Health aspects of the drought in

Uzbekistan 2000-2001:

World Health Organization Regional Office for Europe

Emergency Preparedness and Response Programme

Technical Field Report Series, July 2001

Summary Since spring 2000, an unusual drought has underreporting and unreliable medical affected . The lack of rainfall and statistics. melting of glaciers has greatly reduced the To date, the decreased availability of water water flow of the River. This has has had no major impact on the resulted in the reduced availability of water for communicable disease situation in . drinking and irrigation, which has led to Nevertheless, given the critical gaps at the severe crop failure. In Uzbekistan, the SES, compounded by malnutrition and drought has primarily affected the regions of environmental changes, communicable Khorezm and , particularly the disease surveillance must be given a high districts located downstream of the Amu priority. Darya River (flowing to Uzbekistan from Another major concern is the nutritional Tajikistan). Approximately 13 million people status of the population and the prevention of have been affected, out of which some six famine and poverty. Malnutrition, especially million are children under 14. among children, is a serious health problem Due to the water shortage, most of the crops in Uzbekistan, which has been aggravated by in the affected areas have failed. The the drought. The underlying factors include Republic of Karakalpakstan, with a population inadequate infant feeding, early weaning, of 1.5 million, suffers particularly severely, as inappropriate weaning foods, the introduction its economy relies heavily on agriculture. of breast milk substitutes, poor maternal Joint coordinated actions of national and nutrition and inadequate caloric intake, at international organizations helped prevent least in some regions of the country. An in- serious negative impacts on the health of the depth surveillance project is now being population of the drought affected areas. implemented to define the extent of the Many organizations have sent expert health problems related to nutrition. missions to the area (for example, UNICEF, Priority actions should include strengthening WHO, WFP/FAO, UNDP, US Embassy/USA). water quality control; supporting PHC The supply of drinking water has been the services through the supply of essential drugs main focus of attention. The drinking water and equipment, and the training of health supply problem is acutely serious in the workers; strengthening the communicable and Navoi regions and in disease surveillance system and nutritional Karakalpakstan. As a result of the lack of surveillance; health awareness campaigns for clean drinking water and sanitation, the general population on the most important Uzbekistan bears one of the highest burdens symptoms of ARI and diarrhoeal diseases in of ill health in the region. children requiring me dical assistance; and a Moreover, drinking water quality control is further strengthening of interagency one of several weak chains. The district coordination in the health sector. laboratories of sanitary epidemiological This report reviews the current health stations (SES) lack qualified staff, reagents situation in northern Uzbekistan, focusing on and modern equipment. In addition to new communicable diseases, nutrition, the water equipment and staff training, the disease situation and the health-related relief actions surveillance system needs to be improved. of international agencies. The existing system is characterised by

2 The general situation

Of the 15 newly independent states that raise concern both internally and with the emerged from the break-up of the Soviet neighbouring countries of Afghanistan, Union in 1991, Uzbekistan is the third largest Kyrgyzstan and Tajikistan. in terms of population and fourth largest in land area (447 000 km²). Uzbekistan, the most populous republic in Central Asia, has a population approaching 24 million, with an estimated birth rate of 21.3 per thousand. By 2025, Uzbekistan will have an estimated population of 34.7 million people. More than 48% of the population are 16 years of age or under. Population growth has an impact on every aspect of life in the country.

The heavy use of agro-chemicals, the diversion for irrigation of huge amounts of The Amu Darya River is 40-45% of its normal water from the two rivers that feed the capacity in the lower stretches. region (Amu Darya and Sir Darya) and poor The main indicators of quality of life (Table 1) drainage systems have caused enormous place the country close to the average for health and environmental problems in recent eastern Europe but well below that of years, as exemplified in the disaster. industrialised countries. Regional instability and security continue to

Table 1. Basic health and socio-economic indicators on Uzbekistan (1998) Source: UNDP Population (millions) 23.9 GDP per capita (PPP $) 2 829 Infant mortality rate (IMR) 21.9

Birth rate (per 1 000 population) 23 Mortality rate (per 1 000 population) 5.8 Life expectancy 70.3 Maternal mortality (per 100 000 live births) 9.6 Human Development Index 0.697

The country is not homogeneous as far as the quality of life is concerned. Karakalpakstan and Khorezm, the areas most affected by the drought, have the lowest average per capita income and two of the highest infant mortality rates. In Karakalpakstan the most affected rayons were said to be the rayons at the lower end of the Amu-darya River, (Bozatau, Karauzyak,

Kegeyli, Kungrad, Kanlikol, Muynak, , Takhtakopir, Shoumanay, Chimbay) and the A barren rice field in Uzbekistan. desert zones of the Tortkoul and Ellikkala

3 rayons, a total population of approximately The health status in Uzbekistan is 378 000. characterized by a "double burden" of disease In Khorezm Oblast, rayons south of Urgenc, at that includes a legacy of acute communicable the edge of the desert (Kosh-Kupir, , diseases and conditions related to Yangi-Arik, and Shavat), were the reproduction and childhood, compounded by most affected, a total population of about chronic non-communicable diseases. The 320 000. health status of the population is affected by a wide range of risk factors, particularly high Due to low crop yields, food availability was rates of fertility, inadequate systems for adversely affected in a wide area and the food water and sanitation, high rates of smoking, situation is becoming increasingly critical. alcohol drinking and poor diet. Reduced income resulting from agricultural activities also affected the income of the Intestinal and parasitic infections are population considerably, and this will likely widespread, especially acute diarrhoeal lead to widespread impoverishment. This will diseases in areas lacking safe water and affect nutrition, the carrying over of stocks of sanitation. Diarrhoeal diseases are the third rice and wheat for planting during the next major cause of death in children under one. season and, among other things, the ability to pay for medical services. Low water levels also affected the availability of fodder for livestock, and farmers consequently have started to sell their cattle. This led to an increase of prices on the market, as reflected in UNICEF and MSF-Holland reports. The socio-economic, technological, demo- graphic, environmental and epidemiological changes that are now taking place pose The severe impact of the drought can also be found unprecedented health challenges for in the Uzbek regions upstream on the Amu Darya Uzbekistan. Recent economic shocks have River. affected the functioning of the Uzbek health Currently, only 54% of the urban and 3% of system in terms of its affordability, efficiency the rural populations enjoy access to sewage and quality. The economic transition and networks; the remainder relying on on-site worsening fiscal constraints have led to sanitation, usually unlined pit latrines. This, shortages of medical supplies and equipment. in conjunction with high groundwater tables Historically, the health care system in (caused by poor irrigation) and poor Uzbekistan has been comprehensive and sanitation and hygiene practices, leads to a extensive but has lacked modern medical high bacteriological contamination of water technology and approaches. Current and food. The impact of this in terms of problems exist with the delivery of routine or waterborne disease outbreaks is evident, basic health care, which is continually particularly in the regions of Khorezm, plagued by institutional problems. Karakalpakstan, Bukhara and Kashkadarya.

The water situation One of the most urgent problems is the low levels in the canals in a significant area, this access to safe drinking water, especially in had an impact on the groundwater levels. rural areas. Overall, a third of the population Water levels in shallow wells already started to of the republic have drinking water which does fall in June 2000, at a rate of 1 m per month. not meet quality standards. As water shortage And while the groundwater level had resulted in very low to nearly depleted water previously been at 10-15 m, these levels have

4 now decreased so much, that many artesian shortage, water had to be brought in by wells do not function any more. Moreover, as tankers. a result of anthropogenesis activity, 40% of Below, the two figures show that the level of known fresh groundwater is unsuitable for rainfall in 1999 and part of 2000 are below drinking. To compensate for the severe water average for the period reported.

Rainfall Recorded by Climate Stations in Karakalpakstan

Rainfall for Kungrad Rainfall for Nukus Weather Station Weather Station 1200 1000 800 1000 1000 500 800 600 800 0 600 600 -500 400 400 (mm) 400 -1000 200 200 Total Rainfall 200 -1500 0 Regression (mm) Regression (mm)

Total Rainfall (mm) 0 -200 0 -2000

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 Total Year Total Year Regression Regression Source: UNICEF Mission Report Drought Assessment on Health, Water, Sanitation and Hygiene in Uzbekistan and . August-September 2000.

Water resources An important feature of the annual flow in the There are four potential sources of water for Amu Darya and its canals is the flushing drinking and agriculture in Karakalpakstan: downstream of salts and other contaminants, which have accumulated after the irrigation 1. Amu Darya River and its canals period. The current low flow conditions have 2. Shallow groundwater resulted in poorer quality water remaining 3. Deep groundwater stagnant in the canals for a long period of time, further deteriorating the quality of this 4. Rainwater. resource. Only 32.4% of the population in

Karakalpakstan use piped water as the primary source of drinking water. The majority Water supply of the households with piped water are located In order to strengthen the capacity of local in urban centres. An estimated 57% of SES laboratories to test water WHO provided households use hand-pumps and open wells to four OXFAM water testing kits for Khorezm complement other water sources. Some and Karakalpakstan. A workshop on testing communities buy water from vendors (1.8%), water samples using kits in Dushanbe which is supplied from the large desalination (Tajikistan) was held and three participants plants at Muynak and Takhtakupir. The urban from Uzbekistan were invited. areas of Karakalpakstan use 257 To address the drinking water issue, UNICEF litres/day/person and the rural areas use 7.5 brought in a hydrologist/water engineer l/d/p. The values for rural areas are low expert. As a result, technical proposals for compared to international standards. The short and medium-term interventions, average use for Uzbekistan in urban areas is including rehabilitating existing desalinisation 461 l/d/p and in rural areas 48.3 l/d/p. Most plants and drilling new shallow wells for hand households have been unable to maintain their pumps were drafted. Moreover, 2 000 hygienic private vegetable gardens. Water from shallow kits, 600 water purification powder packs, 500 wells is typically too salty to use for this water purification tabs, 2000 water containers, purpose. 150 (60 litre) water tanks, 500 water containers (20 litre) were provided.

5 The Open Society Institute and USAID have available. Most people who have access to hired the Joint Development Association piped water do not pay and, therefore, do not (JDA) to drill the wells and set up the hand value the resource in terms of conservation. pumps in the Muynak and Bozatau There was no evidence of storage for future districts. USD 95 000 was allocated to supply of the treated (or untreated) water establish up to 200 hand pumps. either by regulating authorities or at community level. Water treatment When the treatment plants operate within their capacities, they provide good quality There are a number of methods of water water to many people who would otherwise treatment used in Karakalpakstan. They have to depend on poor quality groundwater include: or canals. However, it is important to note · Internationally purchased and equipped that when these treatment plants are not desalinisation (and filtration) plants maintained, the quality of water discharged · ECOS treatment systems (desalinisation from them could potentially be of worse and filtration) quality than of the water originally sent to be processed. Filters that are not properly · Chlorination cleaned are a potential breeding ground for · Boiling. bacteria. The difficulty in obtaining parts The delivery of treated water is either via made internationally and the expense of trucks or piped into streets, yards and repair often means that treatment plants are houses. Trucks deliver water either to not adequately maintained or monitored. And communal storage tanks located in the street the community may continue to rely on water or into private household underground from treatment plants as they are not aware storage tanks to those who can afford it. of the potential danger. Not surprisingly, the Truck delivery is not widely used in lack of water also had a deteriorating effect on Karakalpakstan due to the difficulty in sanitary conditions. obtaining, locally, appropriate sized and equipped trucks. Training Most treated water in Karakalpakstan is piped within urban areas. The distribution of piped JDA workers have conducted community water is very unreliable primarily due to health education classes on the use of clean wastage of water along the line (i.e. open water and enteric diseases and diarrhoea. taps or broken pipes) or problems with the Community members have selected a person operation of the plant. The resulting water from their community to take care of the well pressure is so low that most outlying and ensure proper usage of the pump and communities do not receive any treated ionizers. water despite the reticulation system

Communicable diseases

Intestinal infections Karakalpakstan as well as the four in Khorezm In Karakalpakstan and Khorezm, there were showed a similar decrease. Muynak Rayon, many fewer cases of acute intestinal infections however, proved to be an exception as it has (ARI) reported for the period January-August reported a marked increase in ARI cases since in 2000 than for the same period in 1999, June 2000. namely 737 versus 1 923 cases for According to the conclusions arrived at by Karakalpakstan and 1 588 and 2 137 for experts, the decreased availability of water Khorezm. In addition, at the individual rayon had no major impact on the communicable level, all nine affected rayons in disease situation in Uzbekistan.

6 For Khorezm, in fact, there was a decrease in population was aware of possible dangers reported hepatitis A cases. A possible posed by the water available at household explanation for this could be that the scarcity level (following the early warning by the of water had not fundamentally altered the health authorities regarding these dangers) existing sanitation situation, and/or that the and had taken necessary measures.

Figures 1-6: Reported incidence of monthly reported cases of tracer diseases per 100 000 population for affected and non-affected areas in Karakalpakstan for the period January 1997 till August 2000.

ACUTE INTESTINAL INFECTIONS SHIGELLOSIS incidence per 100 000 population 14.00 120.0 12.00 100.0 80.0 10.00 60.0 8.00 40.0 6.00 20.0 4.00 0.0 2.00 4 7 4 7 4 7 4 7 10 10 10 10 0.00 1997 1998 1999 2000

affected not-affected 1997 1998 1999 2000 affected not-affected

SALMONELLOSIS TYPHOID FEVER incidence per 100 000 population (m.a.) incidence per 100 000 population

1.400 6.000 1.200 5.000 1.000 4.000 0.800 3.000 0.600 2.000 0.400 1.000 0.200 0.000

0.000 4 7 4 7 4 7 4 7 4 7 4 7 4 7 4 7 10 10 10 10 10 10 10 10 1997 1998 1999 2000 1997 1998 1999 2000

not-affected affected affected not-affected

HEPATITIS A ACUTE RESPIRATORY INFECTIONS

60.0 250.0 50.0 200.0 40.0

30.0 150.0

20.0 100.0 10.0 50.0 0.0 0.0 1997 1998 1999 2000

affected not-affected 1997 1998 1999 2000 affected not-affected

Source: SES Karakalpakstan

7

Communicable disease risks in the immediate UNICEF to MoH for distribution where future needed. This included Chloramphenicol, The communicable disease risk for the 4 000 capsules, Ciprofloxacine, 1 000 tablets, population in the immediate future should be Tetracycline and water purification powder seen in relation to: 500 10 g packs. Additional drugs provided to MoH included cotrimoxazole, benzillpennicilin, 1. The water and sanitation situation: Given gentamycin amoxicillin, paracetamol and the critical water and sanitation situation, water for injections. A total quantity of 2 500 there remains an ongoing threat of units was delivered. UNICEF had also waterborne, water-washed and sanitation provided 100 000 oral rehydration solutions related diseases. There is a special need (ORS) packs, 60 l water containers, water to be on alert for a threat of an outbreak disinfecting tablets and antibiotics. of cholera. Moreover, the unfavourable hygienic conditions might lead to an The regional epidemiology team of increase in helminthic infestations and MSF-Holland (MSF-H) carried out an eye and skin infections; assessment of the drought situation in Karakalpakstan and northern Turkmenistan in 2. The nutritional status: With less food in August 2000. The survey concluded that the quantity and quality available, there is an dryness had already threatened the drinking increasing risk that immune defence water supplies for local inhabitants and systems may become compromised to the animals, leading to migration and to the extent that it would make children, slaughtering or selling off of cattle. Mass especially, more susceptible to disease, failure of essential crops, including rice and and more so to severe cases of the cotton, compromised people’s livelihoods. A disease. In particular, this may affect strategy was developed which was carried susceptibility to lower respiratory tract over into spring 2001. MSF’s role was seen to infections; and be one of preparedness through the stocking 3. Environmental changes: The top soil in of ORS and other emergency supplies, as well the area has dried out and pulverised, as general surveillance and advocacy. and dust levels were said to have MSF-H distributed a limited number of increased. This carries, among others, washbasins and water containers (50 l and 22 the risk of damaging the mucosa of the l) to larger health centres in eight of the drier upper respiratory tract, facilitating districts of Karakalpakstan. These donations infections by virus and bacteria. A higher were to contribute to the securing of a safer incidence of respiratory infections could supply of water, closer to the hospitalised result during the approaching winter. patient. The equipment was accompanied by donations of chloramine tablets and soap, as Control of communicable diseases well as posters on safe water and clean hands in Karakalpak. 300 000 sachets of ORS were The Ministry of Health of Uzbekistan released also procured, of which roughly one third are a special order on the prevention of to be used in conjunction with training on communicable diseases which included diarrhoeal diseases from spring 2001. measures to strengthen the system of control of the quality of drinking water, including home visits for early detection. The main ARI sentinel surveillance concern in the drought situation is the A programme testing the feasibility of prevention of waterborne communicable sentinel surveillance in the Aral Sea area diseases. The issues have been a priority focus using acute respiratory tract infections (ARI) for WHO. as an indicator of reduced immunity to As part of emergency preparedness, drugs diseases was initiated in Nukus in September for the treatment of cholera were provided by 2000. The basic premise was that ARI would

8 increase in urban areas owing to reduced UNICEF in the framework of existing nutritional intake. The system would also programmes at schools and through the mass allow MSF to test out mapping using a simple media. The training of PHC providers in the GIS for the town of Nukus. Four centres promotion of breastfeeding, case (three clinics and one paediatric hospital) management of diarrhoeal diseases and ARI, participated, reporting anyone with ARI safe immunization practices, cholera and symptoms to MSF using a simple, syndromic anaemia has taken place in all rayons in methodology. By the third week of November Karakalpakstaan. The training was provided 2000, 435 cases were reported, of which over a two-week period by a group of 58% were children under five with cough and specialists from MoH, the Institute of fever, the primary target population. Interim Paediatrics, the Institute of Haematology, the findings of the s urveillance were sent back to Institute of Epidemeology and Communicable those reporting in order to improve Diseases, and the Tashkent Medical motivation and reliability of data collection Paediatric University. A total of 695 PHC (just over 100 doctors in total). In addition, workers were trained in various sessions in a in late October 2000, 20 000 cotrimoxazole training of trainers course. tablets (antibiotics) were distributed by MSF was also involved in the CDD regional training centres in Nukus and programmes in the framework of the Kungrad for use in children under five years educational programme at the regional of age with severe respiratory infections. training centre in Nukus.

Drug supply Next steps WHO’s immediate action included the delivery All efforts are to be made to strengthen the of four new emergency health kits to monitoring of communicable disease incidence Karakalpakstan and Khorezm. through: UNCIEF provided a twelve-month supply of a. Strengthening of disease surveillance by: essential drugs to 17 primary health care - development of practical case units (SVAs and FAPs) in Takhtakupyr for definitions for reporting and designing respiratory infections/diarrhoeal disease case methods for swift reporting; and management. - training an SES epidemiologist on After a request by the Uzbek Government, how to identify clustering of disease; the World Bank decided to reallocate part of the Project Loan Funds (approximately USD b. Amplifying the reporting with reporting from 850 000) from the pilot project on the FAPs (which are the first line of health strengthening PHC in three regions for system/patient contact) for tracer diseases pharmaceuticals/vaccines for drought such as waterborne diseases (acute stricken regions of Karakalpakstan and diarrhoea), respiratory tract infection and eye Khorezm. MoH experts prepared a list of and skin infections. As the impact of the needed supplies to be procured. All of the drought may be most on the nutritional reallocated money is to be spent for Khorezm status, and thus the immune-defence system, and Karakalpakstan. ordinary diseases may also pose a threat to children;

c. Strengthening the capacity of the SES Training laboratory to carry out bacteriological A WHO project tested the knowledge of PHC of examinations and analyse drinking water personnel and held refresher courses on the quality; and control of diarrhoeal diseases (CDD) in the D. Setting up a mechanism and guidelines for district of Muynak. The education of the cooperation between adjacent rayons (for population on the prevention of diarrhoeal laboratory investigations), as not all rayons diseases has been further developed by

9 can function properly due to a lack of properly § strengthen the capacity of qualified staff. communities in the planning and A detailed inventory of resources, including implementation of activities for equipment and staff at the rayon SES level improving sanitation services and also needs to be carried out in order to hygiene; determine the needs for training, equipment § strengthen disease surveillance at and consumables, in particular reagents, and community level; and based on this, a detailed list of requirements. § assure the sufficient availability of A joint working group on drought and health, medicines at the first level of health including senior health officers and services for communities at risk (in representatives of international and non- particular for diarrhoea and lower governmental organizations is to be set up respiratory tract infections); both at central as well as at oblast level. This · Developing an appeal for humanitarian working group should have the task of: assistance to donors to support activities in · Further assessing and monitoring the the health sector identified for relief, communicable disease and health situation; prevention and control, if deemed necessary. This appeal could include a detailed list of · Developing contingency plans for prevention and control in order to: laboratory requirements, equipment for basic drinking water and sanitation services, and § improve basic drinking water services specific medicines. in the communities most seriously affected by the drought;

Nutrition

Food intake income families indicates that energy intake The diet of the population is based on the is approximately 250 kcal less (10%) in consumption of grain products and pulses. Karakalpakstan and Khorezm, as compared Meat is consumed only by the wealthy. to the Tashkent region. This is mainly due to Seafood, fish products, vegetables and fruit a difference in animal fat intake, which is are consumed to a lesser extent, despite their higher in Tashkent, while carbohydrate intake relatively widespread availability and their low is higher in rural areas. On the other hand, cost. The consumption of cereals and total protein is higher in rural than in urban vegetables has been constantly decreasing. areas. Seasonal differences in nutrient intake The structure of the diet has changed over the are not dramatic and there are no differences past 50 years, with a decrease in between adult age groups. carbohydrate consumption and an increase in Although countrywide the diet is based on protein and fat consumption. carbohydrates, in the urban area of Tashkent, Food consumption is related to the average 60% of the energy is derived from income, and therefore Karakalpakstan and carbohydrates, i.e. 5% less than in the rural Khorezm had a lower food intake than most drought affected areas (Khorezm and other regions. Karakalpakstan), while fat consumption is 6% more (28 vs. 22%). Data collected in the year 2000 by the Centre for Dietetics from 2 700 people from middle

10 Figure 7. Macronutrient composition of the diet in Tashkent and in the main regions affected by the drought

Tashkent Khorezm/Karakalpakstan

12,8 13,6 Protein Protein 21,6 Fat c Fat 27,7 60 Carbohydrates 64,8 Carbohydrates

Price monitoring Khorezm and Tashkent. Table 2 gives a To assess accessibility of the general sample of these prices in Sum taken in Nukus, population to a number of staple household from October through December 2000. Table items, mostly food, price monitoring is being 3 compares relative costs across the four carried out in a number of popular, cheaper- reporting centres in November. range market places in Nukus, Dashoguz,

Table 2. Price fluctuations by month, October to December 2000, Nukus bazaar, Karakalpakstan

Item October November December % change1 Bread loaf 53 65 75 + 42% Black tea (kg) 2600 2800 2600 0% Fresh cow milk, 1 l 80 100 100 + 25% Tomato (kg) 120 1200 1200 + 900% Rice (kg) 230 250 180 - 22% Flour (kg) 100 130 120 + 20% Cotton oil, 1 l 470 480 480 + 2% Egg, 1 piece 35 48 50 + 43% Cigarettes, 20 150 100 80 - 46% Laundry soap 150 120 170 + 13% Coca Cola bottle, 1.5 l 350 450 450 + 29% Vodka, 0.75 l 850 930 850 0% Black market USD value 810 890 890 + 10%

Table 3. November 2000 prices (Sum in Uzbekistan; Manats in Dashoguz, Turkmenistan) in four different centres. In bold, the most expensive items at centres in relation to the local, concurrent unofficial USD rate.

Item Khorezm Nukus Tashkent2 Dashoguz3 Bread loaf 25 50 65 1 000 Black tea (kg) 1500 950 2 800 22 000 Fresh cow milk, 1 l 70 80 100 1 500 Tomato (kg) 100 130 1 200 1 500 Rice (kg) 250 260 250 4 500 Flour (kg) 195 100 130 1 600 Cotton oil, 1 l 750 450 480 7 500 Egg, 1 piece 45 40 48 800 Cigarettes, 20 100 110 100 1 850

1 December 1 litre prices as a proportion of October prices without adjustment for variation in value of Sum 2 Kuylukskiy Bazaar 3 Manats

11 Laundry soap 175 160 120 9 000 Coca Cola bottle, 1.5 l 415 355 450 9 000 Vodka, 0.75 l 700 800 930 15 000 Black market USD value 820 835 890 21 000

assistance. It is worth noting that at the end The UNDP office in Uzbekistan was the coordinating agency for all international of the winter planting season many households had not yet planted due to lack of counterparts which were involved in the water in KK. The food security situation will drought relief actions. The drought issue was included as a routine item on the agenda of even be more precarious in future and the number of households unable to meet their regular meetings of all heads of missions. food needs will increase. The need for The US Embassy and USAID also visited the drought affected areas in Karakalpakstan. establishing a monitoring system for food security can not be overemphasized. Early and Thanks to the efforts of the UNDP office a advance information will need to be regularly WFP/FAO mission was invited to visit and evaluate the situation in Karakalpakstan and shared and discussed to enable early intervention before the situation becomes a Khorezm. full blown emergency. The mission visited all drought affected areas in the north of Uzbekistan. The conclusions The nutritional status in Uzbekistan on water management and agriculture evaluated the nutritional status of the There is no nutrition monitoring system in population of drought affected areas. It was Uzbekistan. Paediatricians carry out children’s stated that although acute malnutrition is not anthropometry and classify them with evident, chronic malnutrition among children reference to Russian standards for weight- is present in poorer households. As stated in for-age. Low weight-for-age (hypotrophia, the report, “the drought is making an already see Figure 8) is classified in three grades: bad situation worse. Households are dropping grade I, when the weight deficit is <5%; off foods from their diet that they cannot grade II, when it is <15%; and grade III, afford and are eating more of the cheaper when it is <20%. However, visits to but less nutrient dense foods as a result of paediatricians are not regular and declining productivity and loss of income. The measurements are not standardised. Cases of poorest households rarely have meat and hypotrophia are reported through the dairy products and little fruit and vegetables. information system of the Ministry of Health. The major cause of food shortages and the Population based anthropometric surveys need for welfare assistance is crop failure. were carried out in 1995 and in 1996. The The poorest households live on infertile high 1995 survey indicated that the prevalence of saline land that has low productivity. This low weight-for-height is very low throughout year, due to lack of water, households in the country and is not in excess of what was these areas have lost even the little expected from the statistical distribution of production that they normally have”. indicators. It also indicated that overweight is not widely present, as in only 10% of the

children the weight-for-height was >1 Food assistance standard deviation (SD) score. On the other The areas worst affected are nine districts, hand, 15% of children under seven had low which have a sparse rural population of height-for-age. The prevalence of low height- 227 000. The mission recommended that food for-age was higher in rural areas. assistance for those worst affected in KK In the 1996 survey, the prevalence of low would be best distributed through established weight-for-height (wasting) was found to be NGOs based in KK with logistical support higher than in 1995, but only in rural areas. provided by WFP if needed. The mission Between 7% and 14% of children under three further noted that the central government has were found to be affected. The prevalence so far not requested anyemergency food aid was higher in infants (17%). Low height-for-

12 age (stunting) was also present in a larger the republic, since iodine levels in the proportion of the surveyed children (under environment and, accordingly, in foods are three), even in Tashkent. Stunting was low. Drinking water cannot be a source of present in 22–40% of the surveyed children. iodine as its mean concentration in fresh The prevalence was highest among 2 –3-year- water is only 0.2-1 mg per litre. Foods old children. The prevalence of wasting and throughout the entire territory of Uzbekistan, stunting in the regions of Khorezm and with the exception of the coastal areas of the Karakalpakstan was close to the national Aral Sea, do not contain a sufficient amount average. of iodine. In grain products and vegetables Recent data is only available in local health iodine levels range from 5 to 8 mg per 100 g. centres and is based on a diagnosis of Beef, eggs, butter and fruit are characterised hypotrophia, as made by paediatricians. The by higher contents of iodine (12–20 mg per number of cases of h ypotrophia of all degrees 100 g). Yet these foods, given their average did not increase in 1999 as compared to daily intake, do not meet daily iodine needs. 1998, and in some regions it even decreased. Iron deficiency anaemia has been observed in Khorezm and Karakalpakstan are very close 30–80% of children under three (Table 4) to the national average. and in 50–80% of women of fertile age. Most forms are mild and moderate, particularly Micronutrients among women, but a 5% prevalence of severe anaemia has been observed in Specific nutrition deficiencies have been children under three and 2% in women of documented in children and adults: iodine, fertile age in Karakalpakstan and Khorezm. iron and folic acid. Iodine deficiency is These two regions are the most affected by recognised as a major nutrition problem in anaemia.

Figure 8. Hypotrophia in children under 14 (1998-1999)

600 500 400 300 200 100 0 Cases/1000 population Navoii Yissak Sirdaria Fargana Bukhara Khorezm Tashkent Andishan Tashkent Namangan Kashkadaria Surkhondaria Karakalpakstan

1998 1999

Table 4. Anaemia in children under three in different (1996) <7 g/dL 7-9.9 g/dL 10-11.9 g/dL Karakalpakstan, 5.2 48.2 27.5 122 Khorezm Navoii, Bukhara, 0.5 17.6 29.6 294 Kashkadarya, Surkhandarya Samarkand, 0.5 25.8 26.9 335 Dzhizakska, Syrdarya, Tashkent rural Namangana, 1.4 26.9 50.2 307

13 Fergana, Andizhan Tashkent urban 0 7.1 22.4 48 Source: DHS survey, 1996

Table 5. Anaemia in non-pregnant women of fertile age in different regions of Uzbekistan <7 g/dL 7-9.9 g/dL 10-11.9 g/dL Karakalpakstan, 2.1 21.3 48.1 461 Khorezm Navoii, Bukhara, 0.3 10 33.7 1,049 Kashkadarya, Surkhandarya Samarkand, 0.4 8.5 44.7 1,243 Dzhizakska, Syrdarya, Tashkent rural Namangana, 1.8 23.1 53.4 1,224 Fergana, Andizhan Tashkent urban 0 6.7 50.2 357 Source: DHS survey, 1996

More recent data obtained in obstetric and the women were found to have a low gynaecology clinics indicates that anaemia is haemoglobin count in the second trimester. also a problem in pregnant women, There has been no significant increase since particularly during the second and third 1998. trimester (Table 6). In 1999, more than half of

Table 6. Anaemia rates among pregnant women in Karakalpakstan I trimester II trimester III trimester 1999 2000 1999 2000 1999 2000 Pre-pregnancy 11 9 57.5 54.1 31.5 37 units rural Pre-pregnancy 13 9.5 56 55 32 35 units Nukus city Obstetrical 9 10 59 53 32 35 pathology units rural Obstetrical 12 10 54 51 34 39 pathology units Nukus city Total 12 9.5 57 59 31 31.5 Total Nukus 15 15 38 40 47 45

Table 7. Anaemia new cases in the region of Khorezm, Uzbekistan for 6 months in 2000/2001

Rayons Adults Children 2000 2001 2000 2001 1 town 2048 2206 2282 2641 2 Pitniak (former Druzhba) 457 579 644 793 3 Bogot 1526 1644 1352 1612 4 Gurlan 1168 1273 1278 1579 5 Kushkupir 2688 2711 1579 1874 6 Urganch 1456 1599 1621 1890 7 1512 1621 1705 1974 8 Khonka 1435 1573 1596 1816 9 Khiva 2073 2344 2387 2693 10 1266 1397 1360 1671

14 11 Yangi-Arik 730 895 1102 1304 12 Yangi-Bazar 550 769 831 1021

Region 16909 18611 17737 20841

Causes of anaemia have not been rayons of Karakalpakstan. In addition to the investigated, although it is possible that iron measurements (weight, height, and MUAC – deficiency is associated with other nutrient an indicator of muscular growth), data deficiencies, such as folate and vitamin A. An collected included age, ethnicity, number of indication of the presence of folate deficiencies daily meals and breastfeeding. Initial findings comes from the observation of neural tube from this assessment revealed the presence defects at birth. However, incidence data is of chronic malnutrition but not too excessive not available, as the cases are not recorded malnutrition. It may be expedient to repeat separately. weight measurements in a sub-sample of the same study subjects after a few months to Rapid nutrition assessment ascertain any significant changes over the In November 2000, UNICEF supported a rapid winter months. A WHO drought assessment nutrition assessment (RNA) carried out by in October 2000 recommended sentinel MoH Karakalpakstan. According to the RNA, it surveillance for the nutritional status of was estimated that nearly 500 children out of

Table 8. Low weight at birth and prevalence of anaemia in children in the region of Khorezm in 2000 Source: Khorezm board of health

Low weight at birth (<2.5 kg)

2000 # Rayons 1 Urgench town 210 2Pitniak (former Druzhba) 4 3Bogot 52 4Gurlan 33 5Urganch 28 6Kushkupir 19 7Khonka 142 8Khazorasp 103 9Khiva 33 10Shovot 20 11Yangi-Arik 27 12Yangi-Bazar 16

150 000 children under five in Karakalpakstan children in clinics in Karakalpakstan and were presumed to suffer from severe Khorezm to monitor the impact of drought. malnutrition. Nearly 6 000 children have moderate malnutrition. On the basis of the Infant feeding practices RNA, a donor appeal was prepared and Data collected in 1999 indicates that 98.8% submitted to donor countries. of all infants are breastfed at one month; Anthropometric measurements were made on 96.5% at three months; and 93% at six a sample of over 1 300 children under five months. Breastfeeding rates are higher in years of age from 20 November to 7 rural areas. In Karakalpakstan they are December 2000. The study was carried out in 99.1% at one month; 97.8% at three order to obtain baseline data on the months; and 96.5% at six months. In nutritional status of the general population, Khorezm they are 99% at one month; 96.2% using a cluster sampling technique in three at three months; and 90.2% at six months.

15 In the city of Tashkent, the rates are lower Infants are given an inadequate variety of although still quite high: 96.2% at one complementary foods at 6–11 months: in month; 88.5% at three months; and 70.4% most cases, children only receive cow’s milk at six months. Breastfeeding is, however, not with bread and biscuits, with little or no exclusive, and other fluids are introduced as addition of vegetables, eggs or meat. Meat is early as two weeks post-partum. Undiluted rarely prepared for children. Diluted soups cow’s milk is also used by some mothers are also used. Complementary foods are starting from the first month of the infant’s given in inadequate amounts and energy life. density (usually 0.5–0.8 kcal/g, instead of the optimal 1–1.2 kcal/g).

Conclusions

At the start of the drought, WHO provided an emergency situation with regard to health four new emergency kits to the Ministry of issues at that time. MoH was still able to Health of Uzbekistan. Two of them were manage the situation. However, taking into addressed to Karakalpakstan and two for the account the situation in the bordering region of Khorezm. Moreover, MoH countries, there is a real risk of outbreaks of Uzbekistan has been requested to prepare a waterborne and other quarantine infections list of necessary aid in connection with the (cholera, murrain, dysentery, typhoid fever drought. etc.). A WHO staff member was appointed coordinator of the drought relief actions and Constraints WHO initiated negotiations with all 1. At the onset, the official structures were international agencies present in Uzbekistan reluctant to accept that there was a (UNDP, UNICEF, MSF-Holland, UNFPA, problem with the drought which the USAID, WB, JICA, Red Crescent Society of country might not be able to deal with. Uzbekistan) on the matter of possible emergency actions in connection with the 2. Absence of precise information on the drought. It was agreed with all partners to health situation both baseline and under discuss joint actions. The main obstacle for the influence of drought. The systems of most agencies was the absence of an official disease surveillance, data collection and governmental appeal for help. It was clear processing were out of date. The that Karakalpakstan had suffered significantly reporting forms of official health s tatistics from drought, but nothing could be done until do not fully meet international an official request by the government was requirements (in particular they do not made. WHO, as the agency closest to the contain data on the nutritional status of Ministry of Health, was regularly requested to children under five). provide advisory support on the issue of 3. The information on morbidity is not case obtaining international help. based (database is absent). Use of The Governmental Commission on Drought, aggregated data from the central h ospital which was arranged under the aegis of the level of the district or district SES does Ministry of Macroeconomics and Statistics, not allow for the tracing of trends or for arranged several meetings with the confirming the validity of data. participation of representatives of all 4. Complicated system of custom clearance international agencies and embassies. The slowed down the delivery of humanitarian main focus in the request was on obtaining aid, so the Emergency Health Kits were technical support to construct water pump at the customs storage for more than two stations, pipelines and canals. In the field of months. health it was emphasized that there was not

16 5. Lack of donations for drought relief improve their diet and financial situation. activities. Malnutrition can lead to lower resistance to For the moment, it is only possible to intestinal infections, so it is necessary to evaluate short-term activities. In general, the strengthen water quality testing systems and drought relief campaign has been evaluated the system of disease surveillance and positively by most local experts. The most reporting. The following activities are being important achievement is the successful implemented in order to ensure the proper prevention of outbreaks of communicable management of the situation resulting from diseases, particularly waterborne infections. the drought: The Ministry of Health of Uzbekistan worked 1. The establishment of a monitoring out immediate measures to prevent system based on sentinel sites in the outbreaks of communicable diseases on the Khorezm and Karakalpakstan regions is a territory of districts affected by the drought. part of the WHO activity plan. Two out- Due to the active participation of WHO and patient clinics (SVP) have been selected other international agencies, the issue of in each district (rayon) affected by the drought and its possible impact on the health drought. Equipment (scales, height and epidemiological situation in the republic boards, length boards) and reporting was focused on. The Government, through forms have been provided and staff are the Commission on Drought under the being trained. Monitoring involves all auspices of the Ministry of Macroeconomics children aged 6-59 months registered in and Statistics, regularly updated all involved the sentinel clinics. Approximately 4 000 agencies about the situation in the area and children are included in the system. the progress of activities performed. The Monitoring is being carried out on a provision of drinking water to the population quarterly basis. Reporting forms include was one of the most important factors which the raw data and the elaborations will be made for the success of drought relief carried out at oblast level (Urganch and activities at the first stage. Nukus). Software and training have been The request for aid by MoH led to the delivery provided to the two centres performing and distribution of drugs and consumables the data analyses. The logistics of the needed by the population, with an emphasis monitoring system will be provided by on vulnerable groups. Measures taken to MSF. increase awareness of the population also 2. The setting up of a system to distribute contributed significantly to the prevention of complementary food for young children outbreaks of waterborne communicable (6-59 months) affected by diseases. moderate/severe wasting (weight-for- As a result, the water supply in many rural height <-2 SD) has been initiated. A areas was significantly improved, pipelines proportion variable between 5-10% of were renovated, new shallow wells were dug the children might develop wasting and hand-pumps installed. The population between January and June 2001. received not only humanitarian aid drugs and Screening will be performed at the out- consumables, but also learned how to cope patient clinic level. Approximately 7 000 with drought related problems. children in Karakalpakstan and 8 000 children in Khorezm might be in need of

assistance for a period of at least six Future actions months. A total aid package of 390 MT of The risks to the health of the p opulation vis- flour will be allocated. Training will be à-vis the water supply will remain in the provided to health workers on screening focus of attention. The population of drought and registration methods. Preparation affected areas will receive the new harvest of methods will be illustrated for mothers. crops (pending the water supply situation) in Continuous breastfeeding will also be the middle of summer of 2001, which will encouraged for young children.

17 3. The carrying out of a population-based work will be undertaken by governmental nutrition assessment including children medical research institutes, with technical under ten, women and elderly people, support from WHO/UNICEF. using a cluster sampling technique. The

Table 9. Number and location of surveillance sites Khorezm District Out-patient District Out-patient Clinical clinical Facility facility Shumanai 2 Khiva 2 Kanlikol 2 Gurlen r. 2 Kungrad 2 K. Kupir r. 2 Muynak 2 Shavat r. 2 Kegeyli 2 Ya. Arik r. 2 Chimbai 2 Karauzyak 2 Tahtakupir 2 Bozatau 2 Ellikala 2 Turtkul 2 Total 22 10

Need for WHO assistance public health situation, as existing problems During recent years, WHO has been accumulate. This justifies a continuation of implementing a number of programmes in assistance activities. At the same time, new Uzbekistan, according to priority health health related projects, aimed at alleviation needs. WHO assists the country in areas of of the impact of the drought, can be more health care reform, strengthening primary effective now, as they can benefit from health care, control of communicable certain achievements of last year’s activities diseases and reproductive, maternal and (trained staff, developed networks, etc.). child health. There is a WHO Liaison Office in Public health measures for the alleviation of Tashkent and a Project Office in Nukus the negative impact of the drought situation (Karakalpakstan). on the health of the population in the most Since 2000, WHO has been carrying out an affected areas should include: emergency assistance programme to mitigate · Strengthening of water quality control the effects of the drought (mostly in laboratories of the SES; Karakalpakstan and Khorezm). Cohesive and · Strengthening of the communicable technically sound assistance measures disease surveillance system undertaken in 2000-2001 by the and nutrition surveillance; international community, together with local · Refresher courses for staff of the labs and partners, though limited by a shortage of PHC facilities; funds, still allowed for the avoidance of major public health complications. There have been · Implementation of educational no significant outbreaks of waterborne programmes for mothers aimed at diseases (caused by lack of safe drinking increasing of their awareness on the most water). The pre-existing problem of dangerous symptoms of ARI and malnutrition, especially among children, has diarrhoeal diseases requiring medical not reached disaster proportions. assistance; and The second year of the drought can, · Supplies of essential drugs (antibiotics, however, lead to the exacerbation of the intravenous liquids).

18 Appendixes 1. Technical Hazard Sheet DROUGHT, Department of Emergency and Humanitarian Action, World Health Organization. 2. Schematic map of the region.

References Common Country Assessment of Uzbekistan, United Nations, 2001. Final Report on the Mission for the Assessment of the Impact of the Drought on Communicable Diseases and Health, H.C.A.M. Van Vliet, September/October 2000. Rapid Health Assessment of the Drought Situation in Karakalpakstan, Dr Zakir Khodjaev, World Health Organization, 2001. Report on the OCHA–UNDP–WHO mission to Uzbekistan 1–7 July 2001 UNICEF Drought Update Report, UNICEF, August 2000. United Nations: Reliefweb. Uzbekistan–Drought OCHA Situation Report, United Natioins Office for the Coordination of Humanitarian Affairs (OCHA), 18 July 2001. WHO expert mission to Uzbekistan to report on emergency health problems caused by the drought, Dr. Francesco Branca, 9-15 October 2000

Health aspects of the drought in Uzbekistan 2000-20001 was prepared by the Emergency Preparedness and Response programme (EHA) at the World Health Organization Regional Office for Europe. The views expressed in it do not necessary represent stated policy of WHO.

For more information about WHO emergency preparedness and response programmes, please visit our website at http://par.who.dk/: E-mail: [email protected]

19 Appendix 1.

World Health Organization Department of Emergency and Humanitarian Action

Technical Hazard Sheet DROUGHT

The hazard

1. Drought is a prolonged dry period in natural climate cycle. It is a slow-onset phenomenon caused by rainfall deficit combined with other predisposing factors.

2. Drought often results in mass displacements of population.

3. Drought leads to water and food shortages and is likely to have a long-term environmental, economic and health impact on the population.

4. Droughts are often predictable: periods of unusual dryness are normal in all weather systems. Advance warning is possible.

Factors affecting vulnerability

5. Factors influencing the impact of drought are: · Demographic pressure on the environment; · Food insecurity; · Economic systems strictly dependent on agriculture; · Poor infrastructure e.g. irrigation and water supply and sanitation systems; · Poor health status of the population before the disaster; · Time of the year, with the most critical period being before the harvest; · Absence of warning systems; · Population displacement; · Other concurrent situations: economic crisis, political instability, armed conflict.

Main causes of mortality and morbidity

6. Reduced food intake and lack of varied diet leading to: · Protein-energy malnutrition; · Micronutrient deficiency: Vitamin A deficiency increases the risk of death from measles; severe iron-deficiency anaemia increases the risk of child and maternal mortality. Outbreaks of scurvy due to vitamin C deficiency, of beriberi due to thiamine deficiency, or of pellagra due to niacin deficiency can also occur.

7. Communicable diseases. Lack of water supply and sanitation services, malnutrition, displacement and higher vulnerability of the population all increase the risk of communicable diseases such as cholera, typhoid fever, diarrhoea, acute respiratory infections and measles.

8. Migration, loss of buying power and erosion of coping and caring capacities limit people's access to health services and can contribute to an overall increase in morbidity and mortality.

20 Foreseeable needs

9. Pending assessment, anticipated needs would be: Food aid, water supplies, water quality control, excreta disposal facilities, surveillance and control of communicable diseases, assessment and surveillance of nutritional status of the affected population (nutritional surveys), limitation and/or management of population displacement.

10. Food aid programmes: · General food distribution. Pending a detailed assessment of food aid requirements, the initial basic ration should provide at least 2100 Kcal per person per day. The food ration should be as simple as possible: a basic staple (e.g. rice, corn, wheat flour, Corn Soya Blend), a concentrated source of energy, (oil or another fat) and a concentrated source of protein (e.g. pulses). It should also be culturally acceptable.

· Supplementary feeding is intended to correct moderate malnutrition and prevent deterioration of nutritional status among those most at-risk, namely young children pregnant women and lactating women. It can be distributed through on-site feeding (or wet rations) or as take-home dry rations.

· Therapeutic (intensive) feeding is used as treatment for severely malnourished individuals e.g. children whose weight-for-height is below -3SD (standard deviation) or less than 70% of the median NCHS/WHO references values (termed "severely wasted") or who have symmetrical oedema involving at least the feet.

Remember

11. Help people not move from their home. Badly planned food aid can amplify migration. Efforts must be made to avoid creating displaced-person camps.

12. Food aid is a complex issue: · It affects the economic, social and political systems. · Logistic, political and physical constraints have to be taken into account when planning food aid.

13. Relief food distribution are often necessary in the early stage of an emergency. However, the objective of all assistance should be to help the affected population to achieve self reliance from the earliest possible moment. Thus, food aid must be considered as a palliative and temporary measure.

14. Regional and local purchases should be pursued whenever feasible.

15. Activities should be integrated. Rehabilitated children will slip back into their previous malnourished conditions unless there is a strategy broader than food distribution which encompasses the maintenance of family food security and caring capacity.

16. The health sector can contribute with data and guidelines to intersectoral policies e.g. food security, population. Then it can contribute to early warning systems, dissemination of information, decisions, intersectoral interventions and coordination .

17. The risk and severity of communicable diseases outbreak are increased. A surveillance and response system needs to be in place.

18. All disasters cause psychosocial stress in the affected population. Mental health needs are to be considered part of the health care during all phases of assistance.

21 19. Health services can also be directly affected. Health posts may run out of water; community health workers will be affected by shortages and economic distress and may be forced to leave their villages.

Inappropriate response

20. Do not send household foods or food items unless explicitly requested. Donate money to purchase large amount of food locally.

21. Do not send "baby foods". Encourage breast feeding. Consult WHO's recommendations for " Ensuring optimal feeding of infants and young children during emergencies".

22. Do not send household medicines or prescriptions. These items can be medically and legally inappropriate. Consult WHO's guidelines on essential drugs and the local authority of the beneficiary country first.

23. Do not take unilateral decisions on resource allocation without evidence of needs .

Prepared by: Department of Emergency and Humanitarian Action /Emergency Health Intelligence and Capacity Building. World Health Organization, Geneva, Switzerland. Please contact: [email protected] for further information.

Contacts for specific, related topics

For further information on: Please contact: Environmental Emergencies Mr J Hueb +(41 22) 791 3553 or [email protected] Communicable Disease Surveillance and Dr M Ryan Response +(41 22) 791 3691 or [email protected] Dr C Chaignat +(41 22) 791 3914 or [email protected] Nutrition in Emergencies Ms Z Weise Prinzo +(41 22) 791 4440 or [email protected]

For further reading:

An Overview of Disaster Management, 2nd ed. Geneva, United Nations Development Programme, Disaster Management Training Programme, 1992.

Coping with Natural Disasters: The Role of Local Health Personnel and the Community. Geneva, World Health Organization, 1989.

Do’s and Don’ts After Natural Disasters. Washington, Pan American Health Organization Press Release, 1998.

Drought and the Health Sector. Panafrican Training Centre/World Health Organization, 1998 (unpublished document available from Division of Emergency and Humanitarian Action, World Health Organization, 1211 Geneva 27, Switzerland).

Emergency Health Management after Natural Disaster. Washington, Pan American Health Organization Scientific Publication 407, 1981.

Natural Disasters: Protecting the Public’s Health. Washington, Pan American Health Organization Scientific Publication 575, 2000.

Noji E. Public Health Consequences of Disasters. New York, Oxford University Press, 1997.Noji E. Public Health Consequences of Disasters. New York, Oxford University Press, 1997.

The Management of Nutrition in Major Emergencies. Geneva, World Health Organization, 2000.

22 Appendix 2.

Source: United Nations: Reliefweb

23