I stand in a remote area of Karakalpakstan in Uzbekistan, Central Asia, on sand that was once the bed of the Aral Sea. Rusting abandoned tankers list on their sides like lost arcs. The Aral Sea is one of the major environmental disasters of the twentieth century. The region is also home to some of the highest rates of drug-resistant tuberculosis in the world. How these two afflictions are entwined is a question I have pondered for twenty years.
The Aral Sea was once the fourth largest body of fresh water on Earth, larger than all of the Great Lakes except Lake Superior. Geologically it is a terminal basin, fed in the north by the Syr Darya and in the south Amu-Darya rivers. The river waters originate in the Pamir Mountains high in Tajikistan. The Amu Darya flows through Uzbekistan, forming the border with Turkmenistan in the south and draining into the Aral Sea in the seaport of Moynaq. In the north the Syr Darya courses through the steppe in Khazikstan.
Karakalpakstan is home to the Karakalpaks, or “Black Hats.” In the 1950s and 1960s, during the Cold War, the Soviet Union, recognizing the need for cotton production, decided to engage in extensive irrigation of the areas particularly adjacent to the Amu-Darya and Syr-Darya rivers. Uzbekistan quickly became one of the largest cotton producing areas in the world. After a few dry years in the 1970s, the volume of water that the Amu-Darya and Syr Darya rivers delivered to the Aral Sea diminished considerably. As cotton production grew in economic significance the water from the rivers increased dramatically. From 1960 to 1980 the amount of irrigated land increased from 3,000,000 hectares to 7,600,00 hectares. Irrigation techniques were primitive. Canals were unlined, resulting in massive losses of water into to the desert sands. Evaporative losses were also substantial. Consumptive withdrawals of water greatly exceeded the replacement from the rivers to the sea bed. Then the Aral Sea shore receded and the body of water has largely disappeared. Reliance on cotton monoculture resulted in extensive salinization of the soils. As crop yields diminished, the use of pesticides, fertilizers, and defoliants became excessive.
Aral Sea 1989 (on left) and 2014 (on right)Climate change has come to the region, with hotter and drier summers and colder and longer winters. The Aral Sea fishery became extinct—all twenty-four species of fish are gone. The Amu-Darya delta has been irreparably damaged, including the destruction of the Tugay forests. There has been a catastrophic collapse of animal species in the area from 173 to 38, bird species from 319 to 168, and 19 of 21 reptile species have disappeared. The soil became heavily saline. Ground water in wells declined, and the drinking water quality has become worse.
One of the notable aspects of the Aral Sea disappearance is that a water disaster has created an airborne hazard. The particulate matter carried by air has increased, making Karakalpakstan one of the dustiest places on Earth. As the sea bed was exposed, toxic dust storms occurred, and now an estimated 43 million metric tons of salt have been dispersed by the winds, many of these laden with pesticide residues.
There is pervasive degradation of the physical environment and contamination of the food chain. High concentrations of persistent organic pollutants have been found in cord blood and breast milk. Dioxin levels in food are among the highest recorded.
The health status of the population is poor, with high rates of many chronic and communicable diseases. Psychosocial impacts are substantial. While no specific “causal link” to an environmental source has been identified, it must be admitted that research attention has not been extensive or rigorous.
The second strand in this narrative is the emergence of drug-resistant tuberculosis. My work in the Aral Sea began when Médecins Sans Frontières (MSF; Doctors without Borders) asked me to provide a consultation report on the feasibility of environmental health research to characterize the health impacts of the environmental disaster. The goal was to advocate for a research program to understand the health impacts of the disappearance of the Aral Sea. We wanted to determine whether a “creeping environmental disaster” placed a population at risk and therefore fell under the humanitarian medical mandate of MSF. What also became quickly evident in the assessment period was a very significant tuberculosis problem. At this time I was well positioned to grapple with both issues and their normative dimensions. I had just finished residency training in public health, was serving as a research fellow at the McMaster Institute of Environment and Health, and was working as a tuberculosis consultant for a public health unit in a municipality of Toronto. I was also helping to develop a professional masters-level program in bioethics.
In the 1950s the agronomists and hydrogeologists working in the Soviet Union were fully aware that there was a strong likelihood that the Aral Sea would disappear. Thus, the catastrophe of the ecological destruction of this vast inland sea was of purely human creation, the predictable consequence of a deliberate, scientifically informed interaction with the natural world.
A similar process is occurring with respect to tuberculosis. Alexander Fleming famously predicted the inevitability of drug resistance in his Nobel Prize speech in 1945. Though writing about penicillin, he was prescient with respect to tuberculosis. Tuberculosis is one of the oldest diseases known to humanity. By any standard of what it means to know a disease, tuberculosis is also one of the best known to humankind, better known than any other human ailment. Let me expand on this.
First, let us recognize what trends are occurring globally for tuberculosis. Approximately one third of the world’s population is infected with a latent form of TB. That is, an infection exists in the human host, but it is not causing symptoms of disease because the human immune system keeps it under control. TB is still one of the leading causes of infectious disease death globally, particularly in people suffering from HIV/AIDS. In 1992, after the emergence of multiply resistant strains, the World Health Organization declared a global emergency in tuberculosis. In 2006 to 2007, extensively drug resistant tuberculosis (XDR-TB) was recognized as a new, globally significant pathogen.
Caption Alexander Fleming 1945The struggle against tuberculosis has made an important contribution to medical knowledge and scientific method. Robert Koch won the Nobel Prize for elucidating the biological basis of causation of infectious agents. Much of his work was informed by the study of tuberculosis. In the modern era of evidence-based medicine—which relies upon randomized, controlled trials as the gold standard of medical knowledge—the second modern randomized, controlled trial was done in the Medical Research Unit in Great Britain on streptomycin for tuberculosis. Thus, TB is constitutively linked to notions of causation in the clinical sciences.
Tuberculosis is also remarkable for the extent to which we know its social determinants. That tuberculosis is associated with poverty, poor living conditions, and vulnerability, in particular in prison populations, is incontestable. We know a great deal about the social consequences of tuberculosis infection. It is a highly stigmatized illness. We know that the stigma associated with tuberculosis disease varies by culture. For example, in some cultures persons with tuberculosis are unemployable, and in others, members of their family are shunned when it comes to marriage. We know that the high burden of tuberculosis impairs human flourishing and well-being and diminishes social capital.
XDR-TB has changed the global landscape. In KwaZulu-Natal, South Africa, an outbreak of XDR-TB resulted in fifty-two of fifty-three HIV-positive patients dying within weeks of being diagnosed. There was evidence of extensive person-to-person spread. However, what was unclear at the time was the extent to which drug resistant tuberculosis existed both within South Africa and globally. Leading authorities on the treatment of drug-resistant tuberculosis and global tuberculosis control described the situation as apocalyptic and suggested we are entering the post-antibiotic era.
There is good reason for their concern. XDR-TB, like the disappearance of the Aral Sea, is an entirely human-made phenomenon. For an explanation, one does not need to look to human’s malign intent, as with terrorism and bioterrorism; or to our dysfunctional relationship with the animal world, as with SARS and avian influenza; or to external forces of nature, such as tsunamis, earthquakes, and hurricanes.
Tuberculosis is a curable disease, one of few diseases that can be completely cured. Six months of medication is usually required to effect a cure. However, through the neglect of health systems, the failure to give policy priority to a disease associated with the poor, and the limitations of treatment regimens, a strain of almost untreatable tuberculosis has been created. Treatment courses for XDR-TB are protracted, requiring at least two years of therapy, with one of those agents being an intravenous therapy. XDR-TB is exceedingly expensive to treat in comparison to drug-sensitive TB. There is at this time no guarantee of success of treatment. In fact, clinical cure rates are at best in the 30 percent range, and those only under ideal circumstances in well-resourced settings. With the specter of even worsening resistance looming, one wonders whether C will be the next letter before DR in front of TB, standing for “complete drug-resistant tuberculosis.”
Back to the Aral Sea. When we started to inquire into the health impacts of this environmental disaster, it became clear that we needed some way to interact with the population and gain trust. Providing care for tuberculosis patients was an obvious first step in that direction. It provided tangible health benefits; treating tuberculosis takes people who are consumptive, unwell, and unable to work and restores them to health if cured. What became quickly apparent was that providing medications to tuberculosis patients and starting up a directly observed therapy program in Karakalpakstan was a way for the health system to earn trust with the community and the authorities in a distrustful authoritarian nation. This would create the space to start research into the environmental health impacts of the Aral Sea disappearance. However, what was also quickly apparent was that the amount of drug-resistant TB in this area was quite high, leading to the need to advocate for the inclusion of treatment regimens for multiple drug- and now extensively drug-resistant TB.
The story has no happy ending. Our program of research to try to draw attention to the adverse health effects from the environmental disaster foundered. It foundered for a variety of reasons—some institutional, some geopolitical. In the immediate aftermath of 9/11, an alliance between the United States government and the government of Uzbekistan was formed. Uzbekistan’s previously execrable human rights record was sanitized as a response to concerns about the activities of the Taliban in Uzbekistan. The U.S. government wanted access to the large airbase built by the Soviets in Termez to facilitate the Soviet invasion of Afghanistan. However, this relationship would not prove a durable one. In 2005 the Uzbek government opened fire on citizens in Fergana Valley, slaughtering some seven hundred protesting citizens in cold blood. This was one egregious violation of human rights that allies of convenience could not ignore. When a U.S. congressional group—including future presidential candidate John McCain—went to Tashkent to protest to President Karimov, they were not able to secure a meeting, and very soon thereafter the Americans were expelled from the airbase to relocate in Kyrgyzstan (where they were again subsequently evicted).
Political instability and bomb attacks in Tashkent, combined with a poor human rights record, resulted in the drying up of funds for research in the Aral Sea area. Universities are reluctant to send graduate students into areas where there is even a whiff of potential harm. Unlike MSF, most individuals and organizations flee from the risks of conflict. Finally, MSF as an organization rethought its commitment to the innovation of including an environmental health research component within the mandate of its humanitarian operations. The enduring legacy is the documentation of some of the highest rates of drug-resistant tuberculosis.
So what do these two tales of catastrophe tell us? How does one respond?
There are structural similarities in that both have evolved slowly relative to our usual intuitions of a catastrophe. There seem to be threshold effects, in the sense that the full extent of the problem is grasped only once it is well advanced. They both resist simple solutions.
The Post-Pristine World?
The first lesson is that there are no accountability measures for such creeping catastrophes. The Aral Sea has receded and tuberculosis is becoming progressively difficult to treat. This dual affliction of catastrophe continues to plague an indigenous population.
There is little hope of any form of alleviation, remediation, or restitution with respect to the Aral Sea. There have been some encouraging results of the creation of a reservoir in the north Aral, but the broader basin is now completely dry. One of the enduring ironies of this story is that the architects of the consumptive withdrawal of water from the Aral Sea—including many of the policy makers and scientists who enhanced and intensified the extraction of water and irrigation in the area—are still alive and have not been held accountable for their actions at all.
What has occurred in the Aral Sea is ecocide. Initially, I thought it would be worthwhile to pursue some form of human rights action for ecocide. However, such mechanisms require extensive civil society concern. Dedicated effort and considerable political capital is needed to have such events recognized as actionable by the global community. There has been very little support for these types of responses.
Similarly, with respect to tuberculosis, the global medical research community has failed both individuals and communities. There have been few new drugs developed in forty years. Most of the countries with high burdens of tuberculosis adjacent to South Africa, such as Lesotho, Mozambique, Zambia, Botswana, Zimbabwe, Malawi, and Namibia, have no capacity for doing drug-sensitivity testing, making even measuring the extent of the problem challenging.
Outside of Moynaq, the monument to the Great Patriotic War stands on a ridge overlooking the desiccated sea bed. Fifty years ago families would meet for meals here and children would jump from the cliffs to swim in the sea. Now, from the ridge, you can view the rusted fishing boats, moored in the sand—a testament to the ecological destruction. If you know where to look, you can also see the tuberculosis hospital, close by the boats, on the outskirts of town. No water is in sight. One is surely on the brink of something, but just what is not clear.
The take-home message from this article is not that what has occurred in the Aral Sea is a peculiar legacy of the dysfunctions of the Soviet system. Our management and stewardship of water resources globally is not much better. We may soon see a collapse of our capacity to sustain populations with reliable access to fresh water supplies. Similarly, it is evident that XDR-TB is a significant and growing proportion of the annual number of tuberculosis cases worldwide. Karakalpakstan may just be a bit ahead of the curve of what waits for the rest of us.
The lessons of the Aral Sea seem to resonate more as time passes. Lakes continue to disappear, large urban areas such as Sao Paulo, Cape Town, and entire regions (the southwest United States, for example) are facing situations where the ability to ensure provision to sufficient fresh water supply for their population is increasingly compromised. Water access may be the most disruptive force in the coming decades, providing the justification for conflict in order to assure access to water supplies. The issue with respect to the spread of extensively drug-resistant tuberculosis is no better. Each annual report on the global status of tuberculosis shows a greater and greater percentage of drug resistance annually. Studies published in 2017 demonstrate the firm grip and continued spread of XDR-TB through South Africa, largely through person-to-person transmission. While some optimism has been generated with new pharmaceutical approaches, they are far from magic bullets. The adverse effects of poverty and other social determinants continue to fuel the spread of tuberculosis, with few resources being devoted to addressing the upstream causes, despite their acknowledged causal role.
Scholars in the field of environmental ethics have debated the role of anthropocentrism and whether non-human organisms have moral standing. Scholars in global health have pointed out the importance of taking a global perspective in thinking through the challenges in the twenty-first century. In both discourses, there is a call for new values to illuminate and guide human activity.
We may be entering the post-pristine world. Notions that we can restore ecosystems or actually have the resources to manage some of the critical issues facing us may be misplaced. The debates between anthropocentric and non-anthropocentric ethical stances seem somewhat artificial in light of our collective inability to manage our own messes. Launching numerous aspirational Grand Challenges seems somewhat fanciful given the large number of human-created problems that have not been resolved. Just as White critiqued the Judeo-Christian worldview for its contribution to the environmental issues we face, we similarly remain beholden to notions of restoration and return. If, in fact, we have exceeded thresholds past which no return is possible—which seems to be the case for the Aral Sea, and may be the case with XDR-TB—then a different mindset is required. Moral imagination is certainly an element of this, but I think epistemic humility and a recasting of the notion of rationality may be needed.
For many years, I concluded lectures on global health by recalling the thought of Charles Sanders Peirce, an unconventional nineteenth century American philosopher who was largely ignored in his lifetime, but who later became very influential. One very striking element of Peirce`s thought—indeed, one shared by most philosophers influenced by pragmatism—is that all human interaction with its environment is normative—that is, value informed. Working from the finitude of any one person, and indeed any epoch, Peirce moves to locate the idea of interests with the fate of the unlimited community—namely, all humans past, present, and into the distant future.[1] We are contingent creatures. There have been many accounts of what we may owe future generations, but few are tied to the very nature of logicality. Peirce was one of the most astute students and original contributors to our understanding of logic and scientific inference. There is nothing accidental about his locating logic in the social principle. Our current behavior seems to indicate that we are currently “illogical in all (our) inferences collectively.” The task before us is to see if our collective soul is up to the task of saving the world.
Acknowledgements
The support of the Brocher Foundation, Hermance, Switzerland, in the writing of this essay is acknowledged with sincere gratitude.
