Now, if you stand on the beach front at Muynak, instead of staring over the cool blue waters of the Aral, you look out across 38,000 square kilometres of highly saline and polluted dry wasteland. It is almost impossible to describe the enormity of this man-made tragedy; but suffice to say it took them a mere 40 years to drain the fourth largest inland body of water to almost a quarter of its natural size. The sea is now a staggering 150km away from here; the great Amu Darya desert river trickling to a muddy puddle some distance away. As far as the eye can see lie the rusty hulls of decaying fishing boats strewn across the sand.

Forty years ago Muynak, in western Uzbekistan, was a beautiful seaside spa town on the edge of the Aral Sea. People would come here from all over the Soviet Union in the holidays - for there is something quite special about a giant sea in the middle of a desert - and the area saw a thriving fishing and agricultural industry. For the people of this region, the future looked a bright one indeed.

Although the Russians, under the then Tsar, first colonised Central Asia as far back as the nineteenth century, it was only in the early 1900s that the exploitation potentials of this region were fully recognised. Uzbekistan, and indeed much of Central Asia, was forcibly directed by Moscow to initiate large-scale cotton monoculture with the objective of overtaking the USA in cotton production. It was planted everywhere, "right up against cottage windows, in former flower beds, in courtyards, near fences" as Ryszard Kapuscinski describes it.

"It was planted instead of tomatoes and onions, instead of olives and watermelons. Over these villages drowning in cotton, planes and helicopters flew, dumping on them avalanches of artificial fertilizers, clouds of poisonous pesticides. People choked, they had nothing to breathe, went blind".

No-one appeared to acknowledge that cotton was a thirsty plant (it requires 30 annual inches of rainfall to grow a good yield, Uzbekistan receives on average 14); and that Uzbekistan is indeed an enormous desert that suffers from recurrent drought. So by the early 1950s, in came the diggers. Night and day they set to work, carving out an intricate system of man-made irrigation canals to drain off water from the two giant rivers that feed the Aral Sea, into the fields. From the 1960s through to the 1980s, the area of land under irrigation increased by 20%, and the volume of water drawn annually from the rivers increased by 100%.

Now, if you stand on the beach front at Muynak, instead of staring over the cool blue waters of the Aral, you look out across 38,000 square kilometres of highly saline and polluted dry wasteland. It is almost impossible to describe the enormity of this man-made tragedy; but suffice to say it took them a mere 40 years to drain the fourth largest inland body of water to almost a quarter of its natural size. The sea is now a staggering 150km away from here; the great Amu Darya desert river trickling to a muddy puddle some distance away. As far as the eye can see lie the rusty hulls of decaying fishing boats strewn across the sand.

With no livelihood now to speak of - indeed, the last fish to reach the canning factory in Muynak traveled thousands of kilometres by train from the Baltic sea - and a region still striving to make cotton a success despite successive failures, you will see some of the worst poverty among the people here of anywhere in the world.

For the 5 million people who live within the epicentre of what the UNDP has termed the worst environmental catastrophe of the twentieth century, the fight is now on for economic survival. But few have neither the will nor the way to rise to the challenge. Lethargy hangs in the air, nothing happens, and a mood of waiting and apathy prevails. Groups of men hang about talking on street corners; they are told it's best to leave now, but have no place to go.

Despite the vast amounts of money thrown at the Karakalpakstan region in recent years by the international community (US$150 million at the last tally) and the droves of researchers who have passed through in the hope of reversing the damage, there has been scant focus on the health and wellbeing of the people that remain here.

Most still lack access to safe reliable water supplies, and rates of disease, poverty, and human development have got worse. Indeed, the locals here have a saying, that if every specialist to this region brought with them a bucket of water, the Aral Sea would be full up again and troubles over. Most have now packed up and left.

Addressing the health needs

Although the health effects of this disaster are difficult to quantify scientifically, the 43 million tonnes of toxic laden salt that every year is lifted off the dried seabed and swept through the villages, years of unchecked use of agrochemicals, and limited fresh water supplies, could well be contributing factors to high estimates of cancer, neurological disorders, and diarrhoeal and pneumonic illnesses among the population of Karakalpakstan.

"In the past our district was one of the richest regions of Karakalpakstan", said one local. "There was a lot of fish, different animals particularly muskrat. But now, with the drying of the Aral Sea, the region became one of the poorest. If people are hungry, they develop diseases more frequently".

Recent research indicates that there are high levels of persistent organic pollutants (POPs) in certain local foods, as a result of widespread pesticide use in the region; chemicals that are toxic to humans and are known to have adverse effects on health.

Rising salt levels mean that not only is there a thick layer of salt encrusted over the land (creating a kind of winter wonderland effect, despite it being 40 degrees in the shade), but that the drinking water is salty. Add milk to your tea here and it curdles. You are left to imagine what the effect might be on your kidneys.

But there is one disease of which the cause we can all be clear on. For where there is poverty, even in the absence of an environmental disaster of such mammoth proportions, there is tuberculosis. And, as if things could get any worse, instead of a beach now in Muynak there stands instead a giant concrete tuberculosis sanatorium. I visited it with the Médecins Sans Frontières doctor who assists the national government in running a treatment programme in the Aral Sea area.

The programme aims to bring tuberculosis treatment to a population of 4 million by the end of 2003. Tuberculosis rates are in epidemic proportions in this part of the world. As we hurriedly put our tuberculosis protection masks at the doorway, I could already hear a chorus of hacking coughs echoing down the long dark corridors. Crammed eight, ten to a room in rusty iron beds, these people lie here for weeks on end. Modern treatment consists of an antiquated concoction of antibiotics with uncomfortable side-effects; drugs that are taken for months at a time.

Multi-drug resistant tuberculosis is a new and emerging problem in this region, the doctor tells me. I visited one-such chronic patient. He was 26 years old, painfully thin, and lay contorted on a dirty mattress, wrapped up in a torn mosquito net. He is too weak now to even cough properly, and the pus from his lungs is being drained by tube into a dirty red bucket sticking out from under the bed. The nurse here appears at a loss as to what to do with many of these patients.

"We don't have the drugs to treat them when they are at this stage", she says. "And even if we did, no laboratory facilities to do the tests. What more can we do but send them home?"

Treatment for drug resistant tuberculosis takes two years with no guarantee of success; and there are no drugs yet available in Uzbekistan. Médecins Sans Frontières now hopes to initiate a treatment programme for around 100 of these so-called chronic patients.

"This will be difficult to do and expensive", says the doctor, "but we have all found it increasingly difficult to just watch patients who don't respond to normal tuberculosis treatment die. There are drugs available to treat patients with multi-drug resistant disease, it just requires political commitment and resources".

A future for the people of the Aral Sea area?

Although the environmental damage in the Aral Sea area is largely irreversible, some fundamental policy changes could improve life for the people of this region. Indeed, the focus should now shift from encouraging migration away from the area, towards accepting the damage and creating viable solutions that will enable people to continue living here.

Farmers could be allowed to put their energies and dwindling water supplies into growing food, for example, instead of cotton; alternative supplies of drinking water could be sourced; and badly needed upgrades to an old and inefficient irrigation system would ensure that over 90% of the precious irrigation water did not leach out before it reached the field.

Encouraging the government of Uzbekistan to sign up to the Stockholm Convention, a global treaty to protect human health and the environment from persistent organic pollutants (POPs), would ensure their commitment to decreasing the use of such harmful pesticides in the Aral Sea area.

The international community, whether the World Bank, the UNDP, non-governmental organisations, or the national government, needs to think more about coordinating activities in the region, so that the population can realise maximum benefits from the humanitarian interventions. The US$150 million already put into the region by the international community has created few improvements, particularly in respect to the health of the population.

Tuberculosis is a disease of the poor and the marginalised, and ranks among the most important burdens on human health. The epidemic of tuberculosis, which now kills two million people worldwide every year, mostly in the developing world, is now recognised as a global emergency.

Increasing evidence shows rates of tuberculosis and multi-drug resistant tuberculosis in the Aral Sea area and throughout the former Soviet Union to be high; an inevitable product of the slow deterioration of health services witnessed here since independence from Moscow in 1991, and because of increasing levels of poverty resulting from the desiccation of the Aral Sea.

In the last 10 years drug supplies have been sporadic, Moscow-based expertise lost, and financial support has ground to a resounding halt. Health-care workers in hospitals and tuberculosis sanatoriums here are often not paid for weeks on end.

More research into faster-acting more effective drug treatment for tuberculosis is desperately needed if we are to have any hope of tackling the global epidemic, as well as more effective diagnostics and laboratory support. Indeed, of 1393 new medicines brought onto the market between 1975 and 1999, only 16 were for tropical diseases and tuberculosis.

"Doctors in poor countries are forced to use old and ineffective treatments on patients who are dying from treatable disease because profit, not need, is driving the development of new medicines", said Morten Rostrup, the International Council president of Médecins Sans Frontières, at a conference of disease earlier this year. "We have the scientific know-how to right this fatal imbalance, but serious political and financial commitment is lacking".

Although the Global Fund for HIV/AIDS, tuberculosis and malaria, set up by Kofi Annan, now exists to make money available to help poor countries like this improve the way they treat diseases, the response by the international community has so far been poor. The Fund is supposed to raise $7 billion to $10 billion a year from donors, but in just over a year it has received only $2 billion.

Many of the diseases afflicting the population of Karakalpakstan are complex chronic health problems for which neither the causes nor measures to prevent them are clear. To what extent the environmental disaster impacts directly on human health is difficult to quantify scientifically, and more research is important if policy decisions are to lead to preventive action.

Advocacy is crucial if we are to use the findings of health research to ensure policy changes and health improvements on the ground. While we wait for research policy, the development of better treatments and diagnostics for tuberculosis, and sustainable long-term solutions to catch up, it is crucial that those living in and around this man-made disaster receive the humanitarian assistance they urgently need.