AIDS in Central Asia

Culture and Globalization in the Production of an Epidemic

Michael Cole
2006
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In the two and a half decades since HIV and AIDS were recognized, more than

twenty-five million people have died and 34.9 million people presently live with the

disease. The epidemic has grown to become the fourth most common cause of death

globally, and the World Bank projects that an additional 45 million people will contract

HIV by 2010.1 No cure exists and medications to curb its effects remain prohibitively

expensive for all but the world’s wealthiest patients. Extensive work in the areas of

health and social policy now places HIV/AIDS at the confluence of medicine,

epidemiology, politics, and economics, indicating its character as a social phenomenon as

well as a public health crisis. The global epidemic is composed of distinct regional

epidemics, and challenges in the containment of each are determined by conditions in the

countries where it is found. Although the number of deaths and infections in Central

Asia remains low compared to mature epidemics in Africa and the West, the combined

Eastern Europe-Central Asia region’s epidemic is the fastest growing HIV/AIDS

epidemic in the world, and conditions exist for continued growth.2 Domestic factors are

insufficient to explain the emerging regional epidemic’s growth without examination of

pressure exerted by surrounding regions. Capacities of Central Asia’s governments and

publics, the force with which nearby states influence the region’s affairs, and paths taken

by comparable HIV/AIDS epidemics indicate the disease will devastate productive

sectors with consequences for the region’s continued development and stability. While

incapable governments permitted the epidemic to spread unmeasured and unchecked, it is

fuelled by culture and geopolitics.

The epidemic warrants illustration using available tools. Central Asian states

have failed to make HIV tests universally available and consistently under-report the
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number of new HIV/AIDS infections within their borders to international agencies.

Social taboos surrounding sex, drug-use, and disease lead at-risk populations to choose

not to get tested. Criminalization of high-risk behaviors and discrimination against high-

infection populations (i.e. drug-users, prostitutes, and prisoners) prevent their

representation in infection data and route them away from medical resources.3 No

consistent, reliable surveillance data depicts real infection-rates across Central Asia.

However, real infection rates do not adequately illustrate the epidemic for which public

health agencies must prepare, as symptoms and death from AIDS are usually delayed for

years after contraction of HIV. Infection-rates reflect past conditions with little relevance

to present epidemics.

The epidemic’s development – its growth, demographic and geographic

concentrations, and trends in infection and behavior – are possible using indicators

employed in epidemiology models.

Although scientists have exhaustively analyzed the genetic makeup of the virus, the

public health community knows far less about its spread – the very human

demographic, sociological, and behavioural factors that account for its grim progress

through the world.4

Nonetheless, secondary or parallel phenomena consistently mirror and shape the contours
of HIV epidemics, and represent the most reliable indicators to track and predict its
spread. In profiles of HIV/AIDS epidemics, data sets for sexually-transmitted infections ,
drug-use, and prostitution parallel the growth-rate of HIV.
Whereas epidemiological models are available for epidemics in Africa, the West, and

Asia, Central Asia’s epidemic has escaped the attention of most medical researchers.
Writing about the epidemics in China, India, and Russia, Eberstadt explains,
 4

Sexual transmission patterns, the prevalence of risky sexual practices, and the extent

of other dangerous practices (such as I.V. drug use) will do much to determine the

future trajectory of the HIV/AIDS epidemic in these three countries. Amazingly,

neither local nor international health studies have examined in any sustained manner

these potentially deadly risk factors.5

A simulation of the Asian epidemic (including China, South Asia, and Southeast Asia)
capitalizes on many years of compatible data collection throughout the regions to
determine that rises in intravenous drug-use and prostitution among identifiable
populations produced HIV infections as early as the mid-1980’s.6 Although numbers of
new infections in some Asian countries have declined in recent years, those infected in
past years remain alive and the disease compounds as a single HIV-positive person may
infect multiple others. In the Asian example, this dynamic produced a sharp increase in
the number of cases for which states could not prepare without the predictive capacities

of simulations using secondary indicators. For example, few infections were recorded in

Cambodia until 1992, when the epidemic’s tendency to compound rapidly affected a rise

from fewer than 9,000 cases to more than 50,000 in 1999.7

In addition to profiling the disease, models that employ secondary data facilitate
adaptable health-policies to alleviate epidemics as they mature. A single plan will not
suffice; at regular intervals, countries must ask,
Is our epidemic growing? If so, how fast, where, and in what groups? What will
most effectively slow or stop this growth? What are the implications for future
support, care and treatment needs?8
Between 1988 and 2005, infected populations driving the Asian epidemic evolved from
sex workers (male and female) to married heterosexuals (infecting each other and outside
partners).9 The disease was carried from urban centers to rural areas, often following the
commercial routes that connect them. The mature epidemic’s hallmark is broad
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infection, rather than concentration among vulnerable groups and minorities such as
prostitutes, addicts, and homosexuals. A similar process of maturation is already seen in
the Central Asian epidemic. Governments address these changes with varying levels of
success. Among the reasons it remains effectively unchecked and will soon make the
same precipitous climb seen in Asia is the initial failure of regional governments and the
international community to implement adequate surveillance in its early stages.
Central Asia’s HIV/AIDS epidemic is sufficiently advanced to produce high and
compounding numbers of cases. The number of infections reported increased 88%
between 1995 and 2002.10

In 2000, 514 total cases of HIV infection were reported in Central Asia: 347 in

Kazakhstan, 154 in Uzbekistan, 7 in Tajikistan, 6 in Kyrgyzstan, and none in

Turkmenistan. In 2001, preliminary data indicate increases in the number of reported

cases to 1,175 in Kazakhstan, representing a 238 per cent increase from the previous

year. This alarming increase may portend an explosion in the HIV epidemic in the

region in the coming years.11

Data from 2004 indicate 12,338 HIV/AIDS infections in Central Asia, with Uzbekistan

and Kazakhstan reporting the most cases (6,862 and 4,702, respectively), and Tajikistan

and Turkmenistan either underreporting or failing to report data many years.12 The

World Bank notes, “These figures certainly considerably underestimate the true number

of cases in these countries, and reflect testing policy more than real prevalence.”13

A portrait of the epidemic might still be drawn using available information. Central
Asian governments collect and report data for tuberculosis, syphilis, and hepatitis, which
persist there at levels not seen for decades in the West, because they are understood better
than HIV and no longer carry its related stigma.
 6

Although sexually transmitted infections’ (STI) incidence rates have stabilized in

most countries, official rates are still quite high in Kazakhstan (over 100/100,000) and
the Kyrgyz Republic (50/100,000) … Sexually transmitted diseases other than HIV
are important for two reasons. First, a person with STI is both more likely to transmit
HIV sexually or more susceptible to acquire HIV … Second, high incidence rates of
sexually transmitted infections in a population are a marker for high underlying
incidence of … patterns conducive to HIV transmission.14

Central Asia has endured a syphilis epidemic since the early 1990’s, peaking in 1998

with more than 20,000 cases reported in Kyrgystan, Uzbekistan, and Tajikistan. In 2003,

incidences of syphilis remained between ten and twenty times higher than in Western

countries. Tuberculosis is the most common opportunistic infection in AIDS cases, and

Tajikistan and Uzbekistan report a rise in the incidence of tuberculosis of between fifty

and forty per cent, respectively, since 2001.15

Intravenous drug-users and youth constitute vulnerable populations in the Central

Asian epidemic, and they remain its primary movers. In Kazakhstan and Kyrgyzstan,

“upwards of 70% of HIV-positive persons are under 30 years of age.”16 UNAIDS

estimates that there could be up to 200,000 drug users in Kazakhstan, few of whom are

older than thirty, and that 2% of Kyrgyzstan’s adult population is addicted (compared to

1% in Latvia).17 In addition to poverty, few health resources, and socio-economic

environments configured by the decline of the USSR, unsafe sex and needle sharing

endanger each of these populations. Governments in the region inconsistently support

needle-exchanges, drug-user registration, and sex-education, and surveys indicate that

many expose themselves to risk even where those resources are available due to both

stigma and failure to appreciate the disease’s seriousness.18

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Whereas most cases are men, late data indicate women are the newest vulnerable

group. UNAIDS reports, “Women now account for an increasing share of newly

diagnosed HIV infections – 33% in 2002, compared to 24% a year earlier.” Drug-use by

women remains consistent with past years, so new infections among non-drug users and a

sharp increase in the number of children born with HIV indicate that a growing share of

new cases in women is sexually transmitted. This marks an important juncture for the

epidemic to traverse demographic groups and grow.19

The contribution of prisons to the spread of disease is exacerbated by social and

government practices, including the failure of strategies to control the epidemics to

address their impact. Prisons in the former Soviet states are over-crowded, and fail to

care for inmates’ health and welfare.

The most striking problem in the prisons of the former Soviet Union, particularly
those of Belarus, Kazakstan, and Russia, is their high incidence of tuberculosis. In
March 1998, the ICRC (International Committee of the Red Cross) announced that
among the prisons of the Commonwealth of Independent States the incidence of
tuberculosis was five to fifty times greater than their national averages. The
emergence of multi-drug resistant (MDR) strains of the disease in some prison
populations was especially alarming.20

In 2002, 47% of recorded HIV cases in Kyrgyzstan were prison inmates, and they go

without treatment.21 Central Asia’s prison populations consist largely of drug-users and

political dissidents, and violence and crime (including rape and drug-use) are common.
Little difference is seen in the prison administrations of Central Asian states and Russia.
Public health care is notably absent in the Russian penal system; prison camps are
consequently virtual incubation dishes for diseases such as drug-resistant tuberculosis
and HIV. Unlike under the communist-era gulag, moreover, nowadays prisoners are
 8

released on a regular basis: in 2000, about 300,000 convicts were granted liberty.
Most of them head back to their native towns, and a significant proportion … is HIV
positive. Russia’s prison system, in other words, functions like a carburetor for HIV
– pumping a highly concentrated variant of the infection back through the general
population.22
Turkmenistan’s amnesty of five thousand prisoners in 1996 and 1997 to alleviate over-
crowding in prisons illustrates disregard by regional systems of justice for prisoners’
impact on public welfare and health upon release.
Each of the domestic forces driving HIV intersects with elements of globalization
peculiar to Central Asia and its relationship with surrounding states.

Globalization is typically defined as an expansion of cross-border economic

interaction, though the term also embodies less precise though important, non-

economic connotations relating to the erosion of local control, autonomy, and identity

in the organization of political, social, and cultural life.23

The region’s epidemic must be seen in the context of Central Asia’s position between
Russia, China, and Southern Asia, each of which exert significant influence over the
region, and host distinctive and growing AIDS crises of their own. These warrant
illustration. In China, AIDS is propelled by commercial sex, drug-use, and unsafe
blood-supplies, as indicated by large vulnerable groups and a one hundredfold increase in
sexually transmitted infections.24 Estimates place the number of infected Chinese
between one and six million, and “at current rates the number of victims could double in
30 months.”25 American diplomats report that whole villages will soon die from AIDS-
related diseases and suggest that the Chinese government does little to stop the epidemic
because it sees the disease as a possible source of relief from the country’s over-
population. Russia’s epidemic appears on the verge of extending beyond early at-risk
groups (drug-users, prisoners, men who have sex with men, and sex-workers and their
 9

clients) to the general population, and indictors suggest the generalized epidemic will be
devastating. In 2002, the Indian government set a goal to report no new HIV infections
in 2007, but instead it is positioned to produce more infections than in any previous year.
Its epidemic is distinctive for its production by prostitutes and cross-country truckers, but
data for actual cases as well as cases of other sexually transmitted infections is nearly
impossible to obtain.26 The Indian National AIDS Control Organization estimates that its
infected population numbers 5.21 million people, and its epidemic is (like most others)
configured for explosive growth.

Central Asian states are surrounded on all sides by powerful neighbors with

mature, large-scale epidemics. The states are dependent on economic and cultural

exchange with Russia, China, and Southern Asia, and their relative weakness in the

region renders them unable to mitigate the risks that accompany these transnational

relationships. The countries’ weakness has caused the mobilization of Central Asian

communities in search of employment, increasingly porous borders, weakly regulated

border crossings, and continually weak and corrupt government institutions. In order for

the high volumes of transnational exchange that characterize globalization to serve states

well, they must first be capable of articulating their interests and managing the

mechanisms of exchange. AIDS was introduced by way of transnational exchange

because Central Asian governments have lacked these basic capabilities. For example,

Russia first recorded incidences of AIDS in the 1980’s and the disease spread across the

Soviet Union (possibly including Central Asia) before its dissolution, but Central Asian

governments could certainly not have addressed the threat amid post-independence

crises. Russia and Asian countries trade heavily with Central Asians, and the exchange

of peoples between these heavily infected regions without effective means to regulate

movement or monitor visitors’ health-conditions leaves the region vulnerable.

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The same conditions that make globalization disadvantageous serve international

criminal groups and their networks for human trafficking.

Though limited, existing literature provides some insight into the links between

human trafficking and organized criminal groups. In most cases, trafficking is carried

out by organized criminal groups with extensive international links.27

Whether they are mislead or taken against their will, an estimated ten thousand Central
Asians are smuggled each year to South and Southeast Asia, the Middle East and Russia,
often to work as prostitutes.28 Cases are reported in which women briefly return before
finding work abroad again. 29 Under the present conditions, both migration and illicit
trans-regional movement are highly conducive to the spread of disease.

International organizations with experience addressing other regional HIV/AIDS

outbreaks emphasize the disease’s dual character as a medical and social phenomenon. A

study commissioned by the World Bank suggests goals for the disease’s containment.

Develop strategies that begin to address the factors that make individuals vulnerable

to HIV infection, including under-development, economic insecurity, poverty,

empowerment to women, lack of education, social exclusion, illiteracy,

discrimination, lack of information, and all types of sexual exploitation of women,

girls and boys … Develop multi-sectoral strategies to address the impact of the

HIV/AIDS epidemic at the individual, family, community and national levels.30

UNAIDS encourages states to facilitate AIDS tests, develop and enforce laws and

institutional behaviors that are conducive to testing and treatment, and to regard the

epidemic as a challenge to regional development and stability by coordinating efforts

with neighboring governments. By conceiving of the disease as a significant threat to

development, the U.N.D.P. now promotes education about health, sex, and intravenous
 11

drug-use, and increased communication to address stigma and abuse as components of

human development, which is employed internationally alongside security and economic

development as a pillar of broad development programs.

Programs to contain the spread of HIV/AIDS in Central Asia are primarily

government-based, and they increasingly assume forms recommended by international

organizations. Health and HIV-oriented non-governmental organizations work to

complement government programs and often act as proxies for government agencies;

international organizations (i.e. UNAIDS, World Bank, Centers for Disease Control)

contribute significant resources, but often cannot act independently of host-country

governments, and configure their initiatives to supplement government programs; no

indication is seen that religious and ethnic organizations address the epidemic among

their constituencies.

Brief descriptions indicate the countries’ tendency to addresses HIV/AIDS in

ways that reflect areas of institutional strength or priorities peculiar to respective

governments, especially by centralizing control and emphasizing government functions to

the exclusion of various social functions. “The policy environment of all five Central

Asia Republics regarding HIV/AIDS prevention still reflects the previous history of

Soviet approaches to communicable diseases.”31 Each country has produced a written

plan to state containment goals and direct ministry activities, and each has developed a

separate bureaucracy or AIDS center. However, the issue is not regarded broadly enough

to produce institutional and policy reforms in each area relevant to the epidemic, and is

often not addressed with seriousness even in ministries of health and offices of the prime
 12

ministers.32 Finally, little indication is seen that government programs address elements

of culture relevant to disease contraction, prevention, and treatment.

Uzbekistan’s initiatives are directed by its Ministries of Interior and Health as a

medical crisis. In 2004, the government procured funds from the UNDP to inform

soldiers and military doctors about ways to avoid contracting the disease and to train

them as educators. The military was identified as an organized cadre with relationships

throughout the society that could extend lessons learned to their families and

communities. HIV/AIDS is placed within the purview of Uzbekistan’s Dermatological

and Venereal Diseases Service, which employs militia to corral HIV positive people to

dispensaries.33 Despite its continued insistence that no reported AIDS cases are of

indigenous origin and its extremely low rankings on common measures of development

(i.e. market freedom, access to information and health care), Turkmenistan’s Ministry of

Health has cultivated relationships with international experts to address the spread of

HIV/AIDS The Turkmen government expressed interest in applying to the Global Fund

for AIDS, Tuberculosis, and Malaria in 2004 and 2005, and applied in 2006, consenting

in the process to international reporting standards and visits by foreign medical experts.34

Kazakhstan has developed a Republican AIDS Center to collect resources from its

Ministries of Health, Education, Defense, Interior, Justice, Culture, and Information for a

centralized program of education and treatment. Its effort is the region’s most concerted

program to stem the epidemic, but it is notable for its administration by high-level

bureaucracies, lack of support within the Ministry of Health, and isolation from NGO’s,

the private sector, and average citizens.35 Tajikistan’s government has obtained broad

support from the UNDP for its strategic plan to combat HIV/AIDS because it gives
 13

attention to vulnerable populations and decentralizes control of education and medical

resources. However, its health-policy efforts are not coordinated across sectors:

criminalization of disease-transmission and drug paraphernalia drive vulnerable groups

away from health resources, and discrimination and police harassment persist.36

Poor political and economic conditions bear directly upon the capacities of Central

Asian governments and publics. The scoring system used by Freedom House for its

annual review of politics, Freedom in the World (which accounts for electoral processes,

civil society development, media independence, national and local democratic

governance, judicial development and independence, and corruption) rates none of the

five Central Asian countries as “free.” Only Kyrgystan was ranked as “partly free,”

while Uzbekistan, Tajikistan, and Kazakhstan are marked “not free,” joined by

Turkmenistan, which earns some of the lowest scores of more than two hundred states

and territories assessed.37

During a visit by Kremlin officials to Uzbekistan intended to strengthen political ties,

the director of Russia’s Strategic Studies Institute, Yevgeny Kozhokin asserted that, “The

state and society are parts of a single whole … It is precisely strong state power that can

create the conditions for constituting a market economy and the transition to a developed

democratic system.”38 If Central Asian regimes adopt the same view, then they have still

failed to produce the political and economic conditions to materially improve lives or

promote health.

Poverty in Central Asia has reached unprecedented levels: 51 per cent of the Kyrgyz

population lives below the national poverty line, as do 34.6 per cent of Kazakh

citizens and 26.5 per cent of the Uzbeks. Forty four per cent of Turkmen live on less
 14

than $2 a day. The population groups most affected by poverty are women, children,

and the elderly … The collapse of the Soviet Union resulted not only in poverty and

unemployment but also in the drastic deterioration of the system of social protection.

Many of the social services taken for granted under the Soviet system are no longer

offered. Before the collapse of the Soviet Union, day care for children, education at

all levels, and medical services were provided by the government.39

These services have been scaled back slowly, often for lack of funding. Limited access

to the components of human and economic development – including education,

information, health care, capital, and security – intersects with government

unaccountability, mismanagement, corruption, and oppression, and cause declining

public and political capacities to diminish one another.

Each country’s health policy fails and will remain ineffective without broad

capacity-development, effective means to address transnational dynamics, and human

development in the mode of cultural change. Capacities required for states to administer

conventional programs based on health policy include relevant medical training,

development of health-care infrastructures, easy access to anonymous HIV testing,

reliable epidemiological surveillance, and public health education. The absence of anti-

retroviral drug therapy anywhere in the region will cause higher death rates in Central

Asia than an epidemic of its size would otherwise produce, but capacity-development

could stem the epidemic’s growth.40 The preceding discussion indicates regional

governments are responsive to international agencies’ governance priorities, such as

comprehensive health policy planning. However, the same pre-existing cultural

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conditions that permitted the epidemic’s development and shaped the political

environment in which problematic policies were created also facilitate its growth.

Governments can provide resources to prevent epidemics, but individual choices

foster and shape them. Cultures influence individuals’ receptiveness to educational and

medical resources, and in Central Asia, culture militates against states’ capacity to stem

the epidemic’s growth. Speaking at the World Economic Forum in Davos, UNAIDS

Director Peter Piot noted,

The only solution will not involve the words only (sic); it must be a comprehensive

approach that deals with social and environmental issues at the local level that takes

into account deeply rooted prejudices, gender, poverty and sexuality … AIDS reveals

fault lines in our societies … and any sustainable response requires addressing these

fissures, while taking into account local beliefs, values and traditions.41

In response to AIDS and related health and social issues in Central Asia, religion and

tradition are brought to bear where science and effective problem solving are needed.

For example,

In the predominantly Muslim societies of the region, it is almost taboo to openly

discuss the trafficking of women for prostitution. Victims often do not report their

experiences to the police for fear that the conservative societies in the region will

reject them.42

As vulnerable groups, minorities, and parallel diseases are the consistent precursors of

AIDS epidemics, their marginalization and denial by communities condemn societies to

illness.

At the advice of foreign experts, Central Asia’s governments try with little success
 16

to constructively broach taboo subjects, but culture constrains their capacity to do so

through conventional political means. Tajikistan, for example, which is noted for

acknowledging the plight of at-risk groups at the official level, is unable to overcome

resistance to general AIDS education, community-level program administration, and

health-care training for professionals. Its government reports,

Stigma remains a serious issue to both the physical and psychological well-being of

people living with HIV/A.I.D.S … It has been observed that there is not only a lack

of understanding but also relative reluctance of regional authorities to realize

importance of the program objectives for the future of Tajikistan.43

The development of governments’ capacities to penetrate societies and regulate affairs

for public ends is often sufficient to overcome challenges to public welfare, but

contraction of HIV occurs in the intensely private, conventionally determined settings

over which few states wield influence in opposition to the prevailing culture.

Populations’ unwillingness to acknowledge threats and receive practical solutions

suggests a need for cultural change that lies far beyond the purview of health policy

officials.

From its position at the confluence of state, society, and globalization, HIV/AIDS

calls into question traditional modes of politics and problem solving. The scale of change

required to prevent HIV/AIDS epidemics’ rapid growth, and which may still protect

Central Asian societies, is extraordinary: Beyond increased state capacity, the change

must affect broad modernization to introduce to the region’s traditional practices,

discourses, and sets of cultural references a cosmopolitan awareness, and comprehension

of global influences on private lives.

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Modernization is a revolutionary process comparable only to the shift from primitive

to civilized societies, that is, the emergence of civilization in the singular … The

attitudes, values, knowledge, and culture of people in a modern society differ greatly

from those in a traditional society.44

Huntington locates his concept of modernization in the Western system of states, and

assesses modernization according to degrees of institutionalization and proceduralism for

the purpose of and with the capacity to “give substance to public interests.”45 Migdal

submits that the state must not be conceived of only as a functionary to carry out public

preferences. It is the tool with which visionary leaders reform societies, developing them

to maximize their capacity to satisfy public interests.46 AIDS, like other phenomena for

which globalization is a useful explanatory concept, presents the state with a threat and

an opportunity: Successful mobilization and transformation of societies will save lives

and affirm their relevance, and unabated decimation due to failed policies and

unaddressed cultural shortcomings will call into question their capacity to function in a

changed world.

In Central Asia, as elsewhere, preventable AIDS epidemics are produced where

political communities, in governmental and other forms, fail to configure themselves to

regard and defeat a mortal threat. The international community provides extensive

resources to help Central Asian states develop governmental and medical capacities, but

little attention is paid to the need for public capacity-development beyond education.

In general, existing governance patterns are increasingly obsolete, actual innovations

in governance grossly inadequate, and available ideas for improving governance far

from meeting urgent needs.47

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Dror considers the state in the context of emerging global challenges and concludes that

the problems of modernity require dramatic change. He suggests the capacity of

governments to produce change in the face of scientific and biological innovation and

phenomena is limited, and acknowledges the transformative power of societal trauma.

However, he follows Huntington and Migdal in charging states with responsibility for

reshaping societies to face new challenges.48

The most important and fundamental, but also the most problematic and dangerous

higher order task of governance: namely, to facilitate, control, and guide changes in

the very bases of human existence, including bio-neurological and psychological

structures, patterns, processes, and potentials.

The conventions that protected isolated societies – including prejudices, silence, and

conservatism seen in Central Asian communities’ approaches to AIDS and its signal

phenomena, endanger societies connected by globalization. Openness, awareness of

distant but related societies, acknowledgement of interconnections between societies, and

willingness to aid marginalized groups as a means to serve the broader community are

possible objectives of a new cultural ethos conducive to the defeat of HIV/A.I.D.S. In

addition to government programs and medical services, states must facilitate human

development by cultivating complimentary cultural change.

The form of cultural change absent during the rise of the present epidemic is well

illustrated by Central Asia’s regional politics, which is often characterized by competition

and mutual suspicion. “Regional collaboration to fight the epidemic is weak. However,

these countries have much in common,” including drug-trafficking and use, growing

numbers of commercial sex workers, migration and human trafficking, and weak national
 19

boundaries.49 International organizations urge governments to coordinate their AIDS

policies, and integrate them into regional programs to track and combat its importation

from other regions. Coordination is seen in the context of economic development, but in

formal agreements policy-makers do not yet acknowledge the relationship between public

health and prosperity.50 Beyond this, the region is divided by national identities. A

regional ethos under which the state is inseparable from ethnic groupings, clans, and

religious sects – modes of identity peculiar to nations and exclusive of neighboring

peoples on whom globalization makes their health and success depend – prohibits

acknowledgement of interdependence, and therefore the coordination and exchange of

resources required to defeat a common threat.

The preceding discussion seeks to explain the growth of Central Asia’s AIDS

epidemic, and limits description to those areas required to illustrate the problem and its

prospective growth. For example, little indication is given here of the epidemic’s

security and economic consequences, or of its potential significance to the global balance

of power when placed in the context of the broader Eurasian epidemic.51 Globalization,

weak regional-governmental capacities, and low levels of human development relevant to

HIV/AIDS contributed to the epidemic’s introduction and propel its growth. While one

phenomenon must not be used to explain the growth in isolation from others, they are of

distinctly different orders: Government capacity in the mode of policy execution is a

remedial, functional area that cannot succeed without higher-order change; globalization

and cultures that reflect poor human development characterize the political environment;

whereas globalization is beyond the control of any single government, cultural change

through human development constitutes a higher-order function which governments may

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pursue. By conceiving of AIDS as a social phenomenon, a peculiarly Central Asian ethos

characterized by insularity, regionalism, traditionalism, and dramatic disregard for

perceived deviants is seen to condition the success of government policies regardless of

their merit and execution.

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1 Godinho, Joana, et al., “Reversing the Tide: Priorities for HIV/A.I.D.S.,” The World Bank
(March 2005), Document No. ECSHD/ECCU8, 1
2 UNAIDS, “The Changing HIV/AIDS Epidemic in Europe and Central Asia,” Joint U.N.
Programme on HIV/A.I.D.S. (April 2004), Document No. UNAIDS/04.18E, 3
3 Godinho, 17
4 Eberstadt, Nicholas, “The Future of A.I.D.S.,” Foreign Affairs 81, no. 1 (2002): 32
5 ibid. 42
6 Brown, Timothy and Neff Walker, “The AIDS Situation in Asia: Planning and
Implementing Appropriate and Timely Responses,” The World Bank (PowerPoint
Presentation: 28 July 2005), http://siteresources.worldbank.org/INTSAREGTOP
HIVAIDS/Resources/BrownWalkerAIDSinAsia.pdf

7 ibid. 20
8 ibid. 2
9 ibid. 22
10 UNAIDS, The Changing HIV/AIDS Epidemic in Europe and Central Asia, 7.
11 Centers for Disease Control Division of Epidemiology and Surveillance Capacity
Development Online. “Central Asia” (Accessed 3 November 2006).
http://www.cdc.gov.descd/centralasia.html
12 Godinho, 4
13 ibid. 13
14 ibid. 14
15 ibid. 14
16 UNAIDS, The Changing HIV/AIDS Epidemic in Europe and Central Asia, 4. Compare
this to Ukraine, location of a slightly more advanced epidemic, where 25% are younger
than 20 years old.
17 ibid. 5.
18 ibid. 6
19 ibid. 4. This data is pooled from the UNAIDS combined Eurasia region.
20 Human Rights Watch, “Human Rights Watch Prison Project: Prisons in Europe and
Central Asia” (Accessed 1 December, 2006)
http://www.hrw.org/advocacy/prisons/europe.htm
 22

21 U.N. Development Program, “Epidemiological Fact Sheet on Kyrgyzstan,” UNDP (August

2006), Document No. EFS 2006 Kyrgyzstan
22 Eberstadt, 26
23 Noland, Marcus. “Popular Attitudes, Globalization, and Risk,” Institute for International
Economics (July 2004), Working Paper 04-2 (Presented at the World Economic Forum at
Davos)
24 Eberstadt, 31
25 ibid. 30
26 ibid. 27
27 Sulaimanova, Saltanat, "MigrationTrends in Central Asia and the Case of Trafficking of
Women," in In the Tracks of Tamerlane, ed. Burghartand, Daniel L. and Theresa
Sabonis-Helf. 386

28 Jackson, Nicole J., “The Trafficking of Narcotics, Arms, and Humans in Post-Soviet
Central Asia: (Mis)perceptions, Policies, and Realities,” Central Asian Survey 24, no. 1
(March 2005): 43
29 ibid. 43
30 Godinho, 3
31 ibid. 26
32 ibid. 33
33 ibid. 27
34 U.S.A.I.D. Online. “USAID/Turkmenistan: Operational Plan FY 2006.”
http://pdf.usaid.gov/pdf_docs/PDACH346.pdf
35 Godinho, 57
36 Godinho, 27
37 Freedom House Online. “Freedom in the World: 2006 Edition.” (Accessed December
2006). http://www.freedomhouse.org/template.cfm?page=15&year=2006
38 Kimmage, Daniel, posting to Radio Free Europe Radio Liberty: Central Asia Report, 24
November, 2006, http://www.rferl.org/reports/centralasia/default.asp
39 Sulaimanova, 386-387
40 Godinho, 34
 23

41 World Economic Forum Online. “Social Behaviour: Culture, Denial and the Spread of
A.I.D.S.” World Economic Forum at Davos, 26 January, 2006. (Accessed 16
November, 2006).
http://www.weforum.org/en/knowledge/Regions/CentralAsia/KN_SESS_SUMM_15626?
url=/en/knowledge/Regions/CentralAsia/KN_SESS_SUMM_15626

42 Jackson, 43
43 U.N. Development Program, “Country Fact Sheet: Tajikistan,” (Accessed 3 November,
2006), http://europeandcis.undp.org/files/uploads/John/Fact_Sheet_ Tajikistan.ppt
44 Huntington, Samuel, Political Order in Changing Societies. (New Haven: Yale University
Press, 1968), 68
45 ibid. 28
46 Migdal, Joel S., “Vision and Practice: The Leader, the State, and the Transformation of
Society,” International Political Science Review 9, No. 1 (1988): 39
47 Dror, Yehezkel, The Capacity to Govern. (London: Frank Cass Publishers, 1994), 9
48 ibid. 211
49 Godinho 34
50 Asian Development Bank Online, “Technical Assistance for Capacity Building for
Regional Cooperation in Central Asia,” Asian Devlopment Bank (December 2003),
http://www.adb.org/Documents/TARs/REG/39507-REG-TAR.pdf (Accessed November
2006)
51 See Eberstadt
 24

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