Transdniestria, a pro-Russian enclave in Moldova, has serious health problems, but an MSF team set up a system to help the worst cases, writes JOHN FLEMING
OVER THE past month, the Russian/Georgian clash has turned international eyes to some rather obscure enclaves of the former Soviet Union. Military manoeuvres in South Ossetia and Abkhasia continue to spark a variety of concerns, not least of which are the humanitarian and healthcare needs of injured and displaced people.
A third region with a similar geopolitical context, Transdniestria, the Soviet-looking outlaw republic that declared its independence from Moldova in 1990, has had little political or media currency in the West.
A signatory to an alliance with South Ossetia and Abkhasia, this effective Russian protectorate on the edge of Europe has, for many years, exhibited a high incidence of HIV/Aids.
Dubliner Mark Walsh is head of a Médecins Sans Frontières (MSF) mission tackling this problem. While the clear target is the provision of better healthcare, he and his team had first to negotiate a minefield of logistical difficulties presented by the rebel republic.
"We opened bank accounts in Transdniestrian roubles, a currency nobody recognises, and which gets spat out by any international accountancy programme. We set up a logistic supply line to a place that doesn't officially exist, and then exported hundreds of thousands of euro of drugs and medical equipment to it," says Walsh.
With an average per capita income of €60 per month, Moldova's healthcare is poor at the best of times. In its breakaway region of Transdniestria, it is worse again, with an incidence of HIV/Aids four times that of Moldova, whose ministry of health neglects the zone that has shunned it.
Here, in a frozen conflict region regarded as a no-go by most NGOs, the MSF health programme has three elements: a customised, modern HIV unit in capital Tiraspol's Republican Hospital; weekly clinics at both a men's and a women's prison; and outpatient treatment in the polyclinic in the city of Rybernzita in the north of Transdniestria.
With a team of 35, including six ex-pats, the humanitarian organisation is working with local doctors to set up a sustainable national Aids centre as it implements its strategy to exit Transdniestria by the start of 2009.
A former Moscow-based crime reporter for German TV, Walsh joined MSF in 2002 as its spokesperson for the former Soviet Union. In 2005, he conducted an exploratory mission to Moldova to look into the health needs of Transdniestria.
With a doctor, he travelled around the region for a month: "We looked at basic health indicators and found the population of Transdniestria was far more vulnerable, especially when it came to HIV/Aids."
Moldova was receiving tens of millions of dollars in assistance from the Global Fund, the World Bank and other agencies to combat the disease. But none of this money benefited Transdniestrians unless they went to Moldova's capital, Chisinau. For those in prison (where the HIV infection rate is as high as 20 per cent), too sick to travel or without proper documentation, such a cross-border journey was impossible.
Furthermore, while pregnant women from Transdniestria could receive medication in Moldovan hospitals, they were not allowed to give birth there.
Since the break-up of the Soviet Union, healthcare in Transdniestria has deteriorated terribly, largely due to its imposed isolation by the international community.
Officially, at the end of 2007, it had 1,192 HIV-positive cases out of 4,131 total cases in both Transdniestria and Moldova, according to the Moldovan ministry of health. That figure is believed by medical professionals to be at least two to three times lower than reality.
And while Moldova used the grim Transdniestrian health statistics to attract funds from the international community, it withheld that money from the region itself. It appeared to be using the funds as a punishment to try to blackmail the territory into reintegrating.
MSF concluded that access to healthcare was being denied to the Transdniestrians for political reasons, and initiated the project to treat HIV/Aids.
"Due to the absence of other international organisations or businesses, we had to discover everything ourselves. There was nobody to go to for independent advice about security, where to hire staff, where to rent offices and accommodation and most importantly, how to navigate local legislation and bureaucracy. This endless red tape was a legacy of the Soviet era," explains Walsh.
The Transdniestrians lacked legislation for dealing with international organisations. Pharmaceutical licences there can only be granted to governmental or commercial bodies - it had never been envisaged that an NGO such as MSF might need to import drugs.
After extensive renovation of a floor of a dilapidated wing of the infectious diseases unit in the Republican Hospital, and revamping of a laboratory in a nearby building, the mission opened its first out-patient department in Tiraspol in August last year.
Initially, local health professionals had almost zero knowledge of HIV/Aids. As their knowledge grew through training by MSF experts, they began to refer patients to the mission.
MSF then began lobbying the Global Fund, the World Health Organisation and other potential players to visit and witness that it was possible to operate successfully in Transdniestria.
The idea was to get international donors to encourage the Moldovans to extend HIV/Aids programmes into Transdniestria. Gradually, the two sides began to share some resources and, vitally, drugs supplied by the Global Fund.
As the team works to hand over the mission to the local ministry of health within the next six months, this cross-border co-operation bodes well for its subsequent sustainability.
How did they gain access to the prison? "We had to negotiate with the ministry of justice and make it clear that we would only be treating HIV/Aids and co-infections, with anti-retroviral drugs where necessary.
"They thought we were set on denouncing human rights abuses in the prisons and were quite wary of us. We explained we had a medical agenda and not a human rights one. However, we wouldn't be able to turn a blind eye to abuse."
The authorities accepted MSF's good intentions and agreed to afford them prison access as well as security during the visits.
Next, it was necessary to identify the criminal bosses who run the prisons and explain to them they would only be tackling HIV/Aids. The team had very limited resources and didn't want to raise false expectations. "The structure in the prison is similar to a caste system, and it is the criminal bosses who ultimately control the prisons. From a security point of view, we needed their blessing to operate in their prison.
"Their word is law - as they agreed to our visits, we are afforded a better degree of security than the guards can provide."
Regarding any resonance in the region with the Georgian conflict, Walsh is quick to point out MSF's non-political role:
"We are completely transparent about our activities so both the Transdniestrians and the Moldovans know perfectly well what we are doing," he says.
"With both sides, we have detailed written agreements outlining our activities and each party's responsibilities.
"The Moldovans are occasionally suspicious that our presence might lend credibility to the breakaway republic. But, as we have emphasised we are neutral and impartial, they more or less leave us alone these days."
As the mission prepares to wind down, what lessons can be learnt?
"We have shown that it is possible to work in Transdniestria and have seen a burgeoning interest by other agencies to extend existing programmes to the region."
But Walsh remains crystal clear as to the main achievement: "We have succeeded in prolonging the lives of hundreds of HIV/Aids patients here, who might otherwise have died."
HIV/Aids in Transdniestria
• The HIV/Aids health budget in Transdniestria in 2007 was a few thousand euro.
• As of June 1st, MSF had 506 patients in Transdniestria, 116 receiving anti-retroviral therapy. The MSF programme has cost more than €1.5 million to date.
• With 15 per cent of the population, Transdniestria contributed 43 per cent of all new HIV cases in both Moldova and Transdniestria (end 2007), according to the Transdniestrian ministry of health.
• Prison: HIV incidence is 20 per cent greater than that of civil sector.