustified delays of patients in hospitals have actually transformed large mentalhospitals into long-term asylums, where 2/3 of all patients don’t need any treatment inhospitals. During check-up, no one patient with acute psychotic symptomology,requiring supervision, and active and intensive treatment in hospitals was found (Isfana,Batken, Kyzyl-Kiya, Mailuu-Suu, affiliate №1 RMHC). SO in RPH in Kyzyl-Jar the

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patient stayed with one purpose – “observation” in the following departments: № 1-14,3% of patients, № 4-35,9%, №5-11, 8%, № 10-8,1% of patients. Departments in №№ 7and 11, where mentally ill patients ha TB as well, more than 90% of all patients don’treceive anti-psychotic treatment and can be discharged based on their psychoticconditions. In the affiliate №2 of the RMHC more than a half out of 45 patients didn’treceived any treatment, so, in fact they stayed their in regime of “asylum”.

There are serious deficiencies in organization of rehabilitation process. In major part oflarge mental hospitals, rehabilitation departments were created, but they don’t functionas they should, for example in rehabilitation department of Osh oblast mental healthcenter patients instead of working or doing different rehabilitation activities, stay allmorning in fenced space designed for walking. The same thing is happening in psycho-narcological departments in RMHC affiliates in the following towns: Isfana, Batken,Kyzyl-Kiya, Mailuu-Suu. Newly created rehabilitation departments are simply having aname for it, but they are not equipped with necessary equipment, don’t have trainedspecialists and don’t have well developed technologies for rehabilitation process.Hospitals don’t have conditions for labor rehabilitation of patients, sewing workshopsare not operating and don’t have trained specialists (RPH in Kyzyl-Jar, RMHC affiliatein Chym-Korgon), there are no lawyers, social workers, labor instructors, socialassistant service in hospitals, who would work for providing links with social securityagencies and assist in patients’ adaptation.

Absence of approved rules for involving patients into labor, brings to casual involvementof patients to different works, very often connected with hard physical load, andcompensation for this work is not regulated (except sewing workshops), what isstipulated by our legislation. Involvement of patients for work in private homesteadlands in Kyzyl-Jar was indirectly confirmed by orders, issued by hospital administrationon 1999 – 2002 saying that “some cases were detected, when heads of departmentssend patients to private works and one of the points says that “it is prohibited for allheads of departments and chief nurses to send patients for private works in the village”(orders, dated 21.04., 1999 №19; 7.03.2001; and 30.06.2003г. №17). Office of publicProsecutor of Kemin rayon has confirmed the cases of using patients for working inprivate gardens or other private works for doctors in the RMHC affiliate №1. So head ofthe Department Talipova R. has permanently used a patient К.В. for her domesticworks, and patients C.C., the former taxi-driver was in fact making repair works ofdirector’s Adjibekov hospital car, patients from labor rehabilitation department don’treceive any compensation for their work.

Therefore, despite the implemented work for improvement of the mental health service,the speed of its reforming and quality of provision mental care in the country remainpoor. A number of mental disorders and related disunities keep on growing, alternativeforma of care are not introduced, there is no real efforts to extend psychotherapeuticand children mental health services, day-time hospitals, mental health service is notreally close to population, small crisis departments in territorial hospitals are notcreated, there is not proper interaction with family doctors for early detection of mentalpathology, in particular its “mild” forms, there are numerous violations of patients’ rights,when mental care is provided, the Kyrgyz Republic Law “On Psychiatric Care andGuarantees of Citizens Right when It is Provided”. Mental health service does not makeany efforts to decentralize the service, to break up large mental health center intosmaller units and integrate them into the general network of healthcare facilities;organization of non-hospital rehabilitation for patients with hard mental disorders isneeded.

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Head of the Department of Organization of Health Care К.B.Mambetov

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MATERIALS OF THE 13TH LOCAL POLICY FORUMREGARDING MENTAL HEALTH ISSUES (Held in February 2005)

Questions• What needs do you have?• In what skills are you interested to be trained, in order to become able to influence

actively on mental health policy?Responses (in the order of priority)1st group – professionals:• Information about mental health law, public health law

• Skills in writing project proposals

• English, computer skills

• Lobbying in local government, public health, social care system

• Training, seminars, study tours

• Literature, information

2nd group – users:• Computer skills

• Writing project proposals

• Sharing experience with other self help groups in different countries

• Group working under the support of professionals

• Lobbying

• We need to be employed

• Training on patient’s rights

• Kyrgyz, English

3rd group – family members• Training in mental health law and human rights

• Ability and knowledge to build relations and live together with a mentally ill person.How to avoid conflicts

• Positive experience in other countries

• Lobbying skills

• Organisation of self help groups of family members

• Opportunities to improve the quality of mental health services provided by the state

• Information on the responsibility of state institutions, for indicating the direction oflobbying

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JOINT PRESS RELEASE

BY THE MENTAL DISABILITY ADVOCACY CENTER AND KYRGYZ NGO“MENTAL HEALTH AND SOCIETY” OF 16 FEBRUARY 2005

Kyrgyz Ombudsman Supports Human Rights Protection of People with MentalDisabilities

16 February 2005, Bishkek and Budapest – Today, the Ombudsman of the KyrgyzRepublic, Mr. T. Bakir uulu, signed a Memorandum with the Kyrgyz NGO “Mental Healthand Society” (MHS) and the Mental Disability Advocacy Center (MDAC), aninternational legal advocacy NGO based in Budapest. The Memorandum encouragesthe government to improve implementation of the 1999 Kyrgyz Law on Psychiatric Care,and goes on to emphasize the importance of human rights protection of people inKyrgyz psychiatric institutions, such as the Republican Mental Health Center whereMHS operates a new independent advocacy service for patients.

The Republican Mental Health Center – a large psychiatric hospital in Bishkek washighlighted in MDAC’s 2004 report on human rights and psychiatry in Kyrgyzstan,“Mental Health Law of the Kyrgyz Republic and its Implementation”. A keyrecommendation in this report was to establish an independent advocacy service forpatients at the Republican Center – also required by section 38 of the 1999 Kyrgyz Lawon Psychiatric Care.

Since November 2004, with funding from the Open Society Institute, the NGO “MentalHealth and Society” has been operating an advocacy service with the support of MDAC.As part of the service, there are now complaint boxes in each ward of the RepublicanCenter where patients can anonymously deposit grievances. Lawyers in the advocacycenter and (ex-)users of mental health services are working together to resolveproblems noted, which thus far include complaints about lack of food, involuntarydetention and lack of information about diagnosis and treatment.

As the first independent advocacy service in a psychiatric hospital in central Asia, theexistence of the independent advocacy service is critical for the advancement of therights of people labeled with mental disabilities and housed in grossly inadequatefacilities in this region.

In the signed Memorandum, the Ombudsman pledges to work with NGO “Mental Healthand Society” and MDAC to support the further development of the advocacy service.

As part of a routine support trip to Bishkek last week, MDAC met with the KyrgyzMinister of Health who also expressed support for the advocacy service. However,formal support of the Ministry is still under consideration. Professor Solozhenkin,chairman of the Kyrgyz Psychiatric Association, also voiced limited support of theadvocacy service, but would like the advocacy service to be run by a greater number ofNGOs, including a “user organization” which the Association is currently establishing.MHS and MDAC will be closely monitoring this development.

The Kyrgyz NGO “Mental Health and Society” and MDAC now encourage the Ministerof Health to demonstrate strong leadership in mental health reform and protection ofhuman rights by lending immediate Ministry support to the independent advocacycenter, operated by MHS.

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Notes:

The Mental Disability Advocacy Center (MDAC) is an international non-governmentalorganization that promotes and protects the human rights of people with mental healthproblems and intellectual disabilities across Central and Eastern Europe and Central Asia.MDAC works to improve the quality of life for people with mental disabilities throughlitigation, research and international advocacy. MDAC has participatory status at theCouncil of Europe and is a cooperating organization of the International Helsinki Federationfor Human Rights. www.mdac.info

The NGO “Mental Health and Society” a national non-governmental organization in theKyrgyz Republic that promotes the rights of mental health service users to have a voicein mental health policy and reform.

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PRINCIPAL REFERENCES

Part I

• Stewart R., Weldon S. Kyrgyzstan. The Kyrgyz Republic: Heartland of Central Asia.Odyssey, 2002.

• Kyrgyz State in the twentieth century. Collection of documents (in Russian).Composed by A. Dzhumanaliev. Bishkek, 2003.

• Central Asia: A Last Chance for Change. International Crisis Group Asia BriefingPaper N°25, 29 April 2003.

• Political Transition in Kyrgyzstan: Problems and Prospects. International CrisisGroup Asia Report N°81, 11 August 2004.

• Human Rights Watch’s Letter to President Askar Akaev of February 14, 2005.

• Appendix to Human Rights Watch’s February 14, 2005 Letter to President AskarAkaev.

• Kyrgyz newspapers: “Slovo Kyrgyzstana”, “MSN”, “Res Publica”, “gazeta.kg”, inJanuary/Februay 2005.

Part II

• Highlights on health, Kyrgyzstan. WHO Report, 1999.

• Health care systems in transition, Kyrgyzstan. The European Observatory for HealthCare System Report, 2000.

• Law of Kyrgyz Republic: On psychiatric care and guaranteeing the rights of personsreceiving such care (1999).

• Monitoring of human rights in mental healthcare facilities of the Kyrgyz Republic.Human rights and conditions of treatment in psychiatric, psychiatric-neurological andpsychiatric-narcological institutions. Report on the first stage of the monitoring.Youth Human Rights Group. Bishkek: 2001.

• Monitoring of human rights in mental healthcare facilities of the Kyrgyz Republic.Compliance with the rights to access to information in the Republican Mental HealthCentre: Report on the second stage of the monitoring. NGO “Mental Health andSociety” & Youth Human Rights Group. Bishkek: 2003.

• Monitoring of human rights in mental healthcare facilities of the Kyrgyz Republic.Compliance with the rights to freedom, to appeal in court of acts of retaining patientsin the Chym-Korgon branch of the Republican Mental Health Centre: Report on thethird stage of the monitoring. NGO “Mental Health and Society” & Youth HumanRights Group. Bishkek: 2004.

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• Mental Health Law of the Kyrgyz Republic and its Implementation. Report. TheMental Disability Advocacy Centre (MDAC), 2004.

• Information for the Collegiums Meeting On State of the Mental Health Service inOsh, Jalal-Abad, and Batken Oblasts and on Activity of Republican Mental HealthCentre as Organizational and Methodological Centre of the Service. Bishkek, 2004.

• Kyrgyz Ombudsman Supports Human Rights Protection of People with MentalDisabilities. Joint press release. By the Mental Disability Advocacy Centre andKyrgyz NGO “Mental Health and Society.” 16 February 2005, Bishkek & Budapest.

Internet Resources

• InterMinds Web page: http://www.interminds.org

• Mental Disability Advocacy Centre: http://www.mdac.info

• United Nations Integrated Regional Information Networks: http://www.irinnews.org

• International Crisis Group: http://www.icg.org

• Governments on the WWW Kyrgyzstan: http://www.gksoft.com/govt/en/kg.html

• National Statistical Committee of Kyrgyz Republic:

http://stat-gvc.bishkek.su/English/index.html

• The World Factbook (CIA) – Kyrgyzstan:http://www.odci.gov/cia/publications/factbook/geos/kg.html#Intro

• Kyrgyzstan - Atlapedia Online: http://www.atlapedia.com/online/countries/kyrgyz.htm

• Kyrgyzstan. The Columbia Encyclopedia, Sixth Edition. 2001:http://www.bartleby.com/65/ky/Kyrgyzst.html

• Kyrgyzstan at Infoplease: http://www.infoplease.com/ipa/A0107698.html

• Political Resources on the Net – Kyrgyzstan:http://www.politicalresources.net/kyrgyzstan.htm

• Kyrgyzstan Country Studies - Federal Research Division, Library of Congress:http://lcweb2.loc.gov/frd/cs/kgtoc.html

• The Central Eurasia Project:http://www.eurasianet.org/departments/insight/index.shtml