Prison healthcare in Kyrgyzstan is a set of systemic problems, including the shortage of specialists, difficulties with transfer of sick prisoners, as well as difficulties with prisoners' access to drugs, including vital drugs.

"My client is dying in prison," lawyer Indira Sautova tells her story.

Her current client is 44-year-old Muzafarzhon Abdulkhamidov was born and raised in Kyrgyzstan. A few years ago, he moved to Russia as migrant and changed citizenship.

It didn't work out there, so he came back to his motherland. He offended against the law and was imprisoned.

Now he is serving his time at one of the facilities of the Penitentiary Service at the Ministry of Justice of the Kyrgyz Republic (SIN). However, it is difficult to say whether the man will live to see the end of his term with his diagnosis, type 2 diabetes with complications.

Sautova's client began to receive insulin not so long ago – from autumn 2021. The man was given the vital drug after his story had been published in the media.

"The problem of quality of drugs and access to drugs has been long-standing in our penitentiary system. In particular, it concerns insulin-dependent people who are placed into closed facilities," the human rights defender said.

Imprisoned Kyrgyzstanis diagnosed with "type 2 diabetes", just like other insulin-dependent citizens of Kyrgyzstan, are registered with medical institutions and must receive insulin free of charge, according to the law of the Kyrgyz Republic.

See also: Free Healthcare Services in Kyrgyzstan: What Can Citizens Count On?

"However, according to my practice, prisoners do not get this hormone. Prisoners' relatives buy the drug at the place of their registration and bring it to prisoners. They deliver it from Kyzyl-Kiya or somewhere else. Although this problem could be easily solved at the interagency level under the agreement between the SIN and health ministry, the burden of insulin supply falls on prisoners' relatives. And it's quite unclear how those prisoners who don't have relatives or whose relatives abandoned them survive," Sautova said.

The lawyer sent a request to the health ministry and received a reply saying that prisoners in the Kyrgyz Republic do not actually receive insulin in prisons.

However, the press service of the Ministry of Health said otherwise to CABAR.asia: SIN facilities receive insulin upon request. When an insulin-dependent person is imprisoned, the administration writes a letter to the Ministry of Health and the facility receives the required drug.

However, even if insulin is delivered to prisons properly, according to the main medical agency of Kyrgyzstan, it is not distributed among all prisoners who need it. The point is that state guarantees of provision of this vital drug apply to the citizens of Kyrgyzstan only.

In the same letter from the health ministry, the human rights defender was told, "the current provision of medical services to foreign citizens who are placed into GSIN facilities causes many difficulties because of the lack of laws and regulations and intergovernmental agreements in the field of provision of medical services regarding diabetes."

"As far as I know, non-citizens of Kyrgyzstan have problems with getting insulin in our country. Free state guarantees do not apply to them, and it is practically impossible to buy the drug in a pharmacy. So, it is true not only about imprisoned foreigners," Indira Sautova said.

Kyrgyzstan has no ban on free sales of insulin. But since the drug requires special shelf life conditions, and because the majority of patients get the drug free of charge, pharmaceutical companies just do not buy insulin drugs.

After the story of Muzafarzhon Abdulkhamidov had been published in the media, the man started receiving insulin.

Lawyer Arsen Ambaryan said that the situation with Kyrgyzstan prisoners' access to vital drugs is really difficult: lack of funding has great impact since the start of the coronavirus epidemic.

It means that health care must be provided to prisoners in healthcare settings regardless of their legal forms and ownership forms as part of state guarantees set forth by the healthcare legislation. Administrations of SIN facilities must create conditions for medical and epidemiological service of prisoners.

"Health care is provided by healthcare units according to the government-approved rules of healthcare. If a prisoner has a serious disease, the list of which is approved by the government, the administration of the facility may advise the release from penalty by court decision," the lawyer said.

According to him, the law is structured so that no one should die from diseases or torment in prisons. In other words, if a doctor diagnoses some serious disease in an inmate, the doctor should prescribe treatment based on the health ministry's clinical guidelines, not on the availability of drugs at a warehouse, while relevant services must ensure the sufficient supply of necessary drugs.

Despite the fact that Kyrgyzstan has a legal framework protecting the rights of seriously ill inmates, people in prisons still die from diseases – tuberculosis, oncological diseases, AIDS and non-specific general medical conditions.

51 prisoners died in Kyrgyzstan in closed penitentiary facilities in 2020. 54 prisoners died in 2019, 65 in 2018, 66 in 2017, 64 in 2016.

Bermet Baryktabasova, specialist in evidence-based medicine, call the issue of prisoners' access to drugs and medical treatment a burning issue. According to her, healthcare facilities in prisons have distanced themselves from the healthcare system for the years of independence.

"Today, civil healthcare, many treatment protocols and national reforms do not penetrate into healthcare facilities in prisons. We must prevent it," she said.

According to the expert, now all healthcare workers from various agencies are accountable to their administration in GSIN, Ministry of Defence, etc. As a result, it leads to the fact that treatment standards in closed facilities and civil medicine have become different.

According to her, this is very risky because if an inmate with diabetes is not diagnosed in a timely manner and is left without access to necessary drugs and treatment, it can lead to deplorable consequences.

"The most hazardous complications can be blindness, kidneys fail – nephropathy, as well as neuropathy, when peripheral nerves are damaged, gangrene, and rot feet (diabetic feet), which leads to amputation, disability, reduced life expectancy," the specialist said.

Moreover, she noted the insufficient qualification of healthcare workers of closed facilities because of lack of postgraduate training.

"I know the findings of the causes and structure of mortality in closed facilities based on results of post-mortem examination. Mismatching diagnoses are quite frequent there. This is always a very alarming indicator in medicine. It means wrong diagnoses, wrong prescriptions, complications and mortality," Baryktabasova said.

However, the expert said, international conventions signed by Kyrgyzstan provide for access of prisoners to health care at any healthcare facility. Any inmate may recourse to any doctor – a specialised doctor or a specialised hospital, as well as pay for services individually if the service is not covered by state guarantees.

Inmates with severe incurable diseases may be released from prison according to the law of the Kyrgyz Republic. There is even a special procedure that gives the seriously ill (or even dying) inmate a so-called ticket to freedom.

"The procedure of medical examination of prisoners having severe diseases and their further release has precise wordings, algorithm, times and sequence of actions of healthcare staff of facilities. Every facility must have health commissions in place," Arsen Ambaryan said.

"Thus, the time between the statement of treatment failure or aggravation of health condition and submission of a release recommendation to court should not exceed 15 days. However, this rule does not work in practice," the lawyer said.

Lawyer Indira Sautova, who has been struggling for several months to apply this algorithm to her client who has diabetes, which is on the list of diseases preventing from detention, confirms the fact that this procedure does not work.

According to Sautova, it was not easy to release a severely ill inmate from prison previously, but now it is absolutely impossible because of the criminal charges filed against criminal lord Aziz Batukaev in 2013, who was diagnosed with "blood cancer" and released unlawfully from prison.

"According to the law, SIN must recommend release of a severely ill inmate to the commission, and then to court, so that the latter could decide whether to release or not. But after the scandal with Batukaev, the agency seems to be on the safe side as they use this procedure less frequently. As a result, people suffer. Moreover, it gives rise to corruption. Today, inmates say that the recommendation [for medical examination] is now linked with some corruption moments," Sautova said.

In January 2020, Bakhadyr Dzhuraev died at the age of 45. According to the medical certificate, the cause of death was chronic ischemic heart disease and diabetes.

He was serving his term in a penal colony after he was found guilty of participating in mass disorders and was sentenced to 25 years in prison with forfeiture of property.

During detention and investigation, Bakhadyr Dzhuraev was severely battered, did not receive timely and qualified medical care, and then those injuries had an impact on his health condition. He was exposed to torture, abusive and degrading treatment.

Human rights defenders had been struggling for the restoration of his rights, recognition of him as a victim of torture and retrial. In 2012, the complaint was submitted to the UN Human Rights Committee, and in April 2019 lawyers reduced the term to 18 years by applying the new criminal law focused on humanisation, decriminalisation and depenalisation.

Dzhuraev underwent two surgeries in custody, developed gangrene of toes and type 2 diabetes, hypertension. In the last year of his life, he could hardly move and suffered from persistent pain.

He has died waiting for the decision of the UN Committee and review of his case.

This article was prepared as part of the Amplify, Verify, Engage: Information for Democratisation and Good Governance in Eurasia project implemented by IWPR and funded by the Norwegian Ministry of Foreign Affairs, and mentoring program of the Development of New Media and Digital Journalism in Central Asia project implemented by IWPR with the financial support of the UK Government. The content of the article does not reflect the official position of the IWPR, the Norwegian Ministry of Foreign Affairs, or the Government of the United Kingdom.