One third of the world's population is currently infected with TB; three million people die from it every year; and the HIV/AIDS epidemic is exacerbating the crisis. The last truly innovative medicine was developed over 30 years ago and the last vaccine in 1923. The most effective existing treatment-DOTS-has significant labor costs for governments and wage and social costs for patients that make it impractical in most settings. Thus MSF makes a priority of TB prevention, treatment, and drug development.
The project has a rather strange acronym-DOTS ("directly observed treatment short course"). Ian explained that TB takes 6-8 months to cure if diagnosed in time, but that after a few weeks of treatment, symptoms virtually disappear and the patient, if not directly observed, often stops treatment, leading to recurrence and even the development of multi-drug resistant strains.
MSF established a presence in the Aral Sea area in July 1997, and is still the only international medical aid organization in the region. The program in Uzbekistan was intended to be a pilot project in two districts, but according to Ian, "pilot project is often just another name for plowing ahead without taking long term responsibility for the outcome of the work, so we decided to make it more ambitious. Instead of the two districts originally planned, we are dealing with all 26 districts in the Aral Sea area in Turkmenistan and Uzbekistan - covering a population of four million."Aral Sea Beyond Saving
A popular witticism here goes: "If every expert who flew in to help save the Aral brought a bucket of water, the sea would be full by now." Of course, that's stretching a point; in fact, there is no possibility of saving the Aral Sea. The critical threshold has long since passed. All aid now goes to trying to mitigate the disastrous effects on the local population.
However, unlike many expatriate projects, this one will leave an important legacy. Some of its keys to success:
It built on existing infrastructure. Ian said that the Soviet infrastructure to fight TB was actually good. "TB is about control, which the Soviets were very good at. They had a network of TB clinics and kept patients for up to 2 years to make sure they were cured. We are using the existing polyclinics and medical points, taking over a room in each one in the affected areas, training nurses and providing medicine so that they can keep track of patients and make sure they come to take their medicine. We've trained over 2000 health care workers so far and set up over 1000 'health points.' Instead of long expensive hospital stays or, worse, unmonitored treatment, we have set up a program of two months in the hospital, and six months of outpatient observed treatment at the health points."
It works closely with the government structure. Its 22 expatriates and 110 local full-time staff are helping reform the health care process, with the TB treatment rooms, training and medicines for local health care workers, who work under the Ministry of Health. When the project is completed in 2003, all of the work will be carried out by local health care professionals.
It relies on good specialists who are highly motivated. In a medical NGO, the staff have a high level of training and an ethical foundation. Having observed UN, World Bank, and other projects here, I have seen how stuffy bureaucratic organizations can lose their direction, despite lots of money, and end up with no or even negative results.
Its research component responds to local concerns. Ian explained how they worked for a year before launching their operational research, with researchers from McMaster University interviewing 1000 local people and 50 local scientists to determine what was of concern. They decided on looking at the effects of airborne dust on respiratory diseases (which account for 50% of child mortality in the area), high salt content in water on kidney disease and hypertension (which have sharply increased in recent years), and a study looking at toxicity and the food chain.
Earlier this year, David Suzuki did a program on The Nature of Thingsabout the Aral crisis, and held a live chat program after the show, with Ian on-line in Tashkent. "We had the usual glitches here, but kept a phone line open for the hour-long conference. It was great, and attracted lots of attention to our work."
Another boost was getting the Nobel Peace Prize in 1999. MSF used the proceeds-a bit shy of $1m-to create the Neglected Disease Fund. Initial target diseases include sleeping sickness, leshmaniasis, tuberculosis and malaria. The fund supports the objectives of MSF's campaign, Access to Essential Medicines, on which the program in Uzbekistan relies. Grants are awarded to overcome barriers to accessing existing drugs and to stimulating development of new treatments in all 84 countries where MSF operates.
From 1997-2000, the program in Uzbekistan treated 4,000 patients, and is finding more cases at a rate of 500 per month. So far it has cost about $4m, half of which MSF provided, half, the Swedish International Development Agency. The German Development Bank will finance the future for about $4m. This is a model project compared to dozens of other NGO projects here, many of which may mean well, but fail due to the myriad pitfalls that East-meets-West creates.
While its TB program in Central Asia may look like just another goodwill gesture, MSF is actually well grounded in post-Cold War political theory. Ian Small explained to me their policy of advocacy, not intervention, and the importance of consulting with locals concerning needs of the local population, both of which make it more welcome than other NGOs in many countries. He also described environmental scarcity as a threats to peace in the present world situation. (See "Environmental Scarcity: considering the Aral Sea Basin" by Ian Small in Historical Themes and Current Change in Central and Inner Asia,Toronto Studies in Central and Inner Asia, No. 3 (1997), U. of Toronto-York University Joint Center for Asian Pacific Studies).
We may think that the Cold War was "won" without the usual victims of war. But at the war monument in Muynak, on its promontory overlooking the once flourishing, now desiccated seabed stretching as far as you can see, you realize that the people here are real victims of the Cold War. The Soviet army numbered roughly three million, and the cotton for their uniforms came from the fields of Karakalpakstan (an autonomous republic in Uzbekistan). The toxic dust storms are the legacy of the Cold War and a fertile soil for future conflict.Environmental Scarcity
Thomas Homer-Dixon has developed a theory of conflict at the University of Toronto based on environmental scarcity. It sees conflict today primarily as a function of three variables: environmental destruction, population growth, and the resulting disparities, which get worse as a smaller pie is unevenly divided among the increased population. In this scenario, neither class warfare nor nationalism is the leading cause of war, but environmental degradation. Furthermore, conflicts are increasingly intra-state, since environmentally, borders are meaningless.
A new category of refugees is growing: environmental refugees. They are desperate and bitter and have nothing to lose. When a certain threshold of environmental degradation is reached, society can no longer cope, and international 'help' or other intervention is necessary to stop the downward spiral. Already 100,000 people have left the Aral Sea area as environmental refugees. We speculated as to why there is no more overt unrest in the region in the face of the hopelessness. After all, in Fergana valley, at the opposite end of Uzbekistan, there is considerable unrest, along more traditional religious and regional ethnic lines. However, in Fergana, there are mountains for rebels to hide in, and the environmental conditions, though bad, are not at a crisis stage. Fergana still fits the more traditional model for conflict, based on ethnicity and religion.
The flow of environmental refugees has begun, shifting the problem to other regions. The people of Karakalpakstan who stay behind are demoralized. There are no mountains for rebels to hide in, and no rich untapped resources, like the nearby Caspian Sea, with its huge oil reserves, which attract foreign powers and encourage locals. In the Aral Sea basin there is only creeping despair. If the downward spiral continues, the flight of refugees will accelerate, creating a kind of post-war syndrome. It's the worst of both worlds - no war, but no peace dividend. While there is no overt conflict at present, there is a growing health problem and a constant flow of refugees, draining the state.
Clearly the work MSF is doing is on the very front-line of the struggle for peace. Lifting people out of despair and mitigating the worst effects of the environmental ruin may arrest the downward spiral, and keep a critical situation from becoming the source of violence and instability. Remember: Uzbekistan borders on Afghanistan and religious and separatist rebels operate on the eastern borders of Uzbekistan.
Eric Walberg is a Canadian who has lived the past several years in Tashkent.
infant mortality has increased from 35 per 1000 in 1960 to 100 per 1000, similar to sub-Saharan Africa
100% of women are anemic. Many are not allowed to bear children because of the risk to their health and the risk of birth defects
the life expectancy in some villages is as low as 38, though officially, the government claims it is 69
salt concentration is 6 g/liter of water. In Canada the limit allowed is 20 times less (0.3g/liter) and the WHO recommended limit is 6 times less (1 g/liter).
2/3 of the people in the region are chronically sick
the population of the Muynak region has fallen from 45,000 in 1960 to 27,000.
kidney disease, cancer, TB, asthma, birth defects, and water-borne diseases such as typhoid and hepatitis have increased alarmingly since Uzbekistan's independence in 1991
the ground water, once 50 m below ground level, due to excessive irrigation and lack of water management, is now 1-2 meters below ground level in inhabited areas. The water dissolves the salt in the soil, and both the water and soil become increasingly saline.
Each year, wind whips 45 million metric tons of salty and contaminated dust from the exposed Aral Sea seabed into the air, contributing to health problems such as respiratory infections, tuberculosis, anemia, kidney diseases, diarrhea and cancer.
One of the odder moments in this project was a monster ploff, which Ian and his staff put on for the residents of what has to be one of the most heart-wrenching towns in the world - Muynak - to celebrate the millennium.
"I just couldn't stand all the hype. London built a billion-dollar tent, so I proposed we get as far away from this as possible. We wanted to show our solidarity with these people we were trying to help, to see in the new millennium with them, so that they didn't feel left behind in all the global glitter."
It was the biggest party Muynak had ever seen. Twelve massive pots full of rice and lamb. Three thousand locals joined in the celebration and were absolutely thrilled, since most of the foreigners they meet are journalists and officials who flit in, wring sob stories from their tragic lives and disappear again, leaving nothing.
"After it was over, we still had to get back to Tashkent, and, because of the Y2K fear, we weren't allowed to fly, so we arranged a VIP rail car for $400 and took the 30-hour train trip back to Tashkent. Cheaper than the plane, ecologically correct, and fun to boot."