Safe water for the Aral Sea Area
Could it get any worse?
IAN SMALL, DENNIS FALZON, JOOST B.W. VAN DER MEER, NATHAN FORD *
The environmental adversities around the Aral Sea in Central Asia have been the subject of recent research. Attempts
at sustainable provision of palatable drinking water in low chemical and microbial contaminants for the 4 million
people in the two countries around the Aral littoral have been largely unsuccessful. In the last few years, severe
drought has further depleted the amount of available water. This shortage has negatively impacted on agriculture,
and accentuated the out migration of people. An appeal is made to assist the local population in this arid area to
cope with the acute and chronic deterioration of water security.
Keywords: Aral Sea, Central Asia, drought, salinisation, water security
The Aral Sea area is the site of one of the worst human-
induced environmental disasters.
1
 The shrinking of the
Aral Sea, once the world’s fourth-largest inland body of
water, has had far reaching ecological, social, economic
and public health consequences.
2
Despite recognition of the disaster for almost 20 years,
and after 10 years of international presence in the area
and millions of dollars spent on various assessments,
four million people living in the area around the Aral Sea
face insufficient access to safe and palatable drinking
water. To compound this matter further, the region was
recently confronted with the worst drought in living
memory.
AN EVOLVING CATASTROPHY
The Aral Sea lies in the territory of two countries that
formerly belonged to the Soviet Union: Uzbekistan and
Kazakhstan. The southern bounds of the sea were
dominated by the extensive internal delta of the Amu
Darya, a river that flows west from the mountains and
crosses desertic expanses through much of its range.
Originally, the livelihoods of the nomadic peoples who
roamed the region depended on the wildlife supported by
these waters. After the 1950s, intensive irrigation started
to change this as Moscow centralized agriculture,
concentrating heavily on water-thirsty crops like cotton
and rice. This policy had a profound impact on the water
distribution and amounts of water reaching the sea from
the Amu and Syr Darya, the two rivers that fed the sea.
By the mid-1980s both rivers barely reached the sea and
it began to dry up, losing of half its size and two-thirds of
its volume in the early 1960s.
3
 This shrinkage has
contributed
 
to regional climate change, causing further
aggravation of the already arid climate.
4
 The associated
loss in fishing and hunting, the mainstays of the pre-
Soviet economy, stretched the coping-mechanisms for
the local population in the wake of economic reversal
following the collapse of the Soviet Union.
The intensive cotton farming used an abundance of
pesticides, herbicides, defoliants and fertilisers.
5–7
These chemicals accumulated on the exposed sea bed
– an area roughly the size of the Netherlands – and are
now picked up by dust storms. Each year an estimated
43 million metric tons of salt and pesticide-laden dust is
blown into the air people breathe.
3,8
 Agricultural pro-
duction declined because of the contamination of land,
and by 1985 60% of all irrigated areas in Karakalpakstan,
the area in Uzbekistan immediately bordering the Aral
Sea, were considered salinized.
9
With such ‘creeping environmental degradation’,
10
 the
impact on economic and other determinants of health are
readily jeopardised. According to local public health
professionals, scientists and policy-makers,
11
 and the
population,
12
 access to a safe supply of water was already
one of the most pressing issues before the advent of the
recent drought.
Access to piped water in the Uzbek Aral Sea Area varies
between 84% and 64% for the urban population and
between 32% and 21% for the rural population.
6,13
Often, such supplies are intermittent.
14
 Over a quarter of
the population use irrigation canals as their main water
source.
15
 In one study, 70% of drinking water samples
tested did not satisfy chemical standards and about 30%
exceeded biological norms.
16,17
 The bacteriological
quality of water in some cases indicates heavy con-
tamination with sewage: whereas no coliforms should be
present in 100 ml of drinking water according to the
World Health Organisation (WHO) guidelines,
18
 these
are reported to reach up to 2380 coliforms/l in places.
19
The proportion of infant death due to diarrhoea is as high
as 29.1% compared to the regional rate of 16%.
20,21
Outbreaks of other water-borne diseases such as hepatitis
A are reportedly common.
22
 EUROPEAN JOURNAL OF PUBLIC HEALTH 2003; 13: 87–89 
* I. Small
1
, D. Falzon
1
, J.B.W. van der Meer
1
, N. Ford
2
 
1 Médecins Sans Frontières, Aral Sea Programme, Tashkent, Uzbekistan
2 Médecins Sans Frontières, London, UK
Correspondence: J.B.W. van der Meer, MD, PhD, Médecins Sans Frontières, 
Max Euweplein, 1001 EA Amsterdam, The Netherlands
87
Drinking water typically has a high mineral content. The
Amu Darya is among the most sediment-saturated rivers
in the world,
23
 and salt levels of 5500 mg/l have been
recorded.
24
 The salinity of shallow aquifiers (10–40 m)
from which hand pumps and wells abstract water reaches
up to 3–5 mg/l further from the river
25
 in Karakalpakstan.
Well-water salinity up to 2800 mg/l has been recorded,
26
compared to WHO’s suggested upper limit of 1200 mg/l
for total dissolved solid
18
 based on palatability. Although
the direct relationship between salt intake and human
health is disputed, it is conceivable that if consumer
preference for water is influenced by taste, water which is
undrinkable owing to high salinity may be exchanged for
sweeter water deriving from sources which may be less
safe, such as open canals.
THE IMPACT OF ACUTE DROUGHT
From 1999 to 2001, the flow of the Amu Darya
diminished, with less than half the average amount of
water received in previous years reaching western
Uzbekistan in the first nine months of 2000.
27
 This was
partly due to failure of snowmelt in the feeder mountain
ranges on the Tajik-Afghan border, and also due to trans-
boundary political disputes over sharing of water between
Central Asian states. The impact on agriculture and
animal husbandry in western Uzbekistan has been severe.
In 2000, the increased frequency of diarrhoeal diseases in
Muynak, south of the sea, and the potential for more
serious illnesses such as cholera, was highlighted in a
WHO report.
28
 Field research done by MSF and WHO
in Karakalpakstan in the first half of 2001 showed that
while the levels of acute malnutrition in children under
5 did not exceed 5%, food accessibility was reduced.
The response of the authorities to this acute development
superimposed on a chronic problem accentuated the
shortcomings of the present infrastructure to handle
household water needs in the region. The pleas for
external assistance issued by the Uzbek government in
2000 and 2001 were dominated by requests for water
trucking equipment, hand pumps, laboratory supplies and
medicines that were not expressly indicated for the
purposes of drought-related illnesses.
ACTION AREAS
The Aral Sea Area is historically known for dramatic
swings in water availability.
23
 The development of large-
scale irrigation to support the re-orientation of the local
economy in past decades towards intensive agriculture has
been the making of this man-made disaster. Settlers now
live in an increasingly hostile environment with reduced
possibilities of scraping a living, forcing many to migrate
to more promising pursuits elsewhere.
High levels of dissolved solid in water affects peoples’
wellbeing. The methods currently being employed, from
trucking water to drilling bore holes and installing hand
pumps, will at best have short-term benefit. In an
assessment done in Karakalpakstan in 1997, one-third of
bore holes tested within 2 years of their construction were
nearly 5 metres short of their projected depth, either
because of mismanagement or poor construction and early
silting;
29
 19% had been abandoned, mostly because of
mechanical failure due to shoddy workmanship or un-
palatable water. Inadequate ownership of the hand pumps
by their users resulted in failure of this project.
The lack of reliable data about the quality of water and
the populations’ access to it has been frustrating for MSF’s
research in this area. Information is scattered among
many different institutions and is often inconsistent,
incomplete or unavailable. Facilities to monitor and test
water have been under-resourced for many years. Trans-
parency and accountability within government is not
encouraged. Historical data are not reliable because in the
Soviet past they were ‘adjusted’ to meet targets,
30
 a
practice that has not been fully abandoned. Data given
here are not always devoid of this shortcoming, although
attempts have been made to limit this.
RECOMMENDATIONS
This paper primarily makes the case for provision of safe
water in adequate amounts to the population as a basic
humanitarian and public health measure. Ancillary to
this, due consideration needs to be given to reforming the
environmentally disruptive methods of agriculture, along
lines already recommended.
27
 The prolific deposits of
salty water in deep aquifers, uncontaminated by surface
and river water effluents, chemical or microbial, should
be exploited further through investment directed towards
sustainable methods of desalination such as solar powered
technique. Learning from previous mistakes in the area
and elsewhere, the local community needs to be involved
in ownership of such systems from their inception. There
remains a great need to educate the public on the proper
use of water.
The problems with data quality can be improved by better
monitoring through staff training and provision of low-
tech setups to enable epidemiological and laboratory
work. This can boost the quality of monitoring, and could
well be the prelude to deeper involvement in this study
of water-related health effects.
In sharp contrast to the attention given to food security
in the area in the recent years following the drought, the
issue of water safety and security does not seem to have
attracted as much notice. More effort should be spent
bringing to the fore such a crucial issue. There is a great
deal of excellence in western public health and medical
institutions to implement research aimed at sustainable
solutions, but little attempt, it seems, to bring them
together to improve the lot of this neglected population.
  REFERENCES  
1 Glantz MH, Figueroa RM. Does the Aral Sea merit 
heritage? Global Env Change 1997;7(4):357-80.
2 UNEP. Diagnostic study for the development of an action 
plan for the Aral Sea. In UNEP expert working group for the
project assistance in the development of an action plan for the
conservation of the Aral Sea. Tashkent: UNEP, 1991.
3 Micklin PP. The Aral Sea Problem. Civil Eng 
1994;102:114-21.
4 Zolotokrylin AN. Climate fluctuations and changes in the 
EUROPEAN JOURNAL OF PUBLIC HEALTH VOL. 13  2003  NO. 1
88
Aral Sea basin within the last 50 years. In: Glantz MH, editor.
Creeping environmental problems and sustainable development
in the Aral Sea basin. Cambridge: Cambridge University Press,
1999:86-99.
5 McKee M, Curtin M. An environmental profile of the 
Republic of Uzbekistan. DAI for the Asian Development Bank,
1996.
6 McKee M, Curtin M. Statistical abstract of the 
environment of the Republic of Uzbekistan. DAI for the Asian
Development Bank, 1996.
7 Glazovsky NF. The Aral Sea Basin. In: Kasperson J, 
Kasperson R, Turner B, editors. Regions at risk: comparisons of
threatened environments. Geneva: United Nations University
Press, 1995:92-139.
8 O’Hara SL, Wiggs GFS, Mamedov B, Davidson G, 
Hubbard RB. Exposure to airborne dust contaminated with
pesticide in the Aral Sea region. Lancet 2000;355:627-8.
9 Smith DR. Salinisation in Uzbekistan. Post-Sov Geogr 
1992;33:23-6.
10 Glantz MH, editor. Creeping environmental problems 
and sustainable development in the Aral Sea basin. Cambridge:
Cambridge University Press, 1999.
11 Van der Meer JBW. Voices on environmental health: 
results of key informant interviews about environment, health
and research. Tashkent: Médecins sans Frontières, 1999.
12 Crighton EJ, van der Meer JBW, Yagodin VN, Elliot S. 
Impact of an environmental disaster on psychosocial health and
wellbeing in Karakalpakstan. Tashkent: Médecins sans Frontières,
1999.
13 Iskanderova ST. Problems in the protection of 
environment and influence of negative factors on people’s health
in the Aral Sea Area [Russian]. Med J Uzbekistan 1995;(4):4-6.
14 Falzon D. Study report on knowledge, attitudes and 
practices. Muynak and old Kungrad, Karakalpakstan. Nukus:
Médecins sans Frontières, 1998.
15 Kudat A, Zholdasov A, Ilkhamov A, Ozmen N, Bernstein J. 
Needs assessment for the proposed Uzbekistan water supply,
sanitation and health project. Tashkent: World Bank, 1995.
16 Iskanderova ST. Problems in the protection of 
environment and influence of negative factors on people’s 
health in the Aral Sea Area [Russian]. Med J Uzbekistan
1995;(4):4-6.
17 Elpiner L. Results of the environmental health researches 
on the Aral Sea Area environmental crisis, 1980-1990 [Russian].
Unpublished review.
18 WHO. Guidelines for drinking water quality. 2
nd
 edn. 
Vol 1. Recommendations. Geneva: WHO, 1993.
19 Binnie & Partners, Aral Sea Program 5, Project no. 1 
Uzbekistan Water Supply Sanitation and Health Project. Final
Report Water quality and Treatment. Tashkent: State Committee
on Forecasting and Statistic of the Cabinet of Ministers of the
Republic of Uzbekistan / Binnie & Partners, 1996.
20 Koupilova I. Review of the present and recent 
epidemiological situation regarding diarrhoeal diseases and acute
respiratory infections in children under the age of five years in
the countries of the Former Soviet Union, Albania, Bulgaria and
Romania. WHO, 1994.
21 DHS. Demographic and Health Survey: Uzbekistan 
[English]. Calverton; ML: Institute of Obstetrics and Gynecology,
MoH of Uzbekistan / DHS Demographic and Health Surveys, 1996.
22 Frost L. Assessment Report: health, public health and 
areas for intervention in the midst of ecological destruction and
infrastructure disintegration in the Republic of Karakalpakstan,
Uzbekistan. Tashkent: Médecins sans Frontières, 1997.
23 Kes AS, Klyukanova IA. Causes of the Aral Sea level 
variations in the past. Sov Geogr 1990;31:603.
24 Information bulletin of groundwater pollution in 
Uzbekistan for 1996-1997. Issue 23-24. State Committee of the
Geology and Mineral Resources and State Agency of
Hydrogeology - Uzbekgidrogeologiya, Tashkent, 1998.
25 Magnusson J. An assessment of the drinking water 
situation in Karakalpakstan. Central Asian Free Exchange &
Lifewater International, August 1994.
26 UNDP/Crosslink. Rural water supply and health education 
in the Aral Sea region, in quarterly and final reports. Tashkent:
UNDP/Crosslink International, 1997.
27 FAO/WFP. Crop and food supply assessment mission to 
the Karakalpakstan and Khorezm regions of Uzbekistan. Special
report. Rome: FAO, 19 December 2000.
28 Vliet HCAM. Emergency and humanitarian assistance in 
Uzbekistan. Report for assessment of impact of drought on
communicable disease situation and health. WHO, Regional
Office for Europe, 2000.
29 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.
30 UNESCO Division of Water Sciences with the cooperation 
of the Scientific Advisory Board of the Aral Sea Basin. Water
related Aral Sea basin vision for the year 2025. Tashkent:
UNESCO, 1999.
Received 26 May 2000, accepted 29 October 2001
Commentary
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