Falzon, D

Ford, N

Small, I

Upshur, R

van der Meer, J

English

lan Small

Dennis Falzon

Joost van der Meer

Nathan Ford

Ross Upshur

Crossref

The Lancet

Not a drop to drink in the Aral Sea

MSF Field Research

For personal use.  Only reproduce with permission from The Lancet Publishing Group.
THE LANCET • Vol 358 • November 10, 2001 1649
CORRESPONDENCE
Not a drop to drink in the
Aral Sea
Sir—One  disaster  resulting  in  water
scarcity  requiring  urgent  international
attention,  but  neglected  by  almost
everyone, including by you in your Sept
29 editorial,
1 is the shrinking of the Aral
Sea.
The Aral Sea disaster has evolved over
decades  through  irresponsible  Soviet
exploitation  of  desert  rivers  in  Central
Asia  to  increase  cotton  and  rice
production.  The  slow  course  of  events
has not helped to publicise the plight of
the local population, and has resulted in
a  gradual  disengagement  by  the  few
international agencies working on one of
the largest environmental disasters in the
world.
Central  Asia  has  been  affected  by
acute drought for more than 2 years. In
the region immediately surrounding the
Aral Sea, half the grain and fodder crop,
and all the rice failed in 2000. According
to the United Nations, 100 000 farming
families in western Uzbekistan have no
stable source of income because of failed
harvest,  loss  of  productive  assets,  and
inability to plant through lack of water.
Anecdotal evidence suggests accelerated
economic out-migration. 
The  current  drought  has  been
accentuated  by  political  wrangling
between  countries  sharing  water
resources of the two main rivers that fed
the Aral Sea, which have now run dry.
Drinking  water  in  the  region  is
inadequate. Piped water is rare in rural
areas,  and  intermittent  at  best.
Alternative  water  sources  include  open
canals,  which  may  harbour  chemical
contamination (river salt, pesticides and
fertilisers)  and  pathogenic  microbes
from  uncontrolled  sewage  disposal.  In
2000,  WHO  reported  an  increased
frequency  of  diarrhoeal  disease  in
Muynak,  once  a  peninusla  town,  now
120 km from the receding sea, as well as
the  potential  for  more  serious  illness
such as cholera.
2
Hand  pumps  are  the  standard
response  of  government  and
developmental  agencies,  whereas  more
sustainable  solutions  such  as
desalinators  powered  by  renewable
energy  sources  are  ignored.  However,
these solutions are far from satisfactory.
Water from shallow aquifers (extracted
by  hand  pumps)  reaches  salinities  of
3–5 g/L, three times the WHO accepted
limit.
3 Consumers have little possibility
of desalinating such water. In one area, a
third of bore holes tested by Médecins
Sans Frontières (MSF) within 2 years of
their  construction  were  far  short  of 
their  projected  depth  because  of
mismanagement  or  early  silting.  19%
were  abandoned,  mostly  because  of
mechanical  failure  or  the  delivery  of
unpalatable water.
4
Serious health issues have emerged in
the  area,  probably  because  of
socioeconomic upheaval. The incidence
of  infectious  diseases  such  as
tuberculosis,  hepatitis,  and  respiratory
and  diarrhoeal  disease  are  among  the
highest in the former Soviet Union.
5
Through  environmental-health  re-
search, MSF is advocating for increased
sustainable  investment.
5 The  need  for
meaningful action after years of talk is
evident.  There  is  a  common  saying  in
the region that if every expert brought a
bucket of water, the Aral Sea would be
filled again. After years of international
presence  and  millions  of  dollars
reportedly spent to bolster water security
in the area, many of the 4 million people
living  in  the  region  still  lack  safe  and
palatable water.
Ian Small, Dennis Falzon, 
Joost van der Meer, *Nathan Ford, 
Ross Upshur
*Médecins Sans Frontières, Aral Sea
Programme, PO Box 333, 700 000 Tashkent,
Uzbekistan; and Departments of Family and
Community, and Public Health Services,
University of Toronto, Ontario, Canada
(e-mail: medco@msfh-tashkent.uz)
1 Editorial. Nor any drop to drink. Lancet 2001;
358: 1025.
2 Vliet HCAM. Emergency and humanitarian
assistance in Uzbekistan: report for
assessment of impact of drought on
communicable disease situation and health.
Geneva: WHO, 2000.
3 Magnusson J. An assessment of the drinking
water situation in Karakalpakstan, Central
Asian Free Exchange and Lifewater
International. August 1994.
4 Den Boogard W, Reed B, Oudman M.
Urgent human needs: rural water supply and
health education in Aral Sea region:
evaluation report. UZB/95/Q05/5Q/99, 1999.
5 Small IB, Van der Meer J, Upshur REG.
Acting on an environmental health disaster:
the case of the Aral Sea. Environ Health
Perspect 2001; 109: 547–49.
treatment, which might impact on the
quality of their lives.
The  simplicity  of  many  large  trials
has  contributed  to  their  success  in
obtaining statistically reliable estimates
of  the  effects  of  treatments  on
important  rare  outcomes  (eg,  death),
and  within  prespecified  clinically
relevant  subgroups  of  patients  (eg,
older  people).  The  challenge  is,
therefore,  to  obtain  reliable  data  on
other outcomes likely to be important
to  patients  without  compromising  the
success  of  trials  in  obtaining  reliable
information  about  the  effects  of
treatment on the risks of death.
We believe that this challenge could
be met far more frequently than it has
been  through  the  collection  of
information on more detailed or difficult
to measure outcomes in subsamples of
the  participants  in  large  simple  trials.
For  example,  basic  information  from
68 000  mothers  who  participated  in  a
randomised  study  of  counting  routine,
compared  with  selective,  fetal
movement  during  pregnancy  detected
no reduction in stillbirth rate associated
with  the  more  active  policy.  More
detailed  information  and  subjective
outcomes—maternal  anxiety  and
feelings  of  being  in  control  and
confident—collected from a subsample
of mothers in the trial provided data on
the  effects  of  the  policies  on  further
prenatal  testing,  admission  to  hospital,
and  elective  delivery.
2 This  successs
illustrates a point made by Hill
3 that, as
long as studies have been appropriately
designed  to  control  biases,  subjective
impressions can be given full weight in
analyses of controlled trials.
Greater partnership in the design of
trials  among  patients,  their
representatives, and researchers should
help  to  identify  outcomes  that  are
important to patients, and reveal how
information  about  these  can  be
obtained  without  compromising  the
ability of trials to assess reliably those
important outcomes, such as death, for
which  very  large  numbers  of
participants are required.
4
*lain Chalmers, Mike Clarke
UK Cochrane Centre, Oxford OX2 7LE, UK
1 Naylor DC. Clinical decisions: from art to
science and back again. Lancet 2001; 358:
523.
2 Grant A, Elbourne D, Valentin L, Alexander
S. Routine formal fetal movement counting
and risk of antepartum late death in normally
formed singletons. Lancet 1989; 2: 345–49.
3 Hill AB. The clinical trial. Br Med Bull 1951;
7: 278–82.
4 Hanley B, Truesdale A, King A, 
Elbourne D, Chalmers I. Consumer
involvement in the design, conduct and
interpretation of randomised controlled
trials: a questionnaire survey. BMJ 2001;
322: 519–23.
Outcomes that matter to
patients in tombstone
trials
Sir—In  his  thoughtful  Aug  18
commentary on the art and science of
clinical  decision-making,  David
Naylor
1 asserts  that  many  of  the
outcomes that matter to patients are
subjective and expensive to measure in
the large, simple, so-called tombstone
trials  that  have  been  designed  to
obtain reliable evidence on the effects
of treatments on mortality. Although
all patients are likely to be interested
in  how  treatment  may  affect  their
chances  of  survival,  most  are  also
interested  in  other  effects  of

Not a drop to drink in the Aral Sea.

Not a drop to drink in the Aral Sea.

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