GROUNDWATER ARSENIC CALAMITY AND DHAKA COMMUNITY HOSPITAL'S
EXPERIENCE WITH MITIGATION PROGRAMMES
Dr. Mahmuder Rahman, Dr. Quazi Quamruzzaman, Md. Golam Mostofa, Mr. Altab Elahi,
Mr. Golam Mahiuddin, Mr. Jabed Yousuf, Mr. Ariful Islam
Dhaka Community Hospital, 190/1 Bara Moghbazar, Dhaka - 1217, Bangladesh
E-mail: dch@bangla.net
Bangladesh is a country blessed with abundant natural source of fresh sweet water.
The three major rivers originating from Himalayas and flowing down the Northern regions of Indian Sub-continent reaches the Bay of Bengal through Bangladesh. These rivers frequently flood the vast plain of Bangladesh, deposit silt and contributed largely to create the fertile soil. People of this land use the water from these rivers and their tributaries for cultivation and livelihood. For thousands of years, people settled in this fertile and easily cultivable land along the rivers. The rivers and other water bodies are part of culture and life of Bangladesh and its people. Beside these rivers and their tributaries, this country is blessed with annul average rainfall 2200mm per year.
Apart from the rivers people of Bangladesh depend on other surface water sources like ponds, canals, lakes and lagoons for their daily water use and living. In the past, the villages and towns also used to have ponds and dug-wells for their daily water sorces.
These water bodies are again recharged by the abundant rain during monsoon and also by the flood during the wet season.
In the last century tremendous growth of population resulted in environmental pollution and pollution of the water bodies. Epidemics of water-borne and water contaminated diseases increased. Diarrihoal disorder became one of the major cause of mortality and mobility both for adult and children of this country. With population growth the demand of water also increased, To overcome these great problems of clean water shortage and diarrhoeal disorder, from middle of 1900 tremendous publicity along with massive inflow of resources succeed in mobilize large scale extraction of underground water. All these were done with the advice and active support from UNICEF and other Development
Partners large scale extraction started from both shallow and deep aquifers. The

2 technology to extract water from underground source became so easy that by 1990 all most 95% of our population used water from tube-wells for drinking and household use.
Huge amount of water is also withdrawn for irrigation. The dependency on groundwater became greater and gradually the common surface water sources like Pond, Lagoon,
Cannel and even the rivers are silted up due to neglect and non-use. Some of them were deliberately obstructed and encorched upon by people who are hungry for land.
Arsenic Problem of the Region
The groundwater used was declared safe and pure, but the toxic arsenic content silently started to poison millions of people as the agencies advocated the use of tube-well water overlooked the potential danger. Arsenic is in abundance in the earth's crust, it is also present in seawater. The groundwater arsenic mostly occurs in arsenate and arsenite form and these inorganic forms are toxic.
WHO published its list of Toxic material including Arsenic, yet no agency tested Tubewells for Arsenic or for other toxic material. The agencies like UNICEF or Dept. of Public
Health Engineering of Govt. of Bangladesh who are noted for promoting large-scale installation of tube-wells and also other donors are reluctant to take responsibility for this calamity, which has created a massive health problem for peoples of this region.
Arsenic poisoning was first detected in Bangladesh by the Department of Public Health
Engineering (DPHE) in Chamagram at Barogoria Union of Nawabgonj district.
Subsequently in 1993 the Department of Occupational and Environmental Health of
National Institute of Preventive and social Medicine of Bangladesh first detected 08 patients with clear signs of arsenicosis, regarded as the Index Cases. To our knowledge and records it appears that UNICEF & DPHE took no initiative to counter this problem in the early years and people continued to drink arsenic poisoned water.
In the article titled "Combat arsenic crisis in Ganga-Meghna-Brahmaputra (GMB) plain 1 "
Dr. Dipankar Chakraborti of SOES mentioned that "1,45,000 and 52,000 tube-well water samples from India and Bangladesh are tested with FI-HG-AAS. In India 48.7% water samples had arsenic concentration above 10 ppb and 23.8% above 50 ppb; In
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Bangladesh these values were 43.0% and 31.0% respectively. Almost 9 million people in India was drinking water with more than 10 ppb arsenic and 7 million people with more than 50 ppb arsenic, while in Bangladesh the affected population wee 52 and 32 million respectively. So far 1,42,000 people including children (below 11 years age) were screened by medical team for arsenic toxicity. Almost 9.89% (n=1,23,000) showed arsenical skin lesions while in Bangladesh the ratio was 19.8% (n=19,000).It is further suggests that "within of 3-7 years many village tube-wells which were safe (arsenic <10 ug 1-1) will yet contaminated and arsenic concentration in tube-wells has increase by as much as 5-20 fold".
The first In-depth Door-to-Door Survey in Bangladesh by Dhaka Community
Hospital
One of the first large scale survey to evaluate and understand the arsenic contamination of tube-well water and its health impact (in Bangladesh) was carried out by Dhaka
Community Hospital in 1998-99. In this survey total of 500 villages in 29 districts out of
64 districts of Bangladesh took part. A total of 8,18,924 people of 1,77,842 families wee examined and 62,782 tube-wells were tested from Arsenic. On average 32,154 (52%) of tube-wells were found to have arsenic more than 0.05mg per liter and 2,327 u 2.8 per
1000 population were found to have arsenic skin lesions of various degrees. Children under 14 years of age consisted 9% of total patient. This study was a small one when compared to the scale of the problem as it only look at 2.5% of the total of 464 Thanas of the country or only 0.6% of the total 86000 villages of Bangladesh. Yet it was an eye opener for the agencies and also of all of us in Bangladesh.
Further Activities
Later on few year ago, with WB funding large scale examination of Tube-well are con conducted by Bangladesh Arsenic Mitigation Water Supply Programme. 247 UD of which about 30% Upazillas are highly contaminated Arsenic Tube-well. The problem is without continues monitoring practice, we don’t know how many of the so-called safe
Tube-well sources are now unsafe.
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Health Issues
Retention, excretion and absorption of arsenic in the body depending on the amount and chemical from of ingested arsenic. Following absorption it is distributed rapidly and widely in the body. Inorganic arsenic is methylated to form monomethyl arsenic acid
(MMA) and dimethyl arsenic acid (DMA). Arsenic is excreted mainly as MMA and DMA form. The main site of methylation is liver and arsenic is mainly excreted through urine.
In case of acute arsenic poisoning the fatal dose of arsenic is 125 mg. Chronic
Exposure to arsenic manifests its ill effect on human body and the disease condition is defined as 'Arsenicosis'. As far as we know there in no universally excepted definition of
'Arsenicosis'. It is observed that the type of arsenic ingested, level of exposure, body immunity, food habit etc. may determine the extent of clinical manifestation. Genetic factors may also play an important part in disease manifestation.
In Bangladesh alone, approximately 80 million people are now at a risk of drinking arsenic contaminated water and many are suffering or will suffer from "Arsenicosis". It takes usually years to manifest, but it may starts from 6 months, probably depending upon the nature of poisoning, nutritional status and genetic disposition of the consumers. Arsenicosis manifests as typical skin lesions called melanosis, leucomelanosis and keratosis, but it's range of health effects starts from simple skin lesions to cancers of skin, urinary bladder, lungs and probably other organs as it is a potent carcinogen. Other serious complications like ischaemia of limbs leading to gangrene are also a common complication. The systemic ill effects like Bronchitis and neuropaths are reported and well documented in recent years.
Arsenic contamination of groundwater has now been emerged as a mega health problem of unprecedented magnitude. Govt. of Bangladesh & WHO has already declared it as a public health crisis. More than 30000 patients have been identified so far through scanty field survey. We are still waiting for a proper prevalence survey to know the extent of the disease in Bangladesh, but unfortunately no agency is coming forward to help Bangladesh with a proper prevalence survey.
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Studies indicate that 1 liter of water containing 0.05mg/l of arsenic consumed a day, the lifetime risk of developing skin cancer would be 1-2 per 1000 people and the lifetime risk of dying from cancers of liver, bladder, lungs and kidneys would be 13 per 1000 people
(Smith et al, 2000).
History of Arsenic Toxicity
Long time age, Dr. William Fowler started 1% solution of Arsenic in alcohol to treat many ailments and it became well known as "Fowler's Solution" but some 100 years ago it was discovered that excessive use of this medicine containing arsenic is leading to health problem and cancers. Inhalation of arsenic by vineyard workers from pesticide spray causing lung cancer also noted century ago in France. Liver cancer of the works in PVC plants was also noted in 1970 and all these are due to Arsenic either by ingetion or by inhalation.
In recent years the term 'Arsenicosis' is coined to indicate chronic arsenic poisoning. In
2002 DCH and GoB arranged a collaborative conference on arsenic. There, a case definition of arsenicosis and a management protocol was thrown and discussed among the national and international expertise. Next Year WHO staged a Regional Consultants
Meeting at its SEAR office, Delhi, In that conference the protocols for case definition and management were further revised and endorsed; Arsenicosis is defined as "a chronic condition arising from prolonged ingestion of arsenic for at least six months above safe dose, usually manifested by characteristic skin lesions with or without the involvement of internal organs". There is no known treatment for Arsenicosis. It is believed that arsenic free safe water, appropriate nutrition are the major part of management.
DCH experience with Arsenicosis Patients
In the past years during various field works 16000 arsenicosis patient was identified by
DCH team, out of them 4965 was taken as a sample for a particular study. Among them
55.6% are male and 44.4 are female. Of the total 1796 are children below the age 15 years, 1269 are below the age of 16 to 25 years and 1737 are 26 to 40 years of age.
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Most of the patients had skin problem with ............................ and Keratosis. Source
Developed ................... like Ulcer and Cancer. Besides a large number suffered from-
Skin Manifestations:
Melanosis was present in all the cases. Keratosis found in 40% of cases.
Leucomelanosis found in 21.2% cases.
Other Signs & Symptoms of Chronic Arsenicosis experienced by DCH
Chronic Bronchitis -30.7%
Burning sensation of he body - 2.6%
Burning skin- 17.8%
Conjunctival conjestion - 2.3%
Non-pitting oedema - 1.7%
A small number of these case presented themselves with skin carcinoma and vascular problems like dry gangrene. The other serious problems are of socio-economic nature.
Families suffered from isolation and breakdown of marriage. Children were ousted from school. The karatosis and neuropathy caused pain and physical problem leading to unemploynt and economic hardship along with serious problem to perform routine household activities by the housewives
Rehabilitation of complicated case particularly those with gangrene and needed amputation of limbs or those with severe keratosis and physical inability to walk or work are of paramount importance. Dhaka Community Hospital with its limited resources treating and managing all these cases for the past 10 years. Unfortunately non of the
UN agencies (WHO or UFICEF) or the donors (like WB or ADV) came up with any fund or resources to manage and help these unfortunate people.
Arsenic in soil, water and food chain a Potential Environment and Economic
Hazard
In the 6th International Conference held at DCH in 2005, Dr. Dipankar Chakraborti (of
SOES, Jadavpur University, Kolkata, India) stated that from a single block in North 24 parganans (200sq. km. area) 3,200 irrigation tube-wells are pumping nearly 6 tons of
Arsenic". We suspect that this amount is over a period of 1 year. The above reference is
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7 made is only to illustrate the magnitude of environmental pollution threating Bangladesh and its neighboring countries with large scale extraction of groundwater by tube-wells for irrigation.
In November 1998 the key note paper of 2nd international conference on Arsenic
Mitigation 3 highlighted that "the problem of arsenic in groundwater has grown beyond the drinking water and research is required to understand its effect on soil, environment, food chain and also in productivity (agricultural out-put)". Since then researchers from home and abroad undertook various studies and reported various degrees of soil and food chain contamination. It is reported that arsenic contamination in one area where groundwater is irrigated with tube-wells were found to be as high as 80mg/kg soil. This paper 4 further suggested that maximum arsenic concentration in irrigation water in some areas were found to be 0.55mg/l; it was further calculated that with required amount of irrigation the arsenic load on the irrigated soil will be around 5kg per hector per year (M.J Emamul Haque, Dept. of Soil and Environment, Dhaka University).
In one paper 5 (MM Duxbury and Y.J. Zavala, Cornell University, Ithaca, NY, USA) suggested that per capita exposure to inorganic arsenic in rice is 32 times higher in
Bangladesh than USA (using representative data for arsenic in Bangladesh rice).
The Environmental Protection Agency (EPA) supper funds risk model suggest that a value of 0.43ppm total soil arsenic for a cancer risk of 1 in 10 6 . Total soil arsenic in top
15cm of Bangladesh soil (in arsenic affected areas) was found to be above 10ppm for
48% in 456 sites (USAID study 2002) and 65% of 161 (sites study by Shah etal 2004) 6 .
In other nationwide survey by Bangladesh Rice Research Institute and in collaboration with Bangladesh Agricultural University and Cornell University USA, concluded that no consistent relationship was observed and further research is needed to understand the problem of soil and food chain contamination in relation to arsenic concentration of irrigation water.
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I order to conclude this chapter of soil and food chain contamination it can be said without any reservation that it is absolutely imperative to undertake some large scale and well planed research to understand the ill effect of arsenic, which might pose a threat and unprecedented health and socio-economic suffering for the people of
Bangladesh and of those in the region.
Business Bureaucracy and Politics of Arsenic in Drinking Water
Dhaka Community Hospital (DCH) got involved accidentally in 1996 with Arsenic problem in course of their community health programme and started identifying patient suffering form chronic arsenic poisoning. As community health workers DCH not only involve in management of arsenicosis patient but also started developing arsenic free safe water options for the community. Gradually it became clear that there happened a systematic and motivated whole scale changes in water use from surface water to groundwater between 1950 to 1990.According to UNICEF and Department of Public
Health Engineering, 95% of population of Bangladesh started to use "Safe" groundwater pumped up by tube-wells. This change in water option from surface to tube-well water was basically to mitigate diarrhoeal disorder and was accomplished by spending huge amount of money and time by UNICEF and other donor agencies. It is needless to say that this programme of tube-well was actively supported by the big business, involving national and international business groups. It was also observed that though
Bangladesh is blessed with tremendous amount of surface water and rainwater and has a thousand years old culture of dug-wells, yet no effort was made by the government of
Bangladesh or by UNICEF or other international bodies to invest in surface water and dug-wells for drinking and household use. On the other hand we felt that there exists a conspicuous and motivated apathy to promote dug-wells and invest in surface water by the consultants and executives of intentional funding organisation who dominates the water and sanitation programme of Bangladesh for the past few decades.
Since 1998 after the first international conference on Arsenic Contamination, workers of
DCH along with some water and Hidrogeological experts of Bangladesh rentlessly
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9 lobbied the Government and also the donor community to pay their attention and promote surface and rainwater including dug-wells, which are in abundance in
Bangladesh. DCH also made worldwide appeal through print and electronic media to highlight the groundwater arsenic poisoning issue and use its tremendous resource of surface, rainwater and dug-wells as affordable and sustainable safe water options.
It is interesting to note that big business and politics always thrives and prosper by taking advantage of human disaster and calamites. The two health calamities namely the diarrhoeal disorder and chronic arsenic poisoning are both related to drinking water and in both cases in order to mitigate we observed that some storng interested body in collaboration with big business, manipulates and influences the policies and implementation programme. The so-called NGO who are mainly driven by Donor agenda and depend on Donor funding obey the wishes of the funder and act according to the donors plan.
With these realisations the Bangladeshi scientific community in 2002 and 2003acted proactively and with adequate support and help from some Govt. agencies managed to produce an extensive safe water policy and action plan aiming primarily to mitigate mass poisoning caused by groundwater arsenic contamination. It was not easy as the donor community and their beneficiaries suddenly felt left out and tried to influence the government to get their agendas in places. But this is possible one of a rare examples where government stood firm and with total support of the Bangladeshi Scientist and experts endorsed a policy and action programme 7 without any foreign funding and foreign consultant. In this policy (page 1 para 1.8) and in the action plan (page 9 para
3.2) it is observed that "Arsenic problem attracted attention of diverse groups of stakeholders and different government agencies, academics, NGOs simultaneously bilateral/multilateral development partners are pursuing separate programmes without co-ordination. This is resulting in duplicating of activities and conflicting strategies that inhibit synergy and optional use of scarce resources". In page 3 of the policy paper it also sates "give preference to surface water over groundwater as source for water supply" in page 9 para 3.2 In technology options it is stated that "safe water supply shall
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10 promote a range of options but shall give priority to surface water over ground water sources".
It is also to be noted that before approval of the policy by the cabinet (of Bangladesh
Government) the bilateral Donors and development partners like World Bank, UNICEF etc. were asked to review and comment and their opinion and comments, were taken and incorporated in relevant sections of the action plan. It was expected that once the policy and action plan are approved all concerned will act in accordance to the policy and plan. But in many cases the government agencies with active support from the donor communities are still pushing and trying to implement programmes for large scale groundwater extraction while making very negligible effort for ensuring safe surface water or safe dug-well development and Rainwater harvesting in also not in their agenda. It is interesting to note in this contest that before the arsenic policy was done and approved, one of the influentional donor agency imposed on the Government with an Arsenic Policy Support Unit without any relevant TOR. Further there was connection or raport with the national experts who were engaged by the government to develop the arsenic mitigation policy and action plan. This is one of the many examples how the international and bilateral donors often tries to influence Govt. Policies in the developing countries. This examples further illustrates how huge amount of money, time and manpower are wasted just to assert some particular agendas of some donor.
Recently, since the introduction of Bangladesh Arsenic Mitigation Policy and Action Plan observed that there is a very well orchestrated propaganda launched against the use of dug-well and surface water use for drinking and household purpose, which is in clear violation of national arsenic mitigation policy. Some well-known academic bodies and experts are engaged with the support of some donor community to influence the government and policy planners against surface are use. There is also a strong lobby for increase extraction of deeper aquifer water without considering the hazard and long term sustainability of the deep-water sources. There are some reports where the results of dug-well and also the use of surface water options are improperly and wrongly
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11 described to create unjustified and adverse opinion against Dug-well and surface water use.
It is important to mention that deeper aquifers in many parts of Bangladesh are complex. The vertical and lateral complexity of deeper aquifers prevents the creation of simple and straight forward guidelines for exploration. Great care must be exercised in exploiting deeper aquifer and proper knowledge of local hydrogeological condition is of utmost importance. Besides arsenic, iron, manganese and other toxic maters are also make deeper aquifer unacceptable. Water quality monitoring on regular basis is strongly advocated (J. Whitney etal). It is sadly observed that all these cassationary notes about deeper aquifer extraction are missing or ignored by the promote of deep tube-wells.
Conclusion
For the past 15 years DCH acted very intimately with various government agencies and international organisation like WHO, UNICEF and UNDP and also with major development partners like World Bank, DFID, CIDA etc. and observed that government approved mitigation policy and action plan is yet to be followed in spirit. Three are overt and covert attempts to undermined dug-well and surface water options without proper evaluation. The public sector agencies like DPHE and other government agencies are yet to come out with large scale, long-term and sustainable water shade management programme, taking account of the available vast surface water and rainwater. This will minimize our dependency on groundwater (aquifer water) and possibly will benefit are people in the long run.
It was also witnessed that various research activities and lot of funds are in available for health issues involving arsenic poisoning, but yet, there is no plan or programme for implementing for a nationwide arsenicosis prevalence study and for treatment and rehabilitation. It will not be out of place to suggest that the agencies like UNICEF and other donors along with Department of Public Health Engineering (DPHE) have a moral obligation to support patient identification and management programmes, as these
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12 organisations are on record who initiated and supported large scale tube-well programme in the first place.
We hope and believe that the concerned agencies will come up with skill and resources for patient management programmes and also for advocacy to remove the confusion still exist in addressing a judicious and balanced approach for use of surface and groundwater including rainwater harvesting. As we now know that 95% of total groundwater extracted are used for irrigating the land. Environmentalists and the scientists working with food production and food chain contamination are getting increasingly concerned about the arsenic contamination of soil and its effect on food chain. We are yet to have proper scientific data to evaluation and understand these effects and long-term risks to our Economy and Health. It is therefore necessary from national point of view to address this issues. In order to be more specific and objective, what is necessary is to have a sustainable, acceptable watershed management which will make a sensible balance between the use of surface water, rainwater and groundwater.
Simultaneously all of us working for safe water must clearly understand and define the parameters of safety (because when WHO puts safe arsenic limit to 10ppb, the
Bangladeshis standard remains at 50ppb.) There are some serious problems with all the three major water sources yet there are affordable solutions and it is necessary to have the will to implement these solutions properly. Country like Bangladesh cannot afford the luxury of making experiments by short-term disposable procedures with its limited resources. Arsenic problem is a very expensive and painful example how a casual and "quick-fix" procedure to some diarrhoea brought massive calamity to a nation in the form of Arsenic Poisoning. We hope all stakeholders will understand that it is not the battle between groundwater or surface water, it is a rational action of balanced used of all water services for maximum benefit for people of this region.
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1. "Major issues to be addressed to combat arsenic crisis in Ganga-Meghna-
Brahmapubra (GMB) lain" Dipankar Chakraborti etal - School of Environment
Studies, Jadavpur University, Kolkata 700032, India - Paper presented in 6the
International Conference at Dhaka, Bangladesh
2. "Arsenic in Bangladesh" - report on 500 villages Rapid Assessment Project
(sponsored by Ministry of Health, Bangladesh and conducted by Dhaka
Community Hospital) - Prof. Quazi Quamruzzaman, Prof. Mahmuder Rahman and Alison Quazi - May 2000
3. Key Note 2nd International Conference 14 - 15 Dec. 1998 Dhaka Community
Hospital
4. "Arsenic in Food Chain: Remedial possibilities" S. M Imamul Haque etal -
Department of Soil, Water and Environment, University of Dhaka and Ravi Naidu etal - University of South Australia - Adelaide, Australia - Paper presented in 6th
International Conference, Dhaka
5. "What are Safe Levels of Arsenic in Food and Soils?" - J. M. Duxbury etal -
Cornell University Ithaca, NY, USA - Paper in 6th International Conference on
Arsenic at Dhaka, Bangladesh.
6. Effects of Arsenic contamination field and arsenic accumulation in crops - 2004 in
M.AL Shah etal (ed)
7. "Arsenic in paddy soils of Bangladesh: levels, distribution and contribution of irrigation and sediments" MR. Islam etal of Bangladesh Agriculture University,
BARI of Bangladesh and U. M Duxbury of Texas Cornell University and C.A.
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Meisner of Texas A & M University - Paper presented in Dhaka Conference on
Arsenic Pollution.
8. "Deep Aquifer Recomendation" - Symposium Discussion J. Whitney, D. Clarle,
G. Breit, A. Welet, j. Yount, J. Earle and J. Imes - United States Geological
Survey (USGS).
9. Keynote Paper by Mahmuder Rahman - 6th International Conference on "Safe
Water and Safe Food options in Arsenic Mitigation: Lesson Learnt" - 2006 held in DCH.
10. National Policy for arsenic mitigation and implementation plan - Bangladesh;
Ministry of Local Government, Rural Development and Co-operatives - 2004.
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