Chicago Tribune - September 16, 2007
Alex Rodriguez, Tribune foreign correspondent, ajrodriguez@tribune.com

But after being treated at three hospitals here, they found themselves coping with a far graver health problem. The children had become infected with HIV, victims of doctor-prescribed blood transfusions that exploited a myth long held among locals that the procedure rids the body of impurities.

In many cases, authorities determined that the transfusions were medically unnecessary, according to court documents in a criminal case alleging that corrupt doctors, tainted equipment and a dysfunctional health-care system had combined to mar the lives of 127 children and embarrass a Kazakh government struggling to show a new, modern face to the world.

Since 2006, 10 of those children have died. Many of the rest live like untouchables in Shymkent's crumbling apartment blocks and slums. Alone with her mother in one of four tiny huts along Zheltoksan Street, a cherub-faced 2-year-old girl infected at a Shymkent hospital always plays by herself, shunned by other children her age who live just yards away but heed warnings from their parents to never venture too close.

The mother has pleaded for understanding from neighbors. Her daughter needs acceptance, she explains, not alienation.

"They always put up their hand and say, 'This is a terrible disease. Don't [try to] explain anything,'" the mother said.

Causes run deep

A Shymkent court this summer convicted 21 doctors, nurses and health-care officials of malpractice and negligence for their role in the outbreak. But the root causes of the outbreak run far deeper than the actions of those convicted, experts say.

As in the rest of the former Soviet Union, the quality of health care in Central Asian nations plunged after the Soviet collapse in 1991. Hospitals lack the money to stock basic medical supplies. Doctors making as little as $130 a month resort to a system of bribes to supplement their incomes, extorting cash from patients and their families for everything from office consultations to patient records.

Doctors also turn to blood transfusions as a vehicle for extra cash. Across the steppes of post-Soviet Central Asia, blood has always meant easy money. Heroin addicts routinely queue up at blood banks to donate for a few dollars. Doctors beef up meager wages with an illegal blood trade that foists unneeded transfusions on patients.

"Throughout Central Asia, doctors play on the myth that transfusions boost immunity and clean out the system," said Nicolas Cantau, regional director of the AIDS Foundation East-West office in Almaty, Kazakhstan's largest city.

Since the Shymkent crisis, HIV outbreaks linked to transfusions have occurred elsewhere in Central Asia.

In March in Andijan, Uzbekistan, nine people became infected with HIV through transfusions from an infected donor recently out of prison. In July in Osh, Kyrgyzstan, authorities fired several doctors responsible for transfusions that infected 22 people with HIV, 17 of them children.

So far, the prevalence of HIV, the virus that causes AIDS, in Central Asian nations is low compared to other former Soviet republics such as Ukraine, which has three times Kazakhstan's population but 34 times more HIV infections, the World Health Organization estimates.

Still, experts say Kazakhstan, with an estimated 12,000 HIV cases, and other Central Asian states risk succumbing to the same kind of breakneck growth in HIV cases seen elsewhere in former Soviet states if they don't make AIDS prevention a priority.

"Shymkent rang a bell for Central Asia," Cantau said. "Central Asia is in the same place Ukraine was seven years ago, when authorities missed an opportunity to contain the problem and now have seen [nearly] 1 percent of their population become HIV-positive."

A review of court documents in the Shymkent case, along with interviews of parents of HIV-infected children and health officials, reveals a system that siphoned as much cash as it could from patients and ignored simple sanitary procedures meant to prevent the spread of infection.

Under Kazakh law, parents of children younger than 3 aren't supposed to be charged for blood and plasma transfusions. But at Shymkent hospitals, the prevailing rate was $21 for 6 ounces of blood, said Katira Bekbolova, a lawyer for the parents of HIV-infected children.

At the South Kazakhstan Children's Hospital, doctors relied on the hospital's courier, Khalba Asanova, to act as cashier. Asanova stationed herself in the hospital's cafeteria, where she sold packets of blood and plasma as she sipped tea. Asanova, 50, was convicted for her role in the blood trade but received a suspended sentence.

Several mothers who agreed to be interviewed on condition of anonymity said they had no way to know whether their child's doctor was right in urging a transfusion.

One toddler who would later test positive for HIV was in and out of the hospital for pneumonia and received seven transfusions in eight months. At one point, nurses at Shymkent Children's Hospital No. 2 moved the boy from the emergency room to a hallway armchair, where he and his mother sat for two days until a bed became available. "There were terrible crowds in there," his mother said. "Children crying and urinating on the floor, terrible smells."

'Nothing to this case'

Lawyers for the convicted doctors denied that an illegal blood trade existed at the hospitals and insist that the outbreak was caused by HIV-positive mothers who infected their children.

"There is nothing to this case except the naked words of the mothers whose children are infected," said Musatai Bektasov, who represented three of the defendants. "It's the word of one person against another."

Testing excluded the mothers of the children as a source, Bekbolova said, adding that since the outbreak began, eight of those mothers have contracted HIV through breast-feeding.

Blood used for transfusions at Shymkent hospitals came from the city's blood bank, a spare one-story building next to a bustling market where homeless Kazakhs and drug addicts often congregated. They were frequent donors at the blood bank, receiving roughly the equivalent of $4 for a half-liter of blood, said Valentina Skryabina, director of Nadezhnaya Opora, a local non-governmental group that works to prevent AIDS.

Kazakh authorities are investigating what role the blood bank may have had in the outbreak, though so far experts have not traced any contaminated blood to that facility. Its deputy director, Gulzhan Bekzhanova, denied that her facility had ever accepted homeless people or drug addicts.

While the source of the contaminated blood remains unclear, investigators are sure about how the infection spread.

According to court records, syringes at Shymkent's three children's hospitals were routinely reused. So were catheters. A court-ordered evaluation of supplies and procedures at the hospitals found that South Kazakhstan Children's Hospital should have had 1,500 catheters in stock for the year but had only 12. Shymkent Children's Hospitals No. 1 and 2 should have stocked 1,000 catheters for the year. Hospital No. 1 had eight; Hospital No. 2 had six.

Cover-up alleged

Once health-care officials learned that children were being infected with HIV, some tried to cover up the outbreak, according to court records.

Doctors at the AIDS center told local health-care officials on Feb. 21, 2006, that an 8-month-old boy hospitalized for a stomach ailment had been infected with HIV and that a blood transfusion was the likely cause. The baby's mother had tested negative for the virus.

More warnings from the center followed as other children tested HIV-positive. But the province's health-care chief, Nursula Tasmagambetova, waited nearly five months to ban the reuse of catheters and syringes and call for tougher control over blood transfusions, according to court documents. She issued that directive only after a criminal investigation into the outbreak started. Later, health inspectors would discover that doctors at the three children's hospitals had been removing from the children's files documentation of transfusions, according to court records.

By fall 2006, more than 60 children had been diagnosed as HIV-positive. Kazakhstan's president, Nursultan Nazarbayev, fired his health minister. On Shymkent television, local officials tried to deflect blame.

"The province's governor said prostitutes gave birth to all of these children," said Nurgul Abdiraliyeva, whose son was one of the children who died. "He actually said this on television. I'm still angry about the way they tried to cover this up."

Kazakh authorities reacted to the crisis by pouring millions of dollars into Shymkent's overhaul. A new children's hospital is being built, and old hospitals are getting new X-ray machines and ambulances. Doctors are being retrained. Hospital administrations now undergo weekly inspections.

"It has changed everything here," said Laura Kopzhasarova, a local journalist. "Better roads, better utilities, a new provincial government."

What hasn't changed is the dread that gnaws at mothers in Shymkent about the future of their infected children. Every cough, every half-pound of weight loss makes them wince. Now forced to put her trust in a health-care system that made her son so sick, one mother explains why she steels herself for grim days ahead.

"I ask the doctors about his prognosis, and they say, 'We are not gods,'" said the young Kazakh woman as her boy clambered up to her shoulder. "In any case, I will be with him to the end. It doesn't matter how much I suffer."

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