Surveyors on the New Silk Road

Columbia social workers are pulling back the curtain on AIDS in Central Asia, where the epidemic is spreading faster than anywhere else in the world.

by David J. Craig Published Fall 2010
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From the ground up

Terlikbayeva, 32, is deadly serious in demeanor, which gives her an imposing presence, despite her diminutive, four-foot-ten-inch frame. Like many young Kazakh professionals, she is also fiercely devoted to the project of building her new nation. This reporter, over the course of four days in Kazakhstan, saw her go toe-to-toe with a number of high-ranking bureaucrats to argue for more domestic AIDS spending. When I once made the faux pas of referring to Kazakhstan as a developing country, she bristled. “In the West, it took hundreds of years for research practices to develop,” she said. “We’re trying to do it in 10 or 20. People need to appreciate that.”

A Kazakh man waits to be interviewed as part of Columbia’s research at the Project Renaissance field office in Almaty.In 2001, Terlikbayeva was just out of medical school and working as a physician in the toxicology ward of an Almaty hospital when she decided to ditch her career as a doctor. At the hospital, she was seeing lots of overdose victims, many of whom she knew were likely to have AIDS. “Other doctors regarded them as subhuman,” she says. “Patients would be lying around untreated on gurneys and the staff would walk by like they were invisible. We rarely referred anybody for AIDS testing. I wanted to find out what these people’s lives were like. I wanted to help them before they ended up in a hospital.” The next year, Terlikbayeva enrolled in the Columbia University School of Social Work, which has a strength in training health researchers.

In New York City, Terlikbayeva began working for El-Bassel on an AIDS research program called Project Eban, which she would later help transplant to Kazakhstan, forming the basis of GHRCCA. Project Eban tries to control the spread of AIDS in the U.S. by teaching couples to discuss their feelings. How is that related to HIV prevention? El-Bassel has shown that if a woman feels comfortable talking about her emotions to her boyfriend or husband, she’s more likely to demand that he use a condom. El-Bassel’s colleagues say this is her major contribution to her field.

Terlikbayeva recognized that this approach could slow AIDS in her own country. She thought that women in Kazakhstan also ought to be encouraged to ask their partners to use clean needles if they shoot heroin, since a lot of HIV transmission in Kazakhstan occurs among drug users. So in 2003, a few months before Terlikbayeva received her master’s degree from Columbia, she and El-Bassel applied to the U.S. National Institute of Mental Health for a $100,000 grant to adapt the program for Kazakhstan. They got the grant and soon Terlikbayeva was overseeing Project Renaissance, a small pilot study in the drug-ridden city of Shu.

Since Project Renaissance was launched in 2005, Columbia’s work in Kazakhstan has grown steadily. That project received a big boost in 2008 when Terlikbayeva and El-Bassel received a $3.5 million grant from the U.S. National Institute on Drug Abuse to move it to Almaty. Now, Project Renaissance is housed in a wing of the Kazakhstan School of Public Health and is operating a five-year study with 400 couples. The GHRCCA researchers are fine-tuning their approach for Kazakh culture. They’ve discovered, for instance, that women here are so nervous about asking their partners to use condoms that they need to participate in all-female group-therapy sessions first.

The project in Barakholka Market has grown, too, despite some curious initial findings. The pilot study of 422 market workers, which was completed last year, showed that only one of them was HIV positive. That’s good news, but it might seem to call into question the project’s relevance. I asked El-Bassel if she had looked under the wrong stone. She insisted, however, that Barakholka must still be regarded as a potential gateway location for HIV transmission. “Workers here are having lots of unsafe sex with prostitutes, among whom HIV rates are known to be very high,” she said. “And if you want to stop AIDS, you need to go where it can cross over from marginalized groups, like prostitutes and drug users, into the wider population. The AIDS epidemic in Central Asia is still gaining steam, and Barakholka is a place where it could explode.”

U.S. funders apparently agree: The National Institute of Mental Health awarded GHRCCA $2.4 million last year to determine how best to prevent sexually transmitted diseases from spreading among migrant workers in the region. El-Bassel’s team is now trying to learn, among other things, if an outreach program should be launched at Barakholka to provide HIV-prevention services to all workers, or if it would be more efficient to direct such services to prostitutes.

“Strictly in humanitarian terms, what El-Bassel’s team is doing is extremely valuable,” says Laura M. Kennedy, an official at the United Nations Educational, Scientific, and Cultural Organization in Kazakhstan. “Undocumented workers rarely get their health needs addressed, anywhere in the world. The first step in getting them any services is generating some knowledge about their lives. In Kazakhstan, we’re just beginning to figure out what’s happening within this population.”

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