An NGO worth its salt (with salt to spare)

Since the collapse of the Soviet Union and the end of the Cold War, world peace has seemed closer than ever, but may be slipping between our fingers, like the sands of the Karakum Desert here in Uzbekistan. So thinks Ian Small, the Canadian director of an ambitious project for MSF in Central Asia, the Aral Sea Area Programme to fight the spread of TB, one of the many scourges that have hit the countries of the former Soviet Union since its demise.

Some background on TB: 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. Shorter and simpler TB treatments are needed. 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 labour costs for governments and wage and social costs for patients that make it impractical in most settings. Thus MSF has targeted TB prevention, treatment and drug development as one of its priorities.

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 (MDR-TB).

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 programme in Uzbekistan was intended to be a pilot project in the districts of Muynak and Kungrad, 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 2 districts originally planned for treatment, we are dealing with all 26 districts in the Aral Sea area in Turkmenistan and Uzbekistan - covering a population of 4 million." [ED: They aren’t working in Kazakhstan on this project, which shares what's left of the Aral Sea with Uzbekistan, and has approximately one million people in the area.]

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, contrary to many such projects, which fly in a few expat experts for a high price and leave little behind of lasting value, this project looks like it 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 2 months in the hospital, and 6 months of outpatient observed treatment at the health points.”
· It works closely with the government structure while maintaining control over its daily activities. Its 22 expats and 110 local fulltime 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 continue to be carried out by local health care professionals through the Ministry.
· It relies on good specialists who are at the same time highly motivated by their work. This is the great advantage of a medical NGO, where by definition, the staff have a high level of training and an ethical foundation built into their work. 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 (unfulfilled expectations, cynicism, unasked for or even mistaken projects).
· It is both hands-on and has a research component responding to the concerns of both the local people and local specialists. 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 an EPCS (exposure pathway completion study), basically looking at toxicity and the food chain.

Earlier this year, David Suzuki did a program on The Nature of Things about the Aral crisis, and held a live chat program after the show, with Ian online in Tashkent. “We had the usual glitches here, but kept a phone line open for the hour long tele-conference. It was great, and attracted lots of attention to our work.”

Another boost was getting the Nobel Peace Prize last year. To promote access to lifesaving medicines, MSF used the proceeds from the 1999 Nobel Peace Prize - a bit shy of $1m - to create the Neglected Disease Fund. The fund supports pilot projects worldwide that facilitate clinical development, production, and procurement and distribution of Neglected Disease treatments. Initial target diseases include sleeping sickness, leshmaniasis, tuberculosis and malaria. The fund supports the objectives of MSF’s first internationally coordinated campaign: Access to Essential Medicines, which the programme in Uzbekistan relies on. Grants are awarded to overcome barriers to access of existing drugs and to stimulate development of new treatments in all 84 countries where MSF operates.

From 1997-2000, the programme 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 has agreed to finance the rest for about $4m. A model project compared to dozens of other NGO projects here, which may mean well, but fail due to the myriad pitfalls that East-meets-West creates.

MSF project responds to environmental scarcity

It’s no coincidence that MSF won the Nobel Peace Prize in 1999. Its third-world frontline work is a brave response to the uncertainties of maintaining and promoting peace in the post-Cold War world. And while its TB program in Central Asia may look like just another goodwill gesture, it is actually well grounded in post-Cold War political theory.

Ian Small explained to me the MSF policy of advocacy, not intervention, and the importance of consulting with locals to model their programs to meet the needs of the local population, both of which make it more welcome in many countries than other NGOs. He also explained to me the nuts and bolts of environmental scarcity, which attempts to understand the immanent threats to peace in the present world situation and on which he has written (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), University of Toronto-York University Joint Center for Asian Pacific Studies).

In a nutshell, we think that the Cold War was ‘won’, without the usual victims of war. But at the war monument in Muynak, which is on a promontory overlooking the once flourishing, now desiccated seabed stretching as far as the eye can see, you realize that the people here are just as much victims of the Cold War as those of a real war are. The Soviet army numbered roughly 3m, and the cotton for their uniforms came from the fields of Karakalpakstan (an autonomous republic in Uzbekistan). The desolation of Muynak’s toxic dust storms is the legacy of the Cold War, the face of the brave new post-Cold War world. It is also a fertile soil for future conflict, though not the dramatic conflict of superpowers and nuclear missiles.

Thomas Homer-Dixon developed a theory of conflict in the 1990s at the University of Toronto, which he called environmental scarcity, which proposes that conflict today is primarily 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, it is no longer class warfare and nationalism that are the leading causes of war, but environmental degradation. Furthermore, conflicts are increasingly intra-state, since environmentally, borders are meaningless.

In the face of environmental disasters, a new category of refugees is rapidly growing: environmental refugees. They are desperate and bitter and have nothing to loose. Resettlement, the bitterness of their fate and their lack of future are the soil for unrest. You don’t see the direct violence of ethnic purging or strikes, but hopelessness and helplessness. 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, and the statistics explain why (see below). 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.

For one thing, the flow of environmental refugees has already begun, shifting the problem to other regions. Secondly, the people of Karakalpakstan who stay behind are demoralized. There is no one to turn to, no mountains for rebels to hide in. Besides there are no rich untapped resources, like the nearby Caspian Sea, with its huge oil reserves, which attract foreign powers and encourage locals eager to share in future profits to speak up. In the Aral Sea basin there is only creeping despair. However, if the downward spiral continues, the flight of refugees will accelerate, creating a kind of post-war syndrome.

The worst of both worlds - no war, with no victor to be magnanimous, but no peace dividend. Only losers and victims, with destruction even more radical than that following a tradition war. While there is no overt conflict at present, there is the growing health problem and the constant flow of refugees. These create a constant drain on the state and society, a time bomb waiting to explode.

In this light, clearly the work MSF is doing is on the very frontline of the struggle for peace. Lifting people out of despair and mitigating the worst effects of the environmental destruction around them will at least arrest the downward spiral, and keep a critical situation from becoming the source of violence and instability. Keep in mind that Uzbekistan borders on Afghanistan and that religious and separatist rebels operate on the eastern borders of Uzbekistan.

Some background on Muynak:
· 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.

Ringing in the millennium on the edge of the world

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 that the plane, ecologically correct, and fun to boot."