Introduction

There is a common saying in the Aral Sea area: "if every specialist brought with them a bucket of water, the Sea would be filled again." Countless scientific expeditions and assessments have been conducted in the area, to the degree that the population is "assessment fatigued," still distressed, and yet little further ahead. At this point there is a wealth of information on the causal nature of the disaster, but despairingly little on its effects on human health (1). The media produce sound bites about the region focusing largely on the environmental catastrophe, with little coverage on how the health of the population is affected. The catch phrase is the "death of the Aral Sea," and the fact that 5 million people are living within a degraded and increasingly uninhabitable environment is not mentioned.

The Aral Sea consists of the territory of two Central Asian states formerly of the Soviet empire: Uzbekistan and Kazakhstan. The sole water source that counters evaporation of this terminal sea are two rivers, both of which are extensively tapped for irrigation purposes to produce cotton and rice, and both crops require immense quantities of water. Unlined and uncovered, the irrigation systems are extremely inefficient and poorly maintained. Consequently, less and less water reaches the sea (2). Sitting in a vast desert, the sea evaporates. The entire ecosystem verges on collapse. The intensive agriculture and abundant irrigation has resulted in the salinization of the land and the contamination of the water supplies by salt and agricultural chemicals. The fish basket of Central Asia has become the waste basket of the region, as a large proportion of the salts and agricultural chemicals upstream are deposited in the area. As desiccation of the sea bed continues, these salts and chemicals amass on the dry sea bed and are blown back into the face of the population. The increasingly frequent dust storms now displace roughly 43 million tons of dust per year (3). If and when the Aral Sea completely dries up, countless tons of salts will be exposed and sent airborne. Clearly, given the chain of causal events, the Aral Sea crisis is not just about water: air quality, nutrition, climate, the economy, and the health care system are also plunged into crisis. Towns such as Muynak, which previously were on the shores of the Aral, but are now farther than 100 km away from the receding sea, are some of the most chronically sick places on earth.

Here we explore the health situation of the region and present ideas on how an operational approach can be taken in complex environmental health disasters. We think that this approach could potentially be adapted to similar environmentally fragile and devastated areas in the world. We summarize the health, social, and environmental impacts of the disaster and discuss some of the broader scientific and policy issues relevant to taking action to improve health in the Aral Sea area.

Health Effects

For ease of analysis, two sets of health implications can be described, although they are not mutually exclusive. The first is those diseases and health conditions that are not necessarily directly linked to the environmental disaster. Such diseases are the leading causes of morbidity and mortality in the region and are essentially common public health problems, symptomatic of a population suffering from disruption and upheaval. The most serious concern is the continued spread of infectious diseases such as tuberculosis, hepatitis, and respiratory and diarrheal diseases (4,5). The incidence and prevalence of these diseases in the Aral Sea area are among the highest in all of the former Soviet Union and are higher than national averages (6).

The other sets of diseases are the complex chronic health problems for which neither the causes nor measures to prevent them are clear. The potential of the environmental disaster directly impacting human health lies within such concerns as the salinization of the water table, pesticides in the environment and food chain, and dust storms and air quality (7). The associated diseases and health conditions could be elevated rates of hypertension, respiratory conditions, heart disease, anemia, various cancers, and kidney disease. Other suspected adverse health consequences relate to the maternal-fetal interface such as potential teratogenesis, endocrine disruption, and neurodevelopmental and behavioral effects associated with high exposure to persistent organic pollutants (8). These diseases have a greater probability of having direct biomedical links to the environmental destruction than infectious diseases, but sound research is needed for a clearer understanding of their etiology so that effective preventive action can be taken.

Health Infrastructure

Apart from the epidemiologic concerns of the region, the state of the existing health infrastructure and medical system must also be considered. The hospitals and health centers in the Aral Sea area lack essential medicines and medical equipment. The health professionals are present and eager to work but do not have the means to perform their jobs effectively. They require access to new international protocols and tools for treating disease and improving health services, including effective health information systems, public health infrastructure, the development of a primary health care approach, and access to essential medications and diagnostic equipment.

Water Quality

To have a drink of water in the Aral Sea area could be detrimental to your health.

The Aral Sea area is confronted with a crippling water crisis. The lack of availability of water is precisely the reason for the death of the Aral Sea and for the associated litany of negative ecologic and human health effects. The desiccation of a vast body of water has changed the regional climate (2). The salt content of the sea has gone from slightly brackish to 70 g/L, and may reach as high as 140 g/L, a higher salt content than the oceans (2,9). The 20 fish species in the sea, which were an important economic and nutritional element in the region, have died (9).

Not surprisingly, the quality of water for human consumption is poor. Those processes that contributed to the sea's desiccation--over-irrigation and water mismanagement--have also resulted in a rise of the groundwater table, which then became contaminated with high levels of salts and other minerals. Groundwater quality ranges from a minimum of 0.5g/L total dissolved salts (TDS) to an astounding 6 g/L, 20 times more than in North America (roughly 300 mg/L TDS). Drinking water reaches levels of up to 3.5 g of TDS/L (10).

The Uzbekistan government has set the salt limit at 1 g/L TDS; in line with the World Health Organization's international standard. TDS standards are frequently set as related to palatability (11). When the World Bank conducted a consumer preference survey, it set the rate at 2 g/L TDS (12,13); a recent United Nations Development Program pilot hand-pump project intended to bring ground water to rural consumers, allowed a level as high as 3 g/L TDS (14). In other words, acceptable levels of mineralization are set by personal preference or operational difficulties. Agriculturists can pinpoint a precise ratio and relationship between mineralized or salinized water and crop production, but there is no universally accepted level of water mineralization for human consumption, and reliable data on possible health effects associated with the ingestion of TDS in drinking water are not available (15).

Palatability is, of course, an important consideration when discussing water quality. People will not drink enough water if they do not like the taste. In refugee camps, water is chlorinated to avoid cholera. If so much chlorine is used that it becomes unpalatable, people will go outside the camp fence and drink from the closest natural source. In the Aral Sea area, there is no ch