In Bangladesh, funds dry up for arsenic mitigation research

Abstract

Efforts to tackle what WHO describes as “the largest case of mass poisoning of a population in history” are being hampered by a dearth of funding for research. Patrick Adams reports.“Water, water everywhere—nor any drop to drink.” The plight of Coleridge's ancient mariner is that of present-day populations in some 70 countries on six different continents.From China to Chile, unsafe levels of naturally occurring arsenic—a potent human toxicant and carcinogen—have been detected in the drinking water. And nowhere is the problem more pronounced than in Bangladesh.Beginning in the 1970s, hand-pumped tube wells were installed throughout the country in an effort to provide rural communities with clean water for the prevention of cholera and other water-borne diseases. It wasn't until the early 1990s, however, that geological surveys revealed substantial contamination of the aquifers from which these wells drew their water.In the decades since, as many as 77 million people in Bangladesh alone are believed to have been chronically exposed to raised concentrations of the toxic metalloid. That exposure has been associated with a wide variety of adverse health effects, including reduced cognitive function, peripheral neuropathy, respiratory complications, diabetes and cardiovascular disease, and cancers of the skin, lung, kidney and bladder, among other problems.“Now it's just a matter of adding new items to the list”, says Habibul Ahsan, director of the Center for Cancer Epidemiology and Prevention at the University of Chicago and principal investigator on the Health Effects of Arsenic Longitudinal Study (HEALS). A prospective cohort study of 30 000 men and women in Bangladesh, HEALS has yielded important new findings about the health risks of arsenic exposure.“Like tobacco, arsenic has multi-systemic effects”, says Ahsan, a native of Bangladesh, who reported in a 2010 article in The Lancet that just under a quarter of all chronic disease related deaths in the HEALS cohort could be attributed to arsenic-contaminated well water. Given that well water is the only pathogen-free water to which most Bangladeshis have access, he says, “it's not as though they can easily switch to something else”.Hence the importance of determining exactly how much arsenic people can safely consume—and using that information to tailor sustainable mitigation strategies. “What's the minimum dose and how long does someone have to be exposed?” he says. “We still don't know the answer to that.”Indeed, in spite of the magnitude of the crisis—WHO has called it “the largest case of mass poisoning of a population in history”—experts say measures to mitigate the health effects of arsenic contamination have fallen far short of what is needed, leaving millions of Bangladeshis vulnerable.“This is a neglected public health problem”, says Mahfuzar Rahman, an environmental epidemiologist with the International Centre for Diarrhoeal Disease Research, Bangladesh. In one of the few studies of childhood mortality associated with arsenic-contaminated well water, Rahman and colleagues reported earlier this year that arsenic exposure was associated with “substantial increased risk of deaths at young age”.“We have plenty of evidence of arsenic's effects on human health.” Yet still, he says, “about a quarter of the population is drinking contaminated water”, reflecting the failure of mitigation strategies implemented by a patchwork of poorly coordinated stakeholders.Having largely ignored the problem for years, the Bangladeshi Government, with support from the World Bank and the Swedish International Development Cooperation Agency, adopted in 2004 a national arsenic mitigation strategy. A US$30 million undertaking, the project took a two-pronged approach to mitigation, including screening and identification of the country's 12 million tube wells and the introduction of alternative arsenic-safe water options like rainwater harvesting, dug wells, pond sand filters and arsenic-removal technologies.“At that time, a lot of money was available for mitigation”, adds Rahman. But with so little success after the project's first year, donors began to lose interest and progress stalled. Now, he says, no one wants to support the kind of operational research needed to find out what works. “This is a major environmental challenge. We need a sustainable strategy that is low cost and easily accessible, and to find that we need to evaluate the different options. But we don't do anything because we don't have the money.”A Bangladeshi woman with melanosis due to arsenic poisoningView Large Image Copyright © 2013 Roger Hutchings/In Pictures/CorbisEven in low doses, arsenic is an insidious killer. Odourless and tasteless, it produces no acute symptoms, and disease onset often occurs decades after the contaminated water is consumed. “It's a forgotten issue”, says Ahsan. “Policy makers in Bangladesh have the impression that skin lesions are the only health-related outcome of arsenic exposure. But we clearly documented a large proportion of deaths that can be attributed to arsenic contamination, and these findings don't resonate with policy makers in Bangladesh because they aren't visible to them.”When Allan Smith, director of the arsenic research programme at the University of California, Berkeley, first visited Bangladesh, he was struck by what he saw. “I thought that it should have been declared a public health emergency”, recalls Smith. “And that was in 1997, long before we knew what we do now.”In studies of early-life arsenic exposure in Chile, Smith and colleagues found increases in mortality among young adults from several different causes, including lung cancer and bronchiectasis, bladder cancer, liver cancer, and chronic renal disease. They also reported marked increases in respiratory symptoms among children in Bangladesh who were exposed to arsenic in the womb, underscoring the urgent need to reduce exposure among pregnant women and young children.“You drink crystal-clear water and you end up doing damage to your lungs, and then 20 or 30 or 40 years later you die of lung cancer”, he says. “It's remarkable. Looking back now, I think of all of those mothers and young children who had what turns out to be the highest risk we know of for anything in early life environmental exposure.”Mitigating that exposure is no easy task, Smith adds, and it's made all the more difficult in Bangladesh by a lack of monitoring and evaluation of the various interventions implemented in different contexts. “That leaves you at the mercy of data that may not be valid”, he says. And bad data can lead to false assumptions—such as, for example, that people will always drink arsenic-safe water where it's available.“If a person—and it's always a woman—has to walk half a kilometre or more in the heat everyday to get that water, you can't assume she's actually doing it. These people are struggling to live. It can be very hard for them to always do what they're told they should do by the experts in Dhaka.” Smith has long called for regular testing of urine, the only reliable metric of current exposure, as a way of evaluating programme impact.Also an obstacle to success is the general lack of awareness of arsenic among the people of Bangladesh. In a recent survey of 6700 households, 70% of respondents said they believed that boiling water could cleanse it of arsenic and that by eating or sleeping with someone who has arsenicosis a person could become infected. Those and other misconceptions can undermine even the best solutions, say experts, and their prevalence suggests a need for new approaches to communicating the dangers of contaminated drinking water.That said, well water may not be the only route of exposure. Scientists fear that food crops irrigated by contaminated groundwater, including rice, the region's staple food, could also put people at increased risk of death and disease. “We need comprehensive research, and we need a sustainable mitigation option”, says Rahman. “But to get funding for this now is extremely difficult.”When it comes to mitigation, “there's no simple answer”, says Smith. “But there's an unfortunate idea that you can install in a community an inexpensive arsenic-removal technology and that when you go back a year later it will actually be working—that you've solved the problem.” More often than not, he adds, that isn't the case. “The situation requires much more focus and careful attention than it's been given.”Smith stresses that Bangladesh is not alone in neglecting the problem. “The most inadequate response is in the USA, where millions of people are drinking water from wells that aren't required to be tested.” But the scale of the problem pales in comparison to that of Bangladesh, which experts believe could soon see a dramatic rise in cancers as a result of arsenic exposure.“There is not the political will to tackle this”, says Ahsan. “Bangladesh is a poor country with many other problems. But if the government were committed to solving this, they could engage the NGO [non-governmental organisation] community and get it done. And they haven't done that.” For The Lancet News podcast see http://www.thelancet.com/lancet-news-audio/ Efforts to tackle what WHO describes as “the largest case of mass poisoning of a population in history” are being hampered by a dearth of funding for research. Patrick Adams reports. “Water, water everywhere—nor any drop to drink.” The plight of Coleridge's ancient mariner is that of present-day populations in some 70 countries on six different continents. From China to Chile, unsafe levels of naturally occurring arsenic—a potent human toxicant and carcinogen—have been detected in the drinking water. And nowhere is the problem more pronounced than in Bangladesh. Beginning in the 1970s, hand-pumped tube wells were installed throughout the country in an effort to provide rural communities with clean water for the prevention of cholera and other water-borne diseases. It wasn't until the early 1990s, however, that geological surveys revealed substantial contamination of the aquifers from which these wells drew their water. In the decades since, as many as 77 million people in Bangladesh alone are believed to have been chronically exposed to raised concentrations of the toxic metalloid. That exposure has been associated with a wide variety of adverse health effects, including reduced cognitive function, peripheral neuropathy, respiratory complications, diabetes and cardiovascular disease, and cancers of the skin, lung, kidney and bladder, among other problems. “Now it's just a matter of adding new items to the list”, says Habibul Ahsan, director of the Center for Cancer Epidemiology and Prevention at the University of Chicago and principal investigator on the Health Effects of Arsenic Longitudinal Study (HEALS). A prospective cohort study of 30 000 men and women in Bangladesh, HEALS has yielded important new findings about the health risks of arsenic exposure. “Like tobacco, arsenic has multi-systemic effects”, says Ahsan, a native of Bangladesh, who reported in a 2010 article in The Lancet that just under a quarter of all chronic disease related deaths in the HEALS cohort could be attributed to arsenic-contaminated well water. Given that well water is the only pathogen-free water to which most Bangladeshis have access, he says, “it's not as though they can easily switch to something else”. Hence the importance of determining exactly how much arsenic people can safely consume—and using that information to tailor sustainable mitigation strategies. “What's the minimum dose and how long does someone have to be exposed?” he says. “We still don't know the answer to that.” Indeed, in spite of the magnitude of the crisis—WHO has called it “the largest case of mass poisoning of a population in history”—experts say measures to mitigate the health effects of arsenic contamination have fallen far short of what is needed, leaving millions of Bangladeshis vulnerable. “This is a neglected public health problem”, says Mahfuzar Rahman, an environmental epidemiologist with the International Centre for Diarrhoeal Disease Research, Bangladesh. In one of the few studies of childhood mortality associated with arsenic-contaminated well water, Rahman and colleagues reported earlier this year that arsenic exposure was associated with “substantial increased risk of deaths at young age”. “We have plenty of evidence of arsenic's effects on human health.” Yet still, he says, “about a quarter of the population is drinking contaminated water”, reflecting the failure of mitigation strategies implemented by a patchwork of poorly coordinated stakeholders. Having largely ignored the problem for years, the Bangladeshi Government, with support from the World Bank and the Swedish International Development Cooperation Agency, adopted in 2004 a national arsenic mitigation strategy. A US$30 million undertaking, the project took a two-pronged approach to mitigation, including screening and identification of the country's 12 million tube wells and the introduction of alternative arsenic-safe water options like rainwater harvesting, dug wells, pond sand filters and arsenic-removal technologies. “At that time, a lot of money was available for mitigation”, adds Rahman. But with so little success after the project's first year, donors began to lose interest and progress stalled. Now, he says, no one wants to support the kind of operational research needed to find out what works. “This is a major environmental challenge. We need a sustainable strategy that is low cost and easily accessible, and to find that we need to evaluate the different options. But we don't do anything because we don't have the money.” Even in low doses, arsenic is an insidious killer. Odourless and tasteless, it produces no acute symptoms, and disease onset often occurs decades after the contaminated water is consumed. “It's a forgotten issue”, says Ahsan. “Policy makers in Bangladesh have the impression that skin lesions are the only health-related outcome of arsenic exposure. But we clearly documented a large proportion of deaths that can be attributed to arsenic contamination, and these findings don't resonate with policy makers in Bangladesh because they aren't visible to them.” When Allan Smith, director of the arsenic research programme at the University of California, Berkeley, first visited Bangladesh, he was struck by what he saw. “I thought that it should have been declared a public health emergency”, recalls Smith. “And that was in 1997, long before we knew what we do now.” In studies of early-life arsenic exposure in Chile, Smith and colleagues found increases in mortality among young adults from several different causes, including lung cancer and bronchiectasis, bladder cancer, liver cancer, and chronic renal disease. They also reported marked increases in respiratory symptoms among children in Bangladesh who were exposed to arsenic in the womb, underscoring the urgent need to reduce exposure among pregnant women and young children. “You drink crystal-clear water and you end up doing damage to your lungs, and then 20 or 30 or 40 years later you die of lung cancer”, he says. “It's remarkable. Looking back now, I think of all of those mothers and young children who had what turns out to be the highest risk we know of for anything in early life environmental exposure.” Mitigating that exposure is no easy task, Smith adds, and it's made all the more difficult in Bangladesh by a lack of monitoring and evaluation of the various interventions implemented in different contexts. “That leaves you at the mercy of data that may not be valid”, he says. And bad data can lead to false assumptions—such as, for example, that people will always drink arsenic-safe water where it's available. “If a person—and it's always a woman—has to walk half a kilometre or more in the heat everyday to get that water, you can't assume she's actually doing it. These people are struggling to live. It can be very hard for them to always do what they're told they should do by the experts in Dhaka.” Smith has long called for regular testing of urine, the only reliable metric of current exposure, as a way of evaluating programme impact. Also an obstacle to success is the general lack of awareness of arsenic among the people of Bangladesh. In a recent survey of 6700 households, 70% of respondents said they believed that boiling water could cleanse it of arsenic and that by eating or sleeping with someone who has arsenicosis a person could become infected. Those and other misconceptions can undermine even the best solutions, say experts, and their prevalence suggests a need for new approaches to communicating the dangers of contaminated drinking water. That said, well water may not be the only route of exposure. Scientists fear that food crops irrigated by contaminated groundwater, including rice, the region's staple food, could also put people at increased risk of death and disease. “We need comprehensive research, and we need a sustainable mitigation option”, says Rahman. “But to get funding for this now is extremely difficult.” When it comes to mitigation, “there's no simple answer”, says Smith. “But there's an unfortunate idea that you can install in a community an inexpensive arsenic-removal technology and that when you go back a year later it will actually be working—that you've solved the problem.” More often than not, he adds, that isn't the case. “The situation requires much more focus and careful attention than it's been given.” Smith stresses that Bangladesh is not alone in neglecting the problem. “The most inadequate response is in the USA, where millions of people are drinking water from wells that aren't required to be tested.” But the scale of the problem pales in comparison to that of Bangladesh, which experts believe could soon see a dramatic rise in cancers as a result of arsenic exposure. “There is not the political will to tackle this”, says Ahsan. “Bangladesh is a poor country with many other problems. But if the government were committed to solving this, they could engage the NGO [non-governmental organisation] community and get it done. And they haven't done that.” For The Lancet News podcast see http://www.thelancet.com/lancet-news-audio/ For The Lancet News podcast see http://www.thelancet.com/lancet-news-audio/ For The Lancet News podcast see http://www.thelancet.com/lancet-news-audio/ The Bangladesh paradox: exceptional health achievement despite economic povertyBangladesh, the eighth most populous country in the world with about 153 million people, has recently been applauded as an exceptional health performer. In the first paper in this Series, we present evidence to show that Bangladesh has achieved substantial health advances, but the country's success cannot be captured simplistically because health in Bangladesh has the paradox of steep and sustained reductions in birth rate and mortality alongside continued burdens of morbidity. Exceptional performance might be attributed to a pluralistic health system that has many stakeholders pursuing women-centred, gender-equity-oriented, highly focused health programmes in family planning, immunisation, oral rehydration therapy, maternal and child health, tuberculosis, vitamin A supplementation, and other activities, through the work of widely deployed community health workers reaching all households. Full-Text PDF Harnessing pluralism for better health in BangladeshHow do we explain the paradox that Bangladesh has made remarkable progress in health and human development, yet its achievements have taken place within a health system that is frequently characterised as weak, in terms of inadequate physical and human infrastructure and logistics, and low performing? We argue that the development of a highly pluralistic health system environment, defined by the participation of a multiplicity of different stakeholders and agents and by ad hoc, diffused forms of management has contributed to these outcomes by creating conditions for rapid change. Full-Text PDF Bangladesh: innovating for healthWriting earlier this year, as part of a series of country case studies on good health at low cost, Dina Balabanova and her colleagues concluded that “Bangladesh has made enormous health advances and now has the longest life expectancy, the lowest total fertility rate, and the lowest infant and under-5 mortality rates in south Asia, despite spending less on health care than several neighbouring countries”.1 Why is this so? Full-Text PDF