We recently received the following account of a visit to Azerbaijan from AJN contributing editor Jane Salvage, MSc, BA, RGN. At the time of writing, Salvage was a consultant for the noncommunicable diseases programme, World Health Organization (WHO) Regional Office for Europe. She now works as the policy lead in the support team for the Prime Minister’s Commission on the Future of Nursing and Midwifery in England, and fears that seeing Baku in the springtime will have to wait a year or two. This post is fairly long, but we feel the range of local detail included by Salvage gives a fascinating glimpse into what it’s really like to work in the field of international public health policy. (Note: we’ve retained some UK-style spellings.)
The advance preparation for this WHO mission has also been a lot better than it used to be, since email, internet and teleconferences have already linked me with the WHO Baku office, the WHO European Regional Office in Copenhagen, Denmark, and my travelling colleague, a public health professor whose flight should already have touched down. I know from experience, though, that the best laid plans unravel when no-one comes to collect you from the airport, the local experts are all at some other conference, or your materials for teaching a week’s course in Uzbekistan are still in your suitcase in Istanbul.
Even if things go smoothly here, there’s no guarantee we will achieve anything. The most recent WHO report about oil-rich Azerbaijan tells a tale of economic hardship since it became independent in 1991, reflected in decreasing life expectancy and high infant and maternal mortality. ‘Azerbaijan has moved only part way along the health transition, facing a double burden of diseases of westernization and of poverty,’ the report says. ‘The breakdown in the health care system, affecting both prevention and treatment, has accentuated the situation.’ Helped along by dedicated Western purveyors of cigarettes and alcohol, the rates of noncommunicable diseases (NCD) like heart disease, stroke and cancer are soaring. Health professionals have few skills in disease prevention; management and leadership capacity are lacking; and there is no overall strategic direction for health. Oh, and a nasty little war with neighboring Armenia has been going on since 1992.
In other words, most Azeris are poor and unhealthy—despite the oil wells below them—and noone seems to know what to do about it. We will have our work cut out. Red-eyed and stiff in my plane seat, I suddenly feel depressed, knowing how hard it will be to make an iota of difference. Just as well I like a challenge. As usual, all I can do is give up hope but keep the faith. And there is some evidence of commitment to change, stimulated by public dissatisfaction and new health leadership (we learn later that a previous Minister of Health went to prison). The government has asked WHO to help devise a national plan for NCD prevention and control, and WHO has asked the professor and me to see what’s going on and make recommendations.
Azerbaijan is one of the few ex-Soviet republics that I haven’t visited in my 20-year involvement with the region, so I jumped at the chance. It is taking them a long time to outgrow their Soviet inheritance, so my hunch is that the country will feel familiar, from the downtrodden status of nurses to the continuing use of Russian as a common language – and so it turns out. But in another sign of changing times, our hotel, despite its own Soviet legacy of dim light bulbs and anonymous midnight phone calls, has an English pub in the basement, serving Dutch beer. We may well need it.
The pub turns out to be the venue for my blind date breakfast with the professor. We haven’t met in person – he couldn’t attend the training session I ran for our team of consultants in Copenhagen. Unlike me he speaks Russian; his CV looks good, he comes from a country also grappling with its Soviet-style inheritance, and he turns out to be burly and genial. We have only three full days here, and we’ll be together most of our waking hours, so we quickly devise a way of working: he’ll deal mainly with the technical side while I manage the process and take the notes. A traditional division of doctor-nurse labor, I think to myself.
Then begins a whirl of meetings, starting at the WHO office in a splendid UN building with a stunning view of the Caspian Sea. It’s November but the sun shines brightly on the ancient fortress within the old city walls, surrounded by the 19th-century oil magnates’ palaces, and then ranks of Soviet tower blocks marching over the hills. The WHO country representative, clever and welcoming, is a local man with an overseas education, and we are relieved that he has appointed a young Azeri physician to work on NCD. She has arranged our programme and will accompany us everywhere—a big plus, as she can maintain the momentum after we leave. Otherwise the enthusiasm and promises generated by the mission might vanish without trace.
The three of us are whisked off to meet a succession of health officials, starting at the Ministry of Health, which was built as a casino in 1901 and later housed the Baku soviet, or revolutionary council. Although it’s newly refurbished the accessories and atmosphere are still Soviet. Stalin and Lenin have been replaced by the ubiquitous twin images of current president Ilham Aliyev and his dead father, former president Heydar Aliyev. Everywhere you look, there they are, on office walls, billboards and TV channels, in white coats or black polo-neck sweaters, kissing babies or looking stern and masterful.
I feel like Sherlock Holmes on a case, and the pattern becomes clear after a number of these meetings. These guys, the old guard, are cunning survivors who cut their teeth in Soviet times. They receive a perpetual procession of visitors like us, and feed us all the same lines. WHO consultants, however cynical we may feel, must remain respectful, but their speeches seem endless and as my jet lag kicks in I’m only kept awake by glasses of tea.
There is a breakthrough right at the end of this long and rather dispiriting day. Everyone has mentioned the bright young director of the Ministry’s new centre for public health and reform, and when we finally meet him, he seems the real deal: smart, strategic, focused. Instead of making long speeches, he asks right away what can be done and what we can offer. He seems open and honest about the problems, and committed to finding solutions. We quickly get down to business, and agree to work together to establish a national NCD working group. The wide range of stakeholders should include people outside the health system, in an attempt to promote a multisectoral approach – little short of revolutionary in these countries.
The professor and I dine together in an atmospheric cellar restaurant in the old city. The delicious food is typical Azeri—kebabs, herbs, fresh salads, hot unleavened bread, lots of aubergines and pomegranates—and amazingly cheap, especially compared with the Western prices of coffee and snacks in modern cafes (whose menus also thoughtfully offer a range of cigarette brands). We return the next night and sample the cheap local vodka. The professor hopes it will kill off the cold he thinks he has caught from our hotel’s crummy air conditioning. He also self-treats it next day with over-the-counter antibiotics.
By the end of three days we have endured more largely pointless but diplomatically important meetings, but also met more promising partners with whom good work should be possible. I have coaxed the professor through his ‘man flu’ to co-write our mission report. We recommend that an NCD working group should be established and start collecting data according to a WHO template, to build an evidence base for NCD policy. When they have completed the situation analysis, we will return to run a workshop that will update them on NCD, review the data, and map the national NCD strategy.
I escape on the last night to meet a former colleague, an Azeri psychiatrist. He speaks excellent English, much of it learned when he was sheltering behind rocks avoiding gunfire, having been conscripted into the army in Nagorno Karabakh. I appreciate his wit and intelligence, and hear about the harsh realities of life in Baku. Unlike many highly qualified medics who have migrated, he chooses to stay because he loves his homeland, if not its leaders. He wants me to meet some mental health nurses who have started a special interest group – there are no established nursing organizations in Azerbaijan. As he escorts me to my hotel, he asks me why I am staying there. ‘I think it is a place,’ he delicately puts it, ‘for ladies of the night.’
On the plane home, surrounded by hard-drinking Scottish oilmen, I muse whether this was Mission Impossible or mission accomplished. We probably did as well as we could, but it’s anyone’s guess whether we left any footprint. Communications with Baku have since been sporadic, so it is hard to know what, if anything, is going on. The dates of our proposed spring workshop have still not been fixed, and WHO funds, like everyone else’s, are hard hit by the economic crisis. Previous experience suggests there will be a sudden flurry of activity, we will go at very short notice, a workshop will be held, and things will slowly move on. On the other hand, I wouldn’t be at all surprised if I never went back. That would be a shame as I want to meet the nurses, and make time for the sightseeing that is usually impossible on these whirlwind visits. There are worse ways of earning a living than seeing Baku in the springtime.–Jane Salvage, MSc, BA, RGN, American Journal of Nursing contributing editor