March 2009 - Volume 3, Issue 2

Differentials of Arsenicosis in Bangladesh

	Tapan Kumar Roy Assistant Professor
	Department of Population Science and Human Resources Development, University of Rajshahi, Rajshahi-6205, Email: tapkroy@yahoo.com, roy.tapan@gmail.com

ABSTRACT This study was conducted on the basis of primary data on 250 arsenicosis patients from the arsenic affected districts Nawabganj, Bangladesh. The data indicates that most of the patients are young, illiterate, of low socioeconomic background and they are suffering from various diseases such as diabetes, blood pressure, asthma and heart diseases. The finding also shows that arsenicosis disease has changed the socioeconomic status of the patients and women are divorced due to arsenicosis. The multivariate analysis suggests that source of drinking water is the most important factor for arsenicosis. Proper initiatives should be taken immediately for the welfare of mankind. Key Words: Arsenicosis, Arsenic Contamination, Safe Drinking Water, Multiple Classification Analysis

INTRODUCTION

Arsenic contamination of groundwater and its adverse impact on people has been identified as one of the most horrendous man-made environmental disasters of the twentieth as well as twenty -first centuries. The CBS television of USA compared it with the Chernobyl atomic reactor accident of Russia and Bhopal chemical industry accident of India, with UNICEF and WHO responsible for this extensive and horrible tragedy in Bangladesh (New York Times, 1998). More than 50 per cent of the total population is estimated at risk of contamination and already thousands of people have been affected by the disease arsenicosis (Khan MM et al. 2003). The number of people affected by this arsenic disaster is among the greatest of any disease facing the world today and about 130 million people in 62 districts out of 64 are vulnerable to arsenic contamination (Momotaj et. al., 2001).

Arsenicosis is known as a disease borne by drinking arsenic contaminated water over a long period. The symptoms of this disease manifest after a long period such as from 5 to 20 years from when people start drinking arsenic contaminated water. The period differs from patient to patient depending on the amount of arsenic ingested, nutritional status of the person, immunity level of the individual and the total time period of arsenic ingestion. The different signs and symptoms are observed among arsenicosis patients such as colour changes on the skin, hard patches on the palms and soles of the feet, skin cancer, cancers of the bladder, kidney and lung, and diseases of blood vessels of the legs and feet, and reproductive disorders, etc. The apparent symptoms of arsenicosis may be said to have manifested in patients as melanosis and keratosis mainly. Melanosis is the earliest symptom and is a very common symptom. It results in the gradual change of complexions towards blackishness and or duskiness. Generally, the limbs are first affected and subsequently the change affects all of the body, which is named 'diffuse melanosis'. In the process of melanosis, white and black spots occur over the body, medically termed as 'spotted melanosis', and this stage of melanosis is generally a pre-cursor of cancer. On the other hand, the hardening and thickening of palms and soles is called keratosis.

Diffuse with modular keratosis on palms and soles is a sign of moderately severe toxicity. Rough, dry skin often with palpable modules in dorsum of hands, feet and legs are the symptoms seen in severe cases.

The arsenic contamination of the ground water of Bangladesh is not only the reason forserious health hazards for the people, but also the cause of a widespread social problem (Quamruzzaman and Rahman, 1998). This pollution also creates serious social problems in family relations in the rural areas. It is difficult to arrange marriage for a young girl affected by arsenic. Some affected housewives are divorced by their husbands and even forcibly sent to their paternal home with children. The consequence of this contamination, is that the life of a child faces risks every moment; active people become inactive and overall it creates formidable difficulties for the progress of socioeconomic development in this country.

People who drink arsenic contaminated water (>0.05 mg/l) for 5 to 10 years are attacked by arsenicosis and they have also a risk of developing cancer. The consumption of arsenic contaminated groundwater over a prolonged period of time has adverse health effects such as arsenical dermatosis, melanosis, leuco-melanosis, keratosis, hyperkeratosis, ulcer, gangrene and several other symptoms of arsenicosis (Khan et al. 1997, Haque R et al. 2003, Saha K.C. 2003, Khan MM et al. 2003).

In 1987, the first arsenicosis patient was identified at Baroghoria in Nawabganj district, Bangladesh. The Department of Public Health Engineering confirmed the presence of arsenic in tube-wells in the same district in 1993. They detected 8 arsenicosis patients through a survey in 1994. They have also argued that about 8 million people belonging to 61 of 64 districts have been affected with arsenicosis. At present, there are about 10,000 to 14,000 registered arsenicosis patients and among them hundreds of patients have already died (Mitra A. K. et al. 2002). It is surprising that there are no official statistics about the death caused by arsenicosis. The unofficial statistics suggest that the disease has claimed several hundreds of lives over the year (Silver J. and Wilson R. 2003).

In the backdrop of the above discussion, the arsenic catastrophe is considered as a great threat to the future generations in Bangladesh. This country has emerged as the most vulnerable place with regards to arsenic pollution as the extent and spread of the problem has taken a serious turn. Our next generation will be subject to a more dangerous situation due to arsenic poisoning. This is the right time to be aware of the problem and take steps to combat the spread of arsenic pollution. The present paper investigates the differentials of arsenic affected people in Bangladesh. This study also examines the socioeconomic conditions and factors affecting arsenic patients.

DATA AND METHODOLOGY

The data was collected on 250 arsenic patients by using a simple random sampling technique from May 15 2005 to June 30, 2005. For this sampling, the patient list was collected from the Civil Surgeon office of Nawabganj district in Rajshahi division. For data collection purposes, personal interview approach followed. This method relates to the collection of information directly from the patients. A patient was directly contacted and the desired information was collected through pre-designed questionnaire. The purpose of each question was explained to them and they were told about the scope of the survey and manner in which the answers were to be recorded. The multiple classification analysis (MCA) was used to determine the contribution of various factors on arsenicosis and to know the intensity of the influences of the various factors. MCA can equally handle the normal ordinal variables and can also deal with linear and non-linear relationships of predictor variables with dependent variables. The unadjusted eta-square (h2) coefficient is a correlation ratio that explains how well the predictor variable explains the variation in dependent variables by solving the normal equations with only one predictor. This unadjusted coefficient indicates the proportion of variance explained by a single predictor alone. Similarly, the beta-square (b2) coefficient indicates the proportion of variation explained by a predictor variable taking into account the proportion explained by the other predictor variables. The beta coefficient is compared to the partial correlation coefficient in multiple regressions. The MCA has advantages because it provides estimates of each category of the predictor variable and at the same time provides the coefficient for explaining the strength of the relationship. In this study, arsenicosis condition is considered as a dependent variable. The selected independent variables are: age, sex, education, occupation, working status, source of drinking water, watching television and listening to radio.

Background Characteristics of the Patients

Table 2 presents socio-economic and demographic characteristics of the patients. The 250 arsenic affected patients interviewed ranged in age from 8 to 65, with a mean of 32 years. In this analysis, age was grouped into four classes according to human life cycles such as children, adolescents, youths and older aged. The respondents tend to be young with the largest proportion in their middle age or even younger (61.2 per cent). Only 6.8 per cent are under age 10 years of age, 19.6 per cent are adolescents aged 10-19 years and that less than thirteen per cent (12.4 per cent) are older than 50 and over. About half (54.4 per cent) of the sample was female and the rest (45.6 per cent) of the samples were males. Besides this, about a quarter (24.8 per cent) of the sample was single, while more than half (59.2 per cent) were married at the time of the interview, with 4.8 per cent divorced and 11.2 per cent widowed. The educational level of respondents was generally low. The majority of the respondents (44.0 per cent) were illiterate or had no education. More than a quarter of the respondents (32.0 per cent) had completed primaryeducation, whilst 14.0 per cent had completed secondaryeducation. A small proportion (10.0 per cent) had completed a higher level of education (graduate and higher education). All occupational categories of rural society were represented. The occupations of patients varied widely representing diverse segments of rural Bangladeshi society, including agricultural laborer, day laborers, businessmen, unemployed and others. 32.0 per cent of the sample worked as agricultural laborers, 20.0 per cent worked as day laborers and 6.8 per cent worked in small business and 1.2 per cent worked in other occupations.

Drinking arsenic contaminated water is assumed to be the major cause of arsenicosis. The result indicates that tube-wells are the major sources of drinking water. 60.4 per cent of patients obtain drinking water from tube-wells; 30.4 per cent use well water for their drinking purposes and fewer (9.2 per cent) depend on other sources of water including pond, tank, lake, river, etc. In this study, mass media variables such as watching television, listening to radio and reading newspapers are considered important media to acquire knowledge about the disease, its prevention and cure. The results in Table 2 exhibit that 26.0 per cent of patients watch television, 44.8 per cent listen to radio and 13.2 per cent read newspaper regularly.

Table 3 indicates the health characteristics of the patients. The most common illnesses reported by the patients were asthma (15.6 per cent), diabetes (10.4 per cent), heart disease (9.2 per cent), blood pressure (5.2 per cent) and other diseases (9.6 per cent). Among the patients, 52.0 per cent are suffering second stages, 44.0 per cent are in first stages and only 4.0 per cent are in third stages. More than half of the patients (54.8 per cent) were suffering various physical problems. It is noted that 60.8 per cent have been suffering arsenicosis for five years and below, 32.4 per cent have been suffering forsix to ten years and only 6.8 per cent had been suffering ten years and above. Below fifty per cent of the patients (41.2 per cent) had taken any treatment for arsenicosis. More than fifty per cent of the patients (58.8) didn't take any treatment. 28.0 per cent took treatment from an NGO, 10.0 per cent from thana health complex and 3.2 per cent had taken treatment from other sources.

Changes in the Socio-Economic Status of Patients

An attempt is made to observe what changes occurred to the economic status of patients before and after contracting the disease. For this purpose, the socio-economic status such as working status, kind of work, monthly income, monthly costs and invitation to social ceremonies among the patients prior to the disease are compared with those after disease occurrence.

About 60 percent of patients were working before contracting the disease but after having the disease it declined to 34 percent. Some of the patients got day laborer jobs (20.0 per cent), some got small business related jobs (6.8 per cent), most engaged in agricultural activities (32.0 per cent) and 40.0 per cent were not working before the disease. A radical change of working patterns was observed after the disease. The majority (58 per cent) didn't work after the disease. Due to the disease, agricultural labor, day labor and business work declined to 45 per cent, 29 per cent and 60 per cent respectively.

The disease directly impacts on patients' monthly income. Before the disease the average monthly income of patients was 2556.75 taka and after the disease it has changed to 1563.35 taka. Before the disease, 4 per cent earn monthly salary of 1000 taka and below, 32 per cent earnt 1001 to 2000 taka, 22 per cent earnt 2001 to 3000 taka and only 2 per cent earnt 3000 and above taka. After the disease, it has changed to , 22.0 per cent earnt 1000 and below taka, 14.0 per cent earnt 1001 to 2000 taka, 5.6 per cent earnt 2001 to 3000 taka and a small (0.4 per cent) proportion earnt 3001 and above taka. Actually, family income of patients showed a tremendous decrease after the disease. With deterioration of their condition, the patients gradually lose their ability to work and thus they fall into poverty. Disease also affects expenditure status of patients. Due to disease occurrence, their costs of living have increased. Before the disease, monthly average costs orf patients were 1675.50 taka and after the disease it has changed to 1985.15 taka. Arsenic patients cannot move freely due to social problems. Most of the villagers consider arsenicosis is a contagious disease. Nobody wants to come into contact with the arsenic-affected people and avoid inviting them for social functions. In this study, there has been shown a marked difference in invitations to social functions between before and after disease among the arsenicosis patients. It is found in Table 3 that 94.4 per cent had got invitations before the disease, whereas, after the disease it had declined to 34.0 per cent.

Differentials of Arsenicosis

In this analysis, the selected variables age, sex, education, occupation, working status, source of drinking water, watching television and listening to radio are considered as the determinants of arsenicosis. The results are described in Table 5. Among the selected factors, source of drinking water is the most effective ,(h2=0.31 and b2=0.28). The mean number of arsenicosis patient is 1.80 who drink tube-well water and 1.35 who drink other sources of
water. We may conclude that tube-well is one of the sources of arsenicosis. Education has emerged as the important determinant for arsenicosis. It is important to note that literate people have been found to have lower prevalence of arsenicosis. On average 1.52 persons are affected by arsenicosis who are literate whereas, 1.73 person are affected by arsenic contamination, who are illiterate. It may be that literate people have knowledge of arsenic contamination and they avoid drinking arsenic contaminated water. The work status of patients shows a substantial effect of arsenicosis. The patients who were involved in income generating activities had a lower (1.42) number of arsenicosis sufferers than their non-working (1.91) counterparts. It is often observed in developing societies that occupation is closely associated with social status. It shows a moderate effect on arsenicosis (h=0.05 and b=0.06).

Day laborers (1.30) tend to have a higher prevalence of arsenicosis than the average, followed by agricultural laborers (1.28), small businessmen (1.19) and others (1.14). Sex differentials are observed among arsenic patients. Females (1.62) have a higher prevalence of disease than their male (1.51) counterparts. Age also shows relatively weak influence on explaining variation in mean numbers of arsenicosis patients (h=0.002 and b=0.003). Middle aged (1.85) persons are more vulnerable to developing arsenicosis than young (1.47) and older (1.55) persons. The patients who do not watch television or listen to radio are more likely to attack from arsenicosis than those patients who are exposed to some mass media. On average 1.54 patients have arsenicosis who don't watch television, whereas 1.45 patient have arsenicosis who watch television. On the other hand, the mean number of arsenic patients who don't listen to radio have a 0.5 higher prevalence of disease than those who listen to the radio.

Variable	Unadjusted	Adjusted	Correlation ratio
			2	2
Age < 10 years 10-19 years 20-59 years 50 and over	1.45 1.85 1.67	1.47 1.80 1.55	.002	.003
Sex Male Female	1.50 1.65	1.51 1.62	.046	.051
Education Illiterate Literate	1.75 1.43	1.73 1.52	.083	.065
Occupation Housewife Student Others	1.67 1.50 1.48	1.63 1.57 1.52	.051	.038
Working status Yes No	1.43 1.82	1.42 1.91	.071	.083
Source of drinking water Tube-well Other	1.78 1.43	1.80 1.35	.31	.28
Watching television Yes No	1.43 1.68	1.52 1.54	.003	.005
Listening radio Yes No	1.38 1.59	1.47 1.51	.006	.004
Grand Mean= 1.65 Proportion variation explained, R2=0.57

DISCUSSION AND CONCLUSION

The study reveals some of the important features of arenicosis patients at Nawabganj in Bangladesh. It is evident from the data that more than half of the patients were over twenty years of age. The patients are mostly the young generation, with the largest proportion in their middle age and a sizeable portion are old. The arsenic poses a serious threat to young generations (Watanabe et al. 2003). It is also noted that more than half of the patients were female. Ahmad et al. (1999) observed similar findings. They also showed that female arsenicosis patients were mostly illiterate and most of the patients were between 10 to 39 years. The data also indicates that the sample is uneducated; about sixty per cent were married at the time of interview, a quarter were single and a noticeable proportion were divorced or widowed. The divorced patients were due to the cause of arsenicosis.

The result indicates that the majority of the patients drink tube-well water. In this connection, Khan et al. (1997) conducted a study on arsenic contamination in ground water and its toxicity effect on health. They found that tube-well was the main source of arsenic contaminated water. Those who were drinking contaminated tube-well water, were attacked by melanosis, keratosis, hyperkeratosis and depigmentation (Leukomelanosis) is common. It is noted in a study that more than 50 percent of the tube-wells in 62 out of 64 districts contain more than 0.05 mg of arsenic per liter of water (Momotaj H. et al.: 2001). There is need to take the initiative for developing appropriate alternative water supply options immediately. There is also need to develop awareness about the problems associated with arsenic contamination in drinking water. It has been observed in this study that the maximum number of patients have low socioeconomic status and they are very poor. More than fifty per cent of arsenic patients were suffering from various physical problems. They suffered from different diseases such as diabetes, heart disease, blood pressure and asthma. Several studies have suggested that arsenic patients have been suffering from various physical problems and several diseases (Khan et al. 1997, Rahman et al. 1998, Khan MM et al. 2003). It has been observed that the maximum number of patients are in first and second stages, which can be curable. Immediate action should be taken to provide adequate medicine, proper treatment, nutritious food and availability of pure drinking water. Proper steps should be taken to identify arsenicosis patients with their particular disease and stages of arsenicosis accurately on an emergency basis. In this connection government should take proper action for detecting the early signs of arsenicosis on a regular basis.

Exposure to knowledge and awareness is very poor among arsenic patients. A few proportion of patients watch television, listen to the radio and read newspapers daily. It is essential to have the involvement of mass media and development of information, education and communication material for awareness of the people. For this purpose, campaigns in mass media (radio/television/newspaper/magazine/poster/bill board) should be increased indicating the causes of arsenicosis disease, its effects and efforts to be free from arsenic contamination water. Government and non-governmental levels should take proper steps to increase and modify mass media exposure to arsenicosis i.e. existing programs and steps which are being campaigned in the radio/television/newspaper/magazine/ poster/bill board need to improve the knowledge and attitudes and also should increase the publicity regarding safe drinking water messages in the mass media. The data indicates that the occurrence of arsenic disease has changed the socioeconomic condition of arsenic patients. This disease influences working status, occupation, income, finances and invitations for social functions, of the patients. Due to disease occurrence their incomes have decreased but living cost has increased. It has been found that people exclude them from various social activities. Due to arsenic disease they are less efficient than before. It is remarkable that arsenicosis is not a contagious disease. On the other hand, the mean arsenic patient who doesn't listen to the radio has a 0.5 higher prevalence of disease than those who listen to the radio.

Arsenicosis should not be thought of as a fault of the patients and the patients should not be socially boycotted. Motivation and awareness should be increased regarding arsenicosis disease. It can be concluded that due to lack of literacy, superstitions, insufficient awareness and scarcity of proper motivational programs at both governmental and non-governmental levels, the arsenic problem has been creating a serious crisis in rural Bangladesh. The patients should be diagnosed at their early stages. At the same time, safe drinking water should be supplied to the affected areas as immediate relief on an emergency basis. Proper initiatives should be taken to make people aware of any method of removing arsenic from water prior to introducing the method.

REFERENCES

Haque R., Mazumder DN, Samanta S., Ghosh N., Kalman D., Smith MM, Mitra S., Santra A., Lahiri S., Das S., De BK and Smith AH (2003). Arsenic in drinking water and skin lesions: dose-response data from West Bengal, India, Epidemiology 2003, March 14(2), 174-82.

Khan A.W., Ahmad Akhtar S, Sayed Salim Ullah M.H., Hadi Ahdul S, Khan M.H., Jali M.A., Ahmed R., and Faruquee (1997). Arsenic Contamination in Groundwater and its Effect on Human Health with Particular Reference to Bangladesh, Journal of Preventive and Social Medicine, 16(1), 65-73.

Khan A.W. and Sk. Ahmad A. (1997). Arsenic in drinking water, health effects and managements (A Training Manual), Department of Occupational and Environmental Health, National Institute of Preventive and Social Medicine, Dhaka, Bangladesh.

Kshitish Chandra Saha (2003). Diagnosis of arsenicosis, Journal of Environmental Science and Health, Part-A-Toxic/Hazardous Substances and Environmental Engineering, 38(1), 255-272.

Khan MM, Sakauchi F., Sonoda T., Washio M. and Mori M. (2003). Magnitude of arsenic toxicity in tube-well drinking water in Bangladesh and its adverse effects on human health including cancer: evidence from a review of the literature, Asian Pac J Cancer Prevention, January-March 4(1), 7-14.

Momotaj H. and Hussain I. (2001). Effect of Spirulina on Arsenicosis Patients in Bangladesh. Presentation Prepared for Arsenic in Drinking

Water: An International Conference at Columbia University, New York, November 26-27, 2001.
Mitra A.K., Bose B.K., Kabir H., Das B.K. and Hussain M. (2002). Arsenic-related health problems among hospital patients in southern Bangladesh, Journal of Health Population and Nutrition, 20(3), 198-204.

Quamruzzaman Q. and Rahman M. (1998). Arsenicosis in Bangladesh, Dhaka Community Hospital Trust, Dhaka, Bangladesh.

Rahman M., Tondel M., Ahmad S.A. and Axelsonl O. (1998). Diabetes Mellitus Associated with Arsenic Exposure in Bangladesh, American Journal of Epidemiology, Vol. 148, No.2, Pp.198-203.
Silver J. and Wilson R. (2003). Chronic Arsenic Poisoning: History, Study and Remediation, Bangladesh Archives, 26 June 2003.

Silvia M. (2003). Arsenic in the Groundwater, Bangladesh Archives, 29 April 2002.
The New York Times, New Bangladesh Disaster: Wells that pumps poison, November 10, 1998.

Watanabe C., Inaoka T., Matsui T., Ishigaki K., Murayama N. and Ohtsuka R. (2003). Effects of arsenic on younger generations, Journal of Environmental Science and Health, Part-A-Toxic/Hazardous Substances and Environmental Engineering, 38(1), 129-139.