Dispatches from abroad: aground in a sea of TB.

ral Sea, Karakalpakstan — It's another punishingly hot day as I make my way to the project sites for a routine supervisory visit. Médecins sans Frontières is in this remote , semi-autonomous region of Uzbekistan to help the local Ministry of Health combat a frightening tuberculosis epidemic. By training local health care workers and providing drugs, laboratories , and water and sanitation upgrades to their facilities, we are bringing the World Health Organization's recommended DOTS (directly observed treatment , short course) TB-control strategy to this forgotten corner of the world. Uzbekistan and Turkmenistan are central Asian republics that were once part of the proud Soviet empire. Since 1991 they have been independent and left to struggle alone and against all odds as they try to cobble together an economy and mount a defence against social, health and economic problems left over by a fractured and dispirited Soviet Union. Along with Kazakstan, they have inherited the legacy of the world's worst man-made environmental disaster — the calculated destruction of the fourth largest inland body of water in the world through years of centralized, massive irrigation schemes that ran amok. Years of cotton production under these unnatural circumstances has resulted in a dying and ever-drying sea, in hectares of insecticide-and pesticide-ridden exposed seabed, salt-encrusted land and drinking water laced with so much dissolved salt it is virtually undrinkable. The sea-based economy has already disappeared and the land is becoming ever less productive, thus robbing people of their livelihood. Poverty-related problems like anemia, malnutrition, TB and other infectious diseases are rampant. Recognizing the enormity of the TB crisis in the Aral Sea area — it is acknowledged by WHO to be the worst in Eu-rope and the former Soviet Union — MSF came here in 1997 and established a DOTS control strategy to help stem the epidemic. We also started an operational research program to determine links between the environmental disaster and human health. These programs work with local counterparts and help build local capacity while providing services. Routine supervisory visits are part of my role as medical coordinator for MSF activities here in Uzbekistan and Turkmenistan. They start with an early Monday morning, 2-hour flight in an antiquated Yak or Antanov from my base in the Uzbekistan capital of Tashkent to Nukus, capital of the Karakalpakstan region. After a quick trip to the MSF office there to meet the local and regional …